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Vital Signs in the Ambulatory Setting:An Evidence-Based Approach

Cecelia L. Crawford, RN, MSN

Project

Overview

The Importance of Vital Signs

Foundation of clinical assessmentBasis for many clinical decisionsAccuracy of VS

Influences the patient’s clinical course Impacts patient outcomes

Therefore, VS should be based on evidence, rather than ritual, routine, & tradition!

Frequency of Vital Signs

Trends more important than any single measurement

Should NOT be used as a method of ensuring Health Care Worker (HCW) visits

Standardize methods of VS measurement

Frequency of Vital SignsVS parameters do NOT guarantee normal physiological status

Have VS become routine & unrelated to patient needs?

Is visual observation more important than routine VS?

Couple visual patient observation with VS

The HCW & Vital SignsImportance of communication

What happens to VS data after it is collected is as important as the accuracy of the VS themselves!

Educational programs CAN improve HCW vital sign measurement techniques

The HCW & Vital Signs

HCW has a definite influence on VS

SpeechTouchPhysical presence

The HCW & Vital Signs

Most influence seen with auscultated blood pressure

White coat HTN may contribute 20% towards misdiagnosis of Stage 1 HTN Higher BPs in clinic/work settings

Vital Sign Technology

Automated machines Electronic/infrared

thermometers BP & Pulse Oximetry Convenient May save time & labor

not confirmed by current studies

Vital Sign Technology

Noninvasive Automatic BP is the most favored method

Reduction in measurement errors

Standardized & calibrated device vs. many HCWs & different techniques

Vital Sign Techniques & Methods:An Overview

TemperaturePulseRespiratory RateBlood Pressure

Pulse Oximetry (5th VS)

Temperature

Glass Thermometers Associated with adverse

eventsRectal/oral traumaMercury exposure

Axillary Temps Great variation with no

“norm” found

TemperatureOral Temps

Position oral thermometers in left or right sublingual pockets

NOT influenced by breathing patterns

IS influenced by hot & cold fluids

TemperatureTympanic Thermometers

Can be affected byExtremes in environmental tempsLocalized heating/cooling measures

Ear tug positively affects accuracy Impacted cerumen adversely

influences accuracy

Temperature

Tympanic Temps - Patient Perceptions

Parents prefer re: speed, ease, cleanliness, & safety

Peds patients reacted more positively

Pulse

Count for 60 sec

Count for 30 sec and multiply X2 Shorter time counts = inaccurate data

•PulseApical pulse via stethoscope

Abnormal pulse Difficult to palpate pulse

Pulse rates via automatic devices not discussed in the literature, but often used in the clinical practice setting

Respiratory Rate

Count for 60 sec

Count for 30 sec and multiply X2 Shorter time counts = inaccurate data

Respiratory Rate

Pediatric patients If panting, use

stethoscope to count

Agitation can result in inaccurate RR

Respiratory Rate

RR is NOT a reliable screen for oxygen desaturation states!

RN and MD assessment is needed

Blood Pressure

Use a consistent & standardized method to minimize inaccuracies

Machine or auscultation Functional & calibrated

machine Korotkoff’s sounds Properly trained HCWs

Blood PressureProcedure (Any Method)

Upper arm properly supported at

level Proper arm cuff size Patient sitting & at rest for 5

minutes Back supported, legs uncrossed No talking or gestures by patient

or HCW Repeat BPs – 2 minutes apart

Blood PressureWhat if a BP cannot be obtained?

What if the cuff doesn’t fit?

What if a right-sized cuff isn’t available?

HCW should consult with RN or MD for all troubleshooting issues

Pulse Oximetry

Possible consideration as the 5th VS

Use in situations where patient assessment & monitoring is critical

VS – It’s All About The Numbers!

Terminal Digit PreferenceHCW may show a preference for certain numbers in

Pulse, Respirations, & auscultated BP readings* Zeros, even numbers, odd numbers Research study on BP revealed 99% of auscultated SBP/DBP

readings ended in zero, demonstrating lack of adherence to AHA recommendations*

HCW should be aware of this possible tendency

(*Roubsanthisuk, W., Wongsurin, U., Saravich, S., & Buranakitjaroen, P., 2007)

Final Thoughts on VS

Tempting to view VS as a routine & static piece of data

VS are fluid, dynamic, & ever-changing, just like our patients!

Final Thoughts on VS

Crucial Vital Sign Decisions Base on the Evidence! Equipment & Technology Technique & Methods HCW Education & Training Frequency Protocols

Influences P&Ps & Clinic Setting (and visa versa!)

Final Thoughts on VS

HCW Education & TrainingVS Accuracy & Communication of DataCompetenciesAnnual Review of Skills

Recommendations - Equipment

Automated BP devices (Welch-Allyn)

Vital Sign MonitorTympanic thermometers

(Kendall Healthcare) Genius tympanic thermometer

Recommendations – Reference Texts

American Academy of Ambulatory Care Nurses (2006): Core Curriculum of Ambulatory Care, 2nd Ed., Elsevier

Perry & Potter (2006): Clinical Nursing Skills & Techniques, 6th Ed., Mosby

Perry & Potter (2006): Skills Performance Checklists: Clinical Nursing Skills and Techniques, 6th Ed., Mosby

Recommendations - Procedure

Base Policy & Procedures on AAACN Core Curriculum and Perry & Potter

Use AAACN Core Curriculum and Perry & Potter as a daily clinical reference

Checklists to instruct and validate clinical competence & skills

Personal Stories Make it Real!

Use real life stories to illustrate how the proper use of vital sign equipment can

positively impact the care of your patients…

Remember these stories as they happen and pass them along!

Vital Signs ConclusionsAn evidence-based vital sign measurement method provides a foundation for:

Patient-HCW Relationships Patient Assessment Patient Treatment Quality Patient Outcomes

Shift the paradigm from

ritual to science!

ReferencesAmerican Association of Critical Care

Nurses (AACN) (2006). Practice alert: Noninvasive blood pressure monitoring. AACN Newsletter, June 2006, 4-5.

Lockwood, C., Conroy-Hiller, T., & Page, T. (2004). Vital signs: Systematic review. Joanna Briggs Institute Reports, 2, 207-230.

ReferencesPickering, T.G., Hall, J.E., Appel, L.J., Falkner, B. E., Graves, J., Hill, M. N., Jones, D. W., Kurtz, T., Sheps, S. G., & Roccella, E. J. (2005). Recommendations for blood pressure measurement in humans: A statement for professionals from the subcommittee of professional and public education of the American Heart Association council on high blood pressure research. Hypertension, 45, 142-161.

References

Roubsanthisuk, W., Wongsurin, U., Saravich, S., & Buranakitjaroen, P. (2007). Blood Pressure Determination By Traditionally Trained Personnel Is Less Reliable And Tends To Underestimate The Severity Of Moderate To Severe Hypertension. Blood Pressure Monitoring, 12 (2), 61-6.

ReferencesSchell, K., Bradley, E., Bucher, L., Seckler, M.,

Lyons, D., Wakai, S., Bartell, D., Carson, E., Chichester, M., Foraker, T., & Simpson, K. (2006). Clinical comparison of automatic, noninvasive measurements of blood pressure in the forearm and upper arm. American Journal of Critical Care, 14(3), 232-241.

Thomas, S. A., Liehr, P., DeKeyser, F., Frazier, L., & Friedmann, E. (2002). A review of nursing

research on blood pressure. Journal of Nursing Scholarship, 34, 313-321.

For more information:

Cecelia L. Crawford, RN, MSNProject Manager for Evidence-Based

Nursing PracticeSo. Calif. Nursing Research Program626-405-5802Cecelia.L.Crawford@kp.org