14.1 Vital Signs, Laboratory Values & Activity Precautions
Key Takeaways
- Domain 2 Task 3 requires knowledge of precautions and contraindications associated with a client's condition or stage of recovery, naming postsurgical precautions, vital signs, laboratory values, and suicidal ideation.
- A systolic blood pressure that FALLS with increasing workload is an abnormal, activity-terminating response — it signals that the heart cannot meet demand and is more ominous than a rise.
- Commonly cited acute-care thresholds are a platelet count under 20,000 per microliter for holding resistive activity, hemoglobin under 8 grams per deciliter for limiting to light bed-level activity, and an international normalized ratio above 5 for high bleeding risk.
- Orthostatic hypotension is defined as a drop of at least 20 mmHg systolic or 10 mmHg diastolic within three minutes of assuming an upright position.
- Published laboratory thresholds are guidelines, not orders; the facility's protocol and the physician's clearance always govern, and the therapist documents the value, the trend, and the clinical decision.
Vital Signs, Laboratory Values & Activity Precautions
The NBCOT content outline requires knowledge of precautions or contraindications associated with a client's condition or stage of recovery, and it names four examples explicitly: postsurgical precautions, vital signs, laboratory values, and suicidal ideation. Items built on this knowledge statement almost always use the lead-in "FIRST," "MOST APPROPRIATE," or "CONTRAINDICATED," and the keyed answer is the one that protects physiological safety before it advances function.
1. Normal Adult Vital Sign Ranges
| Parameter | Typical Resting Adult Range | Notes for Therapy |
|---|---|---|
| Heart rate | 60–100 beats/min | Below 60 is bradycardia; above 100 at rest is tachycardia. Beta blockers blunt the exercise response |
| Blood pressure | Normal is below 120/80 mmHg | Elevated 120–129 systolic; stage 1 hypertension 130–139 or 80–89; stage 2 at or above 140 or 90; hypertensive crisis above 180/120 |
| Respiratory rate | 12–20 breaths/min | Rising rate with a falling oxygen saturation is the earliest sign of decompensation |
| Oxygen saturation | 95–100% on room air | Generally keep at or above 90%. In chronic obstructive pulmonary disease a target of 88–92% is often prescribed — do not chase 98% |
| Temperature | About 97–99°F (36.1–37.2°C) | Fever with a low white blood cell count is a reason to hold therapy |
| Pain | 0–10 numeric rating | Unrelieved new pain is a red flag, not a tolerance problem |
2. Criteria to Terminate or Withhold Activity
Stop the activity, position the client safely, take vital signs, and notify nursing or the physician when any of the following occurs:
- Systolic blood pressure falls as workload increases. A drop of roughly 10 to 20 mmHg during exertion is an abnormal hypotensive response indicating the heart cannot meet demand. Candidates frequently assume a high number is the danger; a falling systolic pressure during work is the more ominous finding.
- Systolic pressure above about 180 mmHg or diastolic above about 110 mmHg before or during activity.
- Oxygen saturation below the prescribed floor (commonly under 90%, or under 88% in chronic lung disease).
- New or worsening chest pain, pressure, or radiating discomfort.
- Excessive dyspnea, wheezing, or an inability to speak in short sentences.
- Dizziness, lightheadedness, pallor, cold diaphoresis, nausea, or new confusion.
- New or irregular pulse, palpitations, or a heart rate response far outside the prescribed limits.
- Rating of perceived exertion above the prescribed ceiling. On the 6–20 Borg scale, most inpatient rehabilitation activity is graded to roughly 11–13 ("light" to "somewhat hard"); the 0–10 modified scale usually targets about 3–4.
Orthostatic Hypotension
Defined as a fall of at least 20 mmHg systolic or 10 mmHg diastolic within three minutes of moving to an upright position. Management is immediate: recline the client or lower the head of the bed, elevate the lower extremities, and let the pressure recover before resuming. Prevention includes abdominal binders and compression stockings applied before sitting up, graded upright tolerance using a tilt-in-space chair or tilt table, adequate hydration, and slow staged position changes.
3. Laboratory Values That Change the Session
These are the thresholds most widely cited in acute-care rehabilitation practice. They are clinical guidelines, not standing orders — the facility protocol and the physician's clearance always govern, and values must be read as a trend against the client's recent baseline rather than as an isolated number.
| Laboratory Value | Typical Reference Range | Commonly Used Activity Guidance |
|---|---|---|
| Hemoglobin | Men 14–17.4 g/dL; women 12–16 g/dL | Above 10: activity as tolerated. 8–10: light exercise and ADL with close symptom monitoring. Below 8: essentially bed-level or light activity only; consult the physician. Expect tachycardia, dyspnea, and pallor at low values |
| Hematocrit | Men 42–52%; women 36–48% | Below about 25%: hold or restrict to essential light activity pending medical clearance |
| Platelets | 150,000–450,000/µL | Above 50,000: resistive exercise permitted. 20,000–50,000: light activity and active range of motion, no resistance, no aggressive passive stretching. Below 20,000: therapy typically held or limited to gentle active range of motion; spontaneous bleeding risk |
| White blood cells | 4,500–11,000/µL | Low count with fever: hold. Neutropenic precautions (mask, meticulous hand hygiene, no fresh flowers or produce in the room) when the absolute neutrophil count is severely depressed |
| International normalized ratio (INR) | About 0.9–1.1 untreated; therapeutic 2.0–3.0 on warfarin (higher for some mechanical valves) | Above 5: high bleeding risk — avoid resistive exercise, aggressive passive range of motion, and any activity with fall or impact potential; consult the physician |
| Blood glucose | 70–99 mg/dL fasting | Below 70: hypoglycemia — treat before activity. Above 250 mg/dL with ketones, or above roughly 300 mg/dL, is a reason to withhold exertion |
| Potassium | 3.5–5.0 mEq/L | Values below about 3.0 or above about 6.0 carry arrhythmia risk — hold and notify |
| Sodium | 135–145 mEq/L | Marked derangement causes confusion, weakness, and seizure risk |
The 15-15 Rule for Hypoglycemia
If a conscious client's blood glucose is below 70 mg/dL: give 15 grams of fast-acting carbohydrate (4 ounces of juice or regular soda, glucose tablets), wait 15 minutes, and recheck. Repeat if still below 70. Follow with a protein-containing snack if the next meal is more than an hour away. If the client is unresponsive or unable to swallow safely, give nothing by mouth and activate the emergency response.
4. Lines, Drains, and Devices
Before any transfer, account for every attachment. Common items and their constraints:
- Peripheral and central intravenous lines: keep the pump and pole on the same side as the line; never let tubing become taut or trapped under a wheelchair wheel.
- Urinary catheter: the collection bag must stay below bladder level at all times, and the tubing must never be kinked or stretched — a blocked catheter is the single most common trigger of autonomic dysreflexia in spinal cord injury at T6 and above.
- Chest tube: the drainage system stays upright and below chest level; never disconnect or lift it above the insertion site.
- Supplemental oxygen: confirm tubing length before ambulating, and confirm the prescribed flow rate and saturation target.
- Feeding tube: maintain head-of-bed elevation per order during and after feeding to reduce aspiration risk.
- External fixators and drains: these are never used as handholds for transfers.
5. Integrating Surgical and Psychiatric Precautions
Domain 2 groups these with vital signs and laboratory values because they belong to the same pre-activity screen.
| Precaution Set | Core Restrictions |
|---|---|
| Posterior total hip arthroplasty | No hip flexion beyond 90°, no internal rotation, no adduction past midline |
| Anterior/anterolateral total hip arthroplasty | No hip extension, no external rotation, no adduction past midline |
| Sternal precautions after median sternotomy | Restrict pushing, pulling, and lifting (commonly limited to about 8–10 lb) and avoid unsupported bilateral shoulder abduction/flexion above shoulder height for the healing period; use the "hug a pillow" cough technique and log-roll to rise |
| Spinal precautions after fusion | No bending, lifting, or twisting; log-roll technique; brace as prescribed |
| Skin graft | Immobilize the grafted part 3 to 5 days before initiating gentle active range of motion |
| Suicidal ideation | Any endorsement of self-harm is a life-safety emergency: do not leave the client alone, remove accessible means, and notify the psychiatric and nursing team immediately |
The reasoning rule that resolves most of these items: when a stem gives you a number — a blood pressure, a saturation, a platelet count, an international normalized ratio — the keyed answer is almost never "continue the activity as planned." It is either modify the activity to match the physiological reserve or stop and notify. Choose "continue unchanged" only when the value is genuinely within normal limits.
An occupational therapist is performing standing grooming with a client three days after a coronary artery bypass graft. The client's resting blood pressure was 128/76 mmHg. Two minutes into the task the client's blood pressure reads 104/70 mmHg and the client reports feeling "a little washed out." What is the MOST appropriate interpretation and action?
An occupational therapist reviews the morning laboratory results for a client with acute myelogenous leukemia before an ADL session. The platelet count is 16,000 per microliter and the hemoglobin is 9.2 grams per deciliter. Which intervention plan is MOST appropriate?
An occupational therapist is preparing to complete a shower transfer with a client who has a C5 complete spinal cord injury and an indwelling urinary catheter. Which action is MOST important immediately before initiating the transfer?