Vital Signs Get No RespectBy Carol Moore PhD, ARNP, CNS and Linda Sanko MS, MN, RN

IntroductionThe skills of obtaining accurate vital signs have disinte-

grated to a routine task without regard to the significance ofthe results. If vital signs could speak, they would echo Rod-ney Dangerfield's lament "I can't get no respect." Hence, thereliability of what is recorded in the patient's chart is suspect.The results of vital sign measurements are a prime consid-eration in making a diagnosis or determining a plan of care.How confident are you that the information in your medicalrecord is accurate?

Statement of the ProblemIt began as a coffee break conversation, concern about

the frequency of incorrect techniques noted in obtaining vi-tal signs. What the authors found during the literature re-view is disturbing. The number of articles written about thenonchalant manner of obtaining vital signs is staggering. Itis obvious that the profession is lacking vital sign account-ability—there is no sugar-coating the negligence apparentin these incidents that occurred in Kansas and beyond herborders.

The individuals from these examples represent a widevariation in educational preparation (medical/nurse techni-

WICHITA STATEUNIVERSITYCOLLEGE OFHEALTH PROFESSIONS

School oj Nursing

1845 FairmountWichita, KS 67260-0041

(316)978-3610(800)516-0290www.wichita.edu/nurs

Bachelor of Science in Nursing• BSN (Traditional, Early Admission, and Accelerated Option). LPN to BSN. MICT to BSN• RN to BSN On-line Program

Master of Science in Nursing• RN-BSN to MSN Dual/Accelerated• Clinical Nurse Specialist (Adult Health & Illness)• Nurse Midwifery (in collaboration with KU)• Nurse Practitioner (Acute Care, Family, Pediatrics,• Psychiatric/Mental Health)• Elective Sequence in Nursing Education

Doctor of Nursing Practice• Post Baccalaureate Entry or Post Master Entry• Individual/Family Focus (includes NP or CNS specialization area)

Innovation and Excetience in Nursing Education

dans, LPNs, ADNs, BSNs, and a graduate student studyingto become an FNP).

The most common, deflating the blood pressure (BP)cuff too rapidly. The rate of deflation should be 2-3mmHg per second.Placing the BP cuff over clothing, sometimes bulkyclothing, or pushing up the sleeve and it becomes con-strictive.Overinflating the BP cuff, over 200 mmHg when thepatient has a documented history of systolic pressureof 140 mm Hg.Reinflating the BP cuff for repeat measurements with-out waiting 30-60 seconds or pumping the cuff back upwithout completely deflating first.Placing the stethoscope head on the cuff tubing to takethe measurement (done in the ER)Overheard in a teaching situation, "the bell of thestethoscope is used for children, the diaphragm is foradults."Respirations not obtained for cardiac patients duringoffice visits.Radial pulse taken by placing the thumb on the radialpulse site in a cardiologist's office (occurs repeatedly).

Radial pulse obtained with patientdiagnosis of atrial fibrillation and brady-cardia.

Vital signs obtained immediately afterbeing seated in the exam room.Literature records incidents of dis-

cipline and litigation for the inaccuratetaking of vital signs and for not taking orrecording vital signs. The first case is asituation of the RN not knowing how touse the equipment, failing to seek assis-tance although a visual assessment clear-ly indicated the patient was in trouble.The patient collapsed before she calledthe physician. Subsequent investigationdiscovered the RN's recordings of manyother patients' vital signs were inaccurate.She was warned about her conduct andsent to a special training course to cor-rect/improve her technique (Castledine,2006).

The second case, one that ended inthe court system, was based on an ab-sent record of vital signs and the patientdeath due to internal hemorrhage from aMVA. He was treated for two hours in theER before expiring, the medical recordsdid not indicate the ER nurse obtainingvital signs although she testified she had

continued on page 4

Vol. 85, No. 5 July-August 2010 The Kansas Nurse visit us at www.nursingworld.org/snas/ks 3

Vital Signs Gel No RespectBy Carol Moore PhD, ARNP, CNS and Linda Sanko MS, MN, RN

every 5-10 minutes but recorded them on pieces of papershe placed in her pockets (Gorcey v. Jersey Shore MedicalCenter, 2006).

The patient, an elderly 78 year old gentleman, was ad-mitted with a history of CAD and hypertension after falling athome and fracturing his right arm is an example of treatmentbased on an inaccurately obtain blood pressure. His com-plaints of dizziness, lightheadedness, and being tired all thetime were ignored because his BP readings were elevated.Antihypertensive medication dosages were increased untila student nurse selected the correct sized BP cuff and po-sitioned the arm at the appropriate levelto obtain his vital signs. Results of a cor-rectly obtained reading, and verification bythe nurse and instructor, revealed a verylow blood pressure (Tomlinson, 2010).

DiscussionVital signs are termed cardinal signs

because they represent the homeostaticbalance of the human body. The assess-ment that accompanies obtaining vitalsigns should be recognized by the nurseas an activity high on the list of priorities.

How do nurses obtain correct assess-ment data? Vital signs include temperature, pulse, respira-tions and blood pressure. These basic skills are the toolsnurses have to assess a person's health status. Measuringthe vital signs accurately provide insight to the patient's phys-iological status. A recent article by Rauen, Chulay, BridgesVollman and Arbour (2008) state "About 30% to 40 % of pa-tients do not receive care consistent with current scientificevidence Are we doing what is the best for our patient withthe current evidence available to us." (p. 118).

Medical care and prescriptions, and nursing care arebased on the results of vital sign measurements. Inaccuratedata leads to inappropriate treatments. It is unprofessionalto use the "Jewish Mother" method of obtaining the tempera-ture—placing the hand on the forehead and estimating (Stre-ger, 2000). Accurate measurable techniques to determinethe patient's temperature is the standard. Hyper/hypother-mia each present with specific indicators and in the schemeof things, the temperature may be that one significant clue toan impending crisis.

Atrial fibrillation is the most common cardiac dysrhyth-mia and is associated with uncontrolled elevated systolicblood pressure (Madoc-Sutton, 2009). Atrial fibrillation is animportant risk factor for stroke, therefore obtaining an apicalpulse is paramount as it is often symptomless. The NationalInstitute for Health and Clinical Excellence states that healthprofessionals are in an ideal position to screen for this condi-tion when taking vital signs, particularly the pulse and bloodpressure. They go on to recommend that an electrocardio-gram be performed to confirm the diagnosis.

The assessment data obtained when taking vital signsshould not be taken for granted. Measurement of the vitalsigns is a quick and easy method of monitoring the patient'scondition, identifying problems and evaluating the patient'sresponse to intervention. The assessment data obtained isa critical part of clinical problem solving.

Numerous factors must be considered when taking apatient's blood pressure.

Medications the patient is takingPosition of patient (seated, arm and body position, legsuncrossed)

• Noise levels in the area• Temperature extremes• Clothing worn by the patient (arm

free of constrictive clothing, sup-ported anticubital fossa at appropri-ate level)

• Properly functioning equipmentWhite-coat effect

• Proper BP cuff length or width• Proper placement of the BP cuff• Proper inflation and deflation of BP

cufff • Length of time between taking

BP readings and eating, exercising,and smokingNeglecting to palpate pulse for pulse regularity and toestimate SBPPatient anxietyAttitude of person taking the blood pressureNolan and Nolan researched the nurses' understanding

of the basic principles of taking and recording a blood pres-sure. The intent of the study was to make nurses aware ofthe value of research, but the results demonstrated nurses'inability to obtain accurate BP measurements. The resultsof the 20 item questionnaire revealed the majority of the 65nurses taking the survey scored between 7 and 9, indicatinga limited knowledge regarding sources of error when tak-ing a BP. All nurses participating in the study indicated theywere proficient in the skill of taking a BP. Readers who com-plete the questionnaire may compare their answers in thenext issue of The Kansas Nurse.

Can Nurses Take an Accurate Blood Pressure?

1. Before taking a routine measurement how much timeshould be allowed to elapse after the patient has:(a) Eaten, (b) Exercised, (c) Smoked

2. For how long before taking a BP reading should thepatient be advised to sit and relax?

3. What is the recommended service interval for thesphygmomanometers?

4. On average, what percentage of sphygmomanometersdo you think are accurate?

4 visit us at www.nursingworld.org/snas/ks The Kansas Nurse July-August 2010 Vol. 85 No. 5

vital Signs Get No RespectBy Carol Moore PhD, ARNP, CNS and Linda Sanko MS, MN, RN

5. To the best of your knowledge when was the last timethat the sphygmomanometers on your ward/unit wereserviced?

6. If someone were to ask you, what would you say werethe upper limits of a normal BP in a healthy youngadult? (a) Systolic (b) Diastolic

7. Using a cuff which incorporates a bladder which istoo small for the arm (too short, too narrow or both) islikely to result in: (a) An underestimation of BP, b) Anoverestimation of BP, or (c) It makes no difference.

No one should underestimate the power ofaccurately obtained vital signs and the con-sequences of appropriate interpretation ofthose results.

8. Most modern BP cuffs contain a bladder which doesnot completely encircle the arm. When using such acuff it is still possible to take an accurate reading pro-viding the cuff is positioned so as to ensure that. . .

9. What is the suggested time required to take and recordan accurate BP reading?

10. How high (in mmHg) should the cuff be inflated abovethe palpated systolic pressure?

11. What is the suggested maximum distance that thenurse should be from the sphygmomanometer whentaking a BP?

12. The best way to ensure an accurate BP reading is to:(a). Inflate the cuff quickly and deflate it slowly, (b) In-flate the cuff slowly and deflate it quickly, or (c) Inflateand deflate the cuff at roughly the same speed.

13. What is the recommended speed (in mmHg/second) atwhich the cuff should be deflated?

14. When taking a BP it is important to ensure that theantecubitalfossa is level with . . .

15. Ina healthy patient, providing the arm is positionedcorrectly, there should be little or no difference be-tween the BP when lying, sitting, or standing? (a)True (b) False

16. Rushing the procedure and taking a BP too quickly islikely to result in: (a) An overestimated systolic andunderestimated diastolic reading, (b) An underesti-mated systolic and overestimated diastolic reading,(c) Roughly equal errors to both systolic and diastolicreadings.

17. Patients who have their BP taken while their legs arecrossed are likely to have a recording which is: (a)Falsely low, (b) Falsely high, (c) It makes no differ-ence

18. Approximately how much gap should be left betweenthe bottom of the cuff and the antecubitalfossa?

19. When using a mercury sphygmomanometer it is pos-

sible to record the BP to the nearest (a) 10 mmHg, (b)5 mmHg, (c) 2 mmHg, or (d) 1 mmHg.

20. In a normal healthy adult the most accurate point atwhich to record the diastolic pressure is: (a) When thesounds muffle, (b) When the sounds disappear, or (c)The two are so close it doesn't really matter.

21. Bonus: Critique the photo on the cover based on theinformation in this article, listing the right/wrong tech-niques of obtaining a BP reading.

Figure 1. From "Can nurses take an accurate blood pres-sure?" by J. Nolan and M. Nolan, (1993) British Journalof Nursing. 2(14), pp 724-729. Reprinted with permissionfrom the authors.

Data indicate that professional nurses may not take aBP accurately. Unfortunately, the "task" of taking vital signsis frequently delegate to the lowest paid and least educatedmember of the nursing staff. Hence, the reading obtainedbecomes just a number without regard to the quality charac-teristics that the number represents. Accuracy of the num-ber is also suspect given the technique utilized in obtainingthe reading. The professional nurse is responsible for as-sessing the skill and competency of the adjunct nursing staff.There are certain basic physical requirement competenciesthat are required. The first competency is vision. The dial ofthe monometer or meniscus of the mercury column must beat eye level and dearly seen by the observer without strain-ing or stretching. The second competency is hearing. Theobserver must be able to hear the appearance and disap-

"Measuring blood pressure is a complextask, requiring careful work to avoid ob-server error, instrument error and to mini-mize individual variations."

pearance of the Korotkoff sounds. The third competencyis eye/hand/ear coordination. The observer must be ableto manipulate the equipment at the same time as listing tosounds and visually reading the equipment (Pickering et al.,2005).

Patients who suffer an adverse event (AE) are morelikely to suffer permanent disability or die. Many of theseAEs are preventable and nurses have long played a pivotalrole in their prevention. The ongoing physiological assess-ment of patients is a nursing responsibility and these as-sessment findings by nurses underpin many patient caredecisions. Early recognition and correction of abnormalitiescan improve patient outcomes (Nolan & Nolan, 2004). Noone should underestimate the power of accurately obtained

continued on page 6

Vol. 85, No. 5 July-August 2010 The Kansas Nurse visit us at www.nursingworld.org/snas/ks 5

Vital Signs Get No RespectBy Carol Moore PhD, ARNP, CNS and Linda Sanko MS, MN, RN

vital signs and the consequences of appropriate interpreta-tion of those results. No one should underestimate the im-portance of using properly functioning equipment to obtainvital signs. The use of an inaccurate sphygmomanometer isa blatant violation of professional duty and acting in a non-ethical manner. These healthcare workers could be sued fornegligence by patients who believe the use of malfunction-ing equipment had adverse consequences for their health(Plante, 2005).

McKay, (2008) discussed the differences and benefitsof the auscultation and oscillometry methods of taking aBP and whether the cuff should be used on a bare arm orsleeved arm. The results were inconclusive. The authorsuggested using the auscultation method with bare arm untilmore evidence was obtained.

Madoc-Sutton, Pearson and Upjon (2009) conducted astudy of nurses who measured BP with an electronic devisewho also palpated the pulse. The conclusion indicated thatone quarter of nurses surveyed did not take a pulse, thusmissing the assessment of atrial fibrillation or other dysrhyth-mias.

ConclusionA patient's needs and condition determine when, where,

how and by whom vital signs are measured. It is importantthat the nurse is able to measure the vital signs correctly,understand and interpret the values, communicate the find-ing appropriately and begin intervention if needed.

There must be an attitude adjustment—this ability to obtain vital signs correctly isnot "high tech stuff" but high level cognitivefunction!

The ability to use appropriate skill when taking a BP andcorrectly recording and analyzing the data continues to bea problem. Technology may be helpful, but evidence ques-tions the accuracy of the reading. Recommendations in theliterature indicates that the skill of taking a BP and other vi-tal signs should be evaluated on a regular basis and be in-cluded as part of a competency check-off (Tomlinson, 2010).She goes on to state that "accuracy when assessing bloodpressure has a profound effect on the medical managementdecisions and nursing care that directly impact the patient'sability to achieve positive health outcomes" (p. 94). Measur-ing blood pressure is a complex task, requiring careful workto avoid observer error, instrument error and to minimize in-dividual variations" (Noland & Nolan, 1991, p. 729).

"In an era in which medical technology abounds and re-search explores myriad pathways, it is ironic that BP moni-toring is still the most effective indicator of life expectancy.

Taking the BP seems a simple task, yet it is one of greatmedical importance" (Plante, 2005, p. 35).

There must be an attitude adjustment—this ability to ob-tain vital signs correctly is not "high tech stuff' but high levelcognitive function! It is time to finesse the skills learned inFundamentals of Nursing class and incorporate pathophysi-ology and assessments skills to the interpretation and evalu-ation of what the vital signs indicate. There are absolutely noexcuses for this shabby nursing care. The profession votedmost trusted should not tolerate this lack of accounability topatients and colleagues.

ReferencesCastledine, G. (2006).The importance of measuring and record-

ing vital signs correctly. British Journal of Nursing, 15(5).Considine, J., & Botti, M. (2004). Who, when and where? Iden-

tification of patients at risk of an in-hospital adverse event:Implications for nursing practice. International Journal ofNursing Practice. 70:21-31.

Gorcey v. Jersey Shore Medical Center, 2006 WL 533379 (N.J.Super., March 6, 2006).

Foster-Fitzpatrick, L., Ortiz, A., Sibilano, H., Marcantonio, R., &Braun, L. T (1999). The effects of crossed legs on bloodpressure measurement. Nursing Researc/i.March/April,(2)48.

Madoc-Sutton, H., Pearson, E, & Upton J. (2009). Pulse checkas a screen for atrial fibrillation. Practice Nursing. 20{6).

McKay, D. (February 26, 2008). Measuring blood pressure: Acall to bare arms? Canadian Medical Association Journal.178(5).

Nolan, J., & Nolan, M. (1993). Can nurses take an accurateblood pressure? British Journal of Nursing. 2(19) 724-729.

Martin, B. (April 2010). Noninvasive blood pressure monitoring.AANC Practice Alert.

Potter, P., Perry, A., Stockert, P., & Hall, A. (2010. Basic Nurs-ing, (7th ed.). St. Louis, MO: Mosby Elsevier

.Pickering, T G., (2002). Principle and techniques of blood pres-sure measure measurement. Cardiology Clinics.(20)207-223.

Pickering, T G., et al. (2005). Recommendations for blood pres-sure measurement in humans and experimentalanimals; Part I blood pressure measurement in humans.Hypertension. 45:142-161.

Plante, C. (2005).Blood pressure measurement: Aworthy tech-nique for nurses! Outlook. 28(2).

Rauen, C, Chulay, M., Bridges, E., Vollman, K., & Arbour, R.(2008). Seven evidence-based practice habits: putting somesacred cows out to pasture. Critical Care Nurse. 28(2).

Streger, M. (2000). Back to basics: Taking accurate vital signs.Emergency Medical Sen/ices. 29(8) 2000.

Tomlinson, B. (March/April 2010). Accurately measuring bloodpressure: Factors that contribute to false measurements.Medsurg Nursing. 19(2).

6 visit us at v(Aww.nursingworld.org/snas/ks The Kansas Nurse July-August 2010 Vol. 85 No. 5

Vital Signs Get No RespectCarol Moore PhD, ARNP, CNS &

Linda Sanko MS, MN, RN

Carol Moore PhD, ARNP, CNS is an Assistant Professor of Nursingat Fort Hays State University. She received the BSN from EasternIVIennonite University, a Masters degree in nursing from WichitaState University, and a PhD in Education from Kansas State Uni-versity. She is the Coordinator of Graduate Studies in the NursingDepartment at FHSU and teaches graduate nursing courses.

Linda Sanko, MS, MN, RN is an Assistant Professor of Nursingat Fort Hays State University. She graduated from Fort Hays StateUniversity with a BSN and a Masters degree in education and aMasters degree in nursing from the University of Kansas. She hastaught nursing at ail levéis, LPN, BSN and Graduate ievel nursingcourses.

NOW AVAILABLE TO ORDERAT DISCOUNT ON THE KSNA WEB SITE

www.nursingworld.org/snas/ks

Springer Publishing Company is pleased toannounce the publication of:Florence Nightingale's Notes on Nursing &Notes on Nursing for the Labouring ClassesCommemorative Edition with HistoricalCommentary

Victor Skretkowicz, PhD, EditorMay 2010 - Hardcover, 6 x 9 ,

Stamped cover with gilded pages and ribbon488 pages - $40 - 978-0-82621-1842-4

In this new edition, marking the centenary of Florence Nightingale'sdeath. Notes on Nursing: What It Is and What It Is Not appears inits original form for the first time since it was published in 1860.Together with the 1868 version of Notes on Nursing for the Labour-ing Classes and the additional material in the appendix, it providestoday's educated readership with the nearest possible "authorita-tive, complete and unexpurgated" version of one of the best sell-ing, globally circulated, texts of the Nineteenth Century.

SCOTT aXMYHOMALLeading You To A Healthy Future

Scott County Hospital isseeking a

Director of Nursing

This is a full time salaried positionthat works closely with the ChiefClinical Officer and is responsible forthe staff development and supervisionof the nursing staff. Applicants mustpossess excellent interpersonal skillsto function well in a team settingwhile striving to promote a positiveand supportive work atmosphere. Theideal candidate will have a Bachelor'sDegree or higher in Nursing, a currentKansas R.N. License, five or moreyears of clinical nursing experienceand 2 years or more years of nursingmanagement experience. Must beBLS certified and be willing to obtaincertification in ACLS, PALS, NRP,and TNCC. Scott County Hospital isa 25 bed CAH located in Scott City,a progressive Western Kansas com-munity of 4000 which is currentlypreparing to build a new replacementhospital. Excellent benefit package isoffered with position. Pre-employ-ment physical, drug/alcohol screen,and TB skin test required. SCH is atobacco free facility. Applicationsavailable through Human Resources,Scott County Hospital, 310 East 3^^Scott City, KS, 67871, (620) 872-7796.

Scott County

2010All-America City Finalist

Vol. 85, No. 5 July-August 2010 The Kansas Nurse visit us at www.nursingworld.org/snas/ks 7

Copyright of Kansas Nurse is the property of Kansas State Nurses Association and its content may not be

copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written

permission. However, users may print, download, or email articles for individual use.