Heart Rate / Pulse abnormal, Tachycardia, Bradycardia

Also Consider:  Dehydration, Fever, Hypoglycemia 

1. Take Vital Signs

• Temperature:

• Blood Pressure lying:

• Blood Pressure standing:

• Heart Rate: 

• Respiratory Rate:

• Oxygen Saturation:

2. Evaluate Symptoms and Signs

• Acute mental status change or decline in ADL abilities

• Not eating or drinking as much as usual

• Unrelieved pain, including:  exact locations, pain scale, description (sharp, dull, burning), persistent or intermittent

• Fainting, dizziness or lightheadedness when standing up

• Thirst, signs of dehydration

• Diaphoresis: Cold, clammy, pale skin

• Respiratory: New cough, abnormal lung sounds, Accessory muscle breathing, pursed lip breathing, Respiratory distress, diminished respirations

• Cardiovascular:  Chest pain, new irregular pulse, cyanosis, mottling, edema

• GI: Nausea, vomiting, diarrhea, abdominal distention or tenderness, rebound tenderness, bowel sounds

• GU: New or worsened incontinence, pain with urination, blood in urine, urinary retention / bladder scan

• Neurologic  changes: consciousness/alertness, orientation, weakness

• Potential for drug overdose or withdrawal (for opioid overdose, consider naloxone)

• Fingerstick glucose (patients with diabetes)

3. Take Action using SBAR Report:

• Presence of other, significant symptoms or signs of illness 

  • Refer to appropriate Situation-Specific Evaluation for the identified symptoms and signs.

• Immediately notify the medical staff & resident representative

  • Resting heart rate greater than 120 or less than 40, or

  • Heart Rate >100 and at least 1 of:

    • Temperature >100

    • Systolic Blood Pressure <100

    • Respiratory Rate >20

    • Oxygen saturation (O2sat) <90%

• Notify medical staff & resident representative within the next 16 hours. 

  • Resting heart rate greater than 110 or less than 50

• Notify medical staff on the next business day 

  • Pulse intermittently greater than 110 or less than 50, or has become irregular

• Notify medical staff at the next regular rounds 

  • Pulse intermittently greater than 100 

4. Implement Management Plan

• Monitor vital signs every 4-8 hrs for 2-3 days

• Offer fluids frequently

• Oral, IV, or subcutaneous fluids if needed for hydration

• Place on Intake & Output monitoring

• Monitor meal acceptance

• Place on 24-hour report for 2-3 days

• Obtain lab results (if ordered), and notify medical as needed of significantly abnormal values in lab tests (refer to appropriate Situation)

• Update care plan regarding  fall risk, pressure ulcer prevention, assistance needed with ADLs, supervision for safety, restorative needs

• Review status and plan of care with designated representative

• Update advance directives if appropriate

2025-04-26