Correctional Nurse Self-Care: Preventing Compassion Fatigue

Upset nurse sitting on the floor in hospital wardEven those of us who love correctional nursing know it is a tough specialty. Earlier posts discussed the reasons we need to take care of ourselves, and the issues of secondary traumatization and moral distress. This last post in the Correctional Nurse Self-Care series is about compassion fatigue.

Although some sources consider compassion fatigue and secondary traumatization to be similar concepts, they have different root causes. Secondary trauma comes from absorbing the stress of the traumatic experiences of our patients. It is a taking upon ourselves the weight of another’s past and present life experience and feeling the physical, psychological, and emotional results. Compassion fatigue, on the other hand, is the giving of ourselves to others to the point of depletion repetitively without adequate recovery. The combination of secondary trauma, moral distress, and compassion fatigue can be a deadly cocktail for correctional nurses. Self-care intervention is needed to maintain a healthy equilibrium.

Totally Drained

Compassion fatigue results from the chronic use of empathy in nurse-patient relationships. Correctional nurses battle to stay in the zone of helpfulness while not leaning toward over-involvement or under-involvement with the incarcerated patient population. Maintaining a therapeutic relationship can be draining. We are alternately guarding against being drawn into manipulation on one end of the helpfulness continuum while avoiding becoming jaded to patient needs on the other end.

The key to minimizing compassion fatigue may be in modulating the two elements of empathy and engagement for optimum functioning. Both are necessary for a meaningful nurse-patient relationship, but in balanced and appropriate doses.

Besides the dynamics of the nurse-patient relationship, our environment of care delivery also influences levels of compassion fatigue. The following organizational factors, all prevalent in the correctional health care environment, have been implicated as contributing to compassion fatigue.

  • Bureaucratic constraints
  • Inadequate supervision
  • Lack of available resources
  • Lack of professional colleague support

Preventive Measures

Self-knowledge. As nurses, we know that “an ounce of prevention is worth a pound of cure” for our patients. Unfortunately, we don’t always apply the principle to our own well-being. Going back to the idea of a self-care plan addressed in an earlier post, a first intervention may be gaining knowledge and self-knowledge about your current state of empathy and engagement with your patients. Take stock of where you are on the helpfulness index. If you find yourself over-involved, you may be headed toward compassion fatigue and need to realign. On the other hand, you may have already over-corrected your empathy and engagement and are now under-involved with your patients in order to protect yourself from further compassion fatigue.

Self-care. Basic self-help principles are necessary – even for super nurses! Be sure your schedule includes adequate rest and relaxation. Positive connection with friends and family can help maintain balance. Get some physical exercise. Practice spiritual rituals that are satisfying to you such as prayer, meditation, readings, or service. All of these activities have been found to buffer the effects of compassion fatigue.

Recharge the Battery

Sometimes a serious intervention is necessary. This is especially true if you are going through a season of battery overload and spiking need for emotional reserve. There are times when even the standard self-care activities cannot keep up.

Fellow nurse, Elizabeth Scala, over at Nursing from Within, is running an Art of Nursing program in May that can help recharge your correctional nurse battery.

Art of Nursing

Click here to view more details

How do you manage compassion fatigue? Share your tips with our readers using the comments section of this post.

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Correctional Nurse Self-Care: Are You Carrying the Heavy Burden of Moral Distress?

Kiko con cajaRecently I traded in my clunky 2009 laptop for a new streamlined model. It wasn’t until my first journey with this new laptop that I realized just how heavy my old version was. Now I have a good idea why my shoulders ached after a long day of traversing airports for gate changes while running to make the connection with computer bag in tow.

Moral distress can be like that – a heavy weight on your shoulders that has been slowly building as you work in the criminal justice system. You may not even notice the developing distress until something snaps. Correctional nurses need to monitor moral distress and seek morally satisfying solutions to the ethical dilemmas encountered in day-to-day practice.

What’s in a Name?

The first step in solving moral distress is to identify it. Moral distress has been defined as knowing the right action to take, but being constrained from taking it. In its simplest form, then, moral distress in correctional nursing may be knowing that a patient should be able to make a health decision autonomously but seeing that they are being forced to make that decision against their will.

However, researchers in moral distress among nurses add to this definition in important ways. Nurses are often confronted with an ethical dilemma where the course of action best for the patient is in conflict with what would be best for others; whether it is the organization, other providers, other patients, or society. So, the interior world of the nurse that identifies who they are as a professional is in conflict with the exterior world of the work environment and work team. This is what leads to the distress that can be strongly felt by a nurse.

Moral distress is when:

  1. A nurse is involved in or aware of a situation that calls for a moral action.
  2. Is obstructed from taking that moral action.
  3. Experiences negative feelings because that action was not taken.

I hear of many examples of moral distress among correctional nurses in my various interactions. Intentional bias, poorly staffed medical units, or obstruction from officers or leadership can lead to treatment delays, unrelieved pain, or gaps in care management. Conscientious nurses absorb the stress of longstanding unethical treatment.

The Grimy Build Up of Moral Distress

Absorbing moral stress over time leads to a grubby film that builds up in our nursing souls and affects our emotional, psychological and physical well-being. This has been defined as ‘moral residue’ and is particularly intense when injury to a nurse’s moral integrity is repeated over time. In a correctional setting, a nurse may see the ‘take down’ of mentally ill inmate multiple times over months of practice and have a ‘here we go again’ response to the moral wound caused by seeing this action and feeling unable to do anything about it.

Identifying Moral Distress

Although nurses cannot always name the feeling, most of us know what it is like to be in moral distress. We feel powerless, anxious, and unhappy. Moral residue can lead to typical stress-related symptoms such as nausea, insomnia, and headaches. It can cause us to seek other employment or even leave the profession. When these feelings are present, it is important to seek the source of discontent. It may be the weight of long-standing moral distress.

Seeking a Good Response

Nurses can also feel belittled or unimportant in morally distressing situations. It is easy to experience isolation if we do not feel supported in talking about the morally injuring situations around us. Yet, talking to a supportive colleague is an important action to help identify and clarify moral distress.

Critical care nurses also often find themselves in a morally distressing situation. The American Association of Critical Care Nurses (AACN) developed a 4 step process to help nurses address and reduce moral distress.

STEP ACTION
ASK Ask yourself if what you are feeling is moral distress. Are others exhibiting signs of moral distress, as well?
AFFIRM Affirm your feelings and consider what aspect of your moral integrity is being threatened.
ASSESS Objectively analyze the situation and what the ‘right’ action would be. Consider what is currently being done, who the players are, and your readiness for action.
ACT Create a plan of action considering any pitfalls and strategies to overcome them.

Have you had to deal with moral distress in your correctional nursing practice? Share your experience with our readers using the comments section of this post.

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Correctional Nurse Self-Care: Wear That Secondary Trauma Protective Gear!

Firewoman in fire protection suitHave you ever had a patient that really affected you? I still have memories of caring for a severely burned toddler girl in the early 90’s when I was in a clinical rotation for my graduate nursing program in Burns, Emergency, and Trauma. It was an urban teaching hospital and regional burn center and this little girl was pulled from a burning Philadelphia row house. I was swept in to her intense physical pain (burn pain is the worst) and her abusive family history. It affected my personal life, robbed me of sleep, and almost made me physically ill for a time. This experience taught me I wasn’t cut out to be a burn nurse but was also my first experience with secondary trauma.

Secondary Trauma: Patient Trauma Spill-Over

Secondary trauma (also called vicarious trauma) is the experiencing of the trauma of another through their account or indirect exposure to their trauma. A nurse’s mental or emotional ‘reliving’ of the patient’s traumatic experience can then lead to symptoms or reactions similar to post traumatic stress disorder (PTSD).

Our patient population has high levels of trauma in their lives, past and present. For example, many of our patients, especially women, have history of child abuse, domestic violence, or sexual abuse. Military veterans may enter the system with PTSD from combat duty. Inmates have a heavy burden of current trauma while in the criminal justice system. There can be high levels of assault, coercion, and victimization in inmate cultures.

Depending on the type of nursing care you are delivering, this traumatic stress can spill over onto you and be absorbed into your own system; many times without even realizing it. This is why it is important to guard against secondary trauma and take action when you see signs in your own feelings and behaviors.

Monitor for Warning Signs

Here are some common signs of secondary trauma. Watch for them in yourself and those you work with:

  • Anger and cynicism
  • Avoidance of patients
  • Chronic exhaustion
  • Dropping out of normal social activities
  • Fear
  • Hopelessness
  • Hypervigilance
  • Increased family arguments and agitation
  • Sleeplessness

What to Do About Secondary Trauma – Put on Your Protective Gear

In the first post in this series on correctional nurse self-care, I talked about putting on your oxygen mask first before helping others. We also need to put on our protective gear, just like other professionals. Construction workers have hard hats and football players have extra padding and mouth guards. What protective gear do correctional nurses need to work with traumatized patients day after day? Here are some ideas from the National Center on Family Homelessness:

  • Regularly take your stress temperature – do you see signs of stress in your emotional and interactional responses to daily activities? If so, accelerate your protective activities.
  • Make time for regular decompression. This can include reflection, meditation, or physical activities like yoga.
  • Consider the possibility of a change in work assignment, work shift, or work group for a period of time.
  • Seek out employer-offered programs such as employee assistance or an outside support group for those in helper roles like nursing, social work, counselors, or child assistance workers.
  • Take regular meal breaks.
  • Focus on increasing sleep and nutrition.
  • Find things that make you laugh.
  • Spend time with supportive friends.

Just understanding the possibility of secondary trauma and monitoring for signs of increased stress can make a world of difference in your correctional practice. I didn’t understand secondary trauma back in that burn unit rotation years ago. I might have been able to manage it better if I had. Awareness is a powerful thing!

Have you had to deal with secondary trauma in your correctional nursing practice? Share your experience with our readers using the comments section of this post.

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Correctional Nurse Self-Care: Do You Have Your Oxygen Mask On?

Oxygen maskAt one point in my career I was in an airplane for business more than I liked. At that time, I could have probably filled in for the flight attendant in making the required safety announcement. I wish I had been on a flight with the wacky attendant in this video. It might have been more enjoyable!

One direction you will always hear from the flight attendant is to “place the oxygen mask over your own nose and mouth first” before assisting others. Of course, it makes perfect sense that you can’t be very helpful if you can’t breathe yourself! Fire rescue workers must first gear up before entering a burning house to rescue others. Nurses are also in a helping profession yet we can be the worst at following the principles of self-care so we are of benefit to others.

Being a Nurse is Stressful

Nurses, in general, are prone to personal, physical, and emotional stress due to the nature of the profession. Work stress and burn out among nurses has long been identified as hazards of the occupation often overlooked by practitioners themselves. Many environmental and role conditions contribute to work stress such as the long hours, physical labor, and inadequate staffing situations nurses often encounter. In addition, most nurses are in constant contact with human suffering and must maintain interpersonal work and patient relationships in the midst of an often turbulent environment. Added to this can be, in some organizational cultures, bullying and lateral violence among staff such as verbal aggression or incivility.

Being a Correctional Nurse is Especially Stressful

Correctional nurses contend with the added stressors of the correctional environment and patient population. Research into correctional officer stress has shed light on the occupational stressors of correctional nurses, as well. In particular, experts point to the continuing exposure to traumatic stressors in the correctional environment that creates an added burden to workers. This exposure includes actual and potential assault, witnessing and responding to inmate death, and the continual need to be hyper alert to physical harm and psychological manipulation. It is estimated that up to25% of those working in corrections meet criteria for a post traumatic stress disorder (PTSD) diagnosis.

Correctional Nurse Self-Care Plan

Have you ever thought of creating a nursing care plan for yourself? Mental health nurse, Joan Lorenz, suggests this method for stressed nurses. By creating a self-care plan, you can use the familiar nursing diagnoses of our profession to your advantage.  Here are some diagnoses to consider for your personal nursing care plan.

  • Altered nutrition
  • Anxiety
  • Ineffective individual coping
  • Knowledge deficit
  • Spiritual distress

Lorenz rightly suggests that many nurses see caring for themselves as somehow selfish. This attitude definitely needs adjusting! Like a flight attendant instructs “place the oxygen mask on yourself first”. A physically, mentally, and emotionally drained nurse is unable to meet the needs of patients and is unsafe in our risky environment. So, buckle yourself in to a self-care plan that keeps you at full capacity to do your job well!

Fellow nurse, Elizabeth Scala, over at Nursing from Within, is running an Art of Nursing program in May that can add a deep breath of fresh oxygen into your nursing career. Maybe this should be on your personal care plan.

Art of NursingClick here to view more details

How do you take care of yourself in the midst of work stress? Share your tips with our readers using the comments section of this post.

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Vital Signs: How Often and What to Do

ACTION REQUIRED

 

 

Case Example: A nurse sees a 55 year old male inmate at sick call. His sick call request says that he has a sore throat and heartburn. During the nurses’ assessment he has body aches, chills and constipation in addition to the sore throat and heartburn. The patient’s vital signs are T=100, P = 92, R=16, BP=170/100. The patient is seen periodically for treatment of hypertension and his next scheduled appointment is a month and a half from now. The nurse gives the patient milk of magnesia and ranitidine per the nursing protocol for heartburn. The nurse also schedules the patient for ….

What do you think the other parts of the nurse’s plan of care for this patient include? This is the fourth and last of a series of posts about vital signs in correctional nursing practice. Other case examples used in this series have involved urgent or emergent situations. This time the case example takes place during sick call, a non-emergent ambulatory care encounter when a significantly elevated blood pressure is found during the nursing assessment. It raises the question of when and how often correctional nurses should take vital signs?

How often should vital signs be taken? It was interesting to find out while researching for this post that there is no body of evidenced based research to suggest when and how often vital signs should be taken (Storm-Versloot et al. 2014). However the information provided by a complete set of vital signs has been considered valuable in provision of patient care for the last century. Likewise we haven’t needed evidenced based research to know that having a parachute significantly affects survival in the event of a plane crash.

One of the reasons for failure to identify and treat deterioration in patients’ conditions was that vital signs have not been monitored regularly but instead left to nursing discretion. A best practice recommendation is to establish guidelines for when vital signs are to be taken. Expert recommendations applied to correctional health care are to take vital signs as follows:

  • Ambulatory care: At the time health care attention is sought for non-emergent health care concerns. If abnormal, daily thereafter until stable or referred to another level of care.
  • Chronic care: According to nationally established clinical guidelines for the initial work up of the patient’s condition and then according to a plan of care established by the provider individualized to the patient’s needs and goals (National Commission on Correctional Health Care 2014).
  • Emergency care: At the time health care attention is sought for an urgent or emergent health care concern. If abnormal, every 15 minutes until stable or referred to another level of care. If normal, every hour while receiving emergent care (Armstrong, Clancy & Simpson 2008).
  • Inpatient care: On admission to an infirmary or medical observation bed at the correctional facility. If abnormal, every 30 minutes until evaluated by a physician. If initial vital signs are normal, subsequent vital signs should be taken every four hours for the first 24 hours after admission. After the first 24 hours if vital signs are stable and within normal limits, every six hours thereafter (Bunkenborg et. al 2012, Australian Commission on Quality & Safety in Healthcare 2009).

One of our readers asked whether vital signs should be taken as part of the routine screening for placement in segregation. My inclination is that if there was violence or use of force immediately prior to placement in segregation, taking vital signs should be taken as an emergent intervention and be repeated an hour after placement as well. If abnormal then the patient should be referred to a higher level of care and vital signs monitored more closely until stabilized. What do you think?

Taking action when vital signs are abnormal. Another reason for failure to identify and treat deterioration in patients’ conditions was that assistance was not requested or not provided timely (Moldenhauer, Sable & Chu 2009). This has led to the recommendation that health care programs develop “track and trigger” systems. These are procedures which establish expectations for the frequency of vital sign monitoring, set parameters for abnormal findings and specify the actions and timeframes by which subsequent action is to be taken (Berwick, Hackbarth & McCannon 2006). For example criteria such as these trigger a referral for a higher level of medical attention within fifteen minutes at the Denver Health Medical Center:

  • Temperature: greater than 102.2°.
  • Pulse: less than 50 or more than 120 beats per minute.
  • Respiration: less than eight or more than 28 per minute.
  • Blood pressure: systolic blood pressure less than 90 mmHg or a sustained diastolic blood pressure greater than 110 mmHg.
  • Neurologic: confusion, agitation, delirium, lethargy, difficult to arouse, difficulty speaking or swallowing, any acute change in pupillary response (Moldenauer et.al. 2009).

While correctional facilities are not hospitals, they are healthcare organizations and inmates are unable to seek healthcare anywhere but within the program offered at the facility. The health care programs in the Oregon and Georgia Department of Corrections have developed similar protocol for the recognition of and actions taken with regard to patients whose physiologic condition is deteriorating (LaMarre 2006, Puerini 2015).

In closing, the standard for the practice of nurses with regard to patient vital signs is to:

  1. Take and record vital signs frequently
  2. Recognize patient’s physiological deterioration and the urgency of the situation
  3. Summon appropriate assistance
  4. Communicate findings and recommended actions clearly, sensibly and with confidence
  5. Give a deadline for response to the patient care situation (Kyriacos, et. al. 2011).

If you have established parameters for abnormal vital and what action to take will you share your information by replying in the comments section of this post? For more on the professional practice of nursing in the correctional setting get a copy of our book Essentials of Correctional Nursing. If you order directly from the publisher you can get $15 off and free shipping. Use code AF1209.

References

Armstrong, B.P., Clancy, M. & Simpson, H. (2008) Making sense of vital signs. Emergency Medicine 25 (12): 790-791.

Australian Commission on Safety and Quality in Healthcare (March 2009) Recognizing and Responding to Clinical Deterioration: Use of Observation Charts to Identify Clinical Deterioration.

Berwick DM, Hackbarth AD, McCannon CJ. IHI Replies to “The 100,000 Lives

Campaign: A Scientific and Policy Review.” Joint Commission Journal on Quality and Patient Safety. 2006;32:628-630. See also resources for early warning systems on the IHI website.

Dincan, K.D., McMullan C., Mills, B.M. (February 2012) Early warning systems. Nursing 2012 pages 38-44.

Kyriacos, U., Jelsma, J., Jordan, S. (2011) Monitoring vital signs using early warning scoring sytems: A review of the literature. Journal of Nursing Management 19:311-330.

LaMarre, M. (2006) Nursing Role and Practice in Correctional Facilities. In Puisis, M. (2nd Ed) Clinical Practice in Correctional Medicine. Page 421.

Moldenhauer, M. A., Sabel, A., Chu E. S., Mehler, P. S. (2009) Clinical triggers: An alternative to a rapid response team. The Joint Commission on Quality and Patient Safety 35(3) 164-174.

National Commision on Correctional Health Care (2014) Standards for Health Services in Prisons. National Commission on Correctional Health Care. Chicago, IL. Page 107-108.

Puerini, M. (2015) Personal correspondence regarding ODOC nursing protocol, Looks Critically Ill.

Storm-Versloot, M.N., Verweij, L., Lucas, C., Ludikhuize, J., Goslings, J.C., Legemate, D.A, Vermeulen, H. (2014) Clinical relevance of routinely measured vital signs in hospitalized patients: A systematic review. Journal of Nursing Scholarship 46 (1) 39-49.

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Vital Signs: Interpretation and Synthesis

 

Doctor at workA case example: It is Saturday evening at a large prison that houses medium and maximum security men. The facility medical department is staffed twenty four hours a day seven days a week with both registered and licensed practical nurses. It has a twelve bed infirmary and two providers are on site Monday through Friday and rotate call each week. At 7:30 pm a nurse is called to assess an inmate who has been assaulted in the gym. He has a bruise next to his left eye, a small laceration on his left forehead and another on his scalp (left). He reports no loss of consciousness. The injuries are treated and he is cleared to return to housing. At 10:30 pm nursing is called again because the inmate is lying in his segregation cell and is not responsive to verbal inquiry by the correctional officers. The inmate is shaking and his verbal response to the nurse during the assessment is slow; he complains of a headache. His vital signs are T= 95.6, P = 106, and BP = 166/94.

This case is a good example of the kind of situation correctional nurses face and the clinical judgments they are required to make. Nurses are the first health care professional an inmate is likely to see when they have a medical problem and it is the nurse who will determine the inmate’s subsequent access to care. In this case the nurse’s initial assessment and resulting decisions had a deadly impact on the inmate. It is not just the vital signs themselves but the interpretation and synthesis of this data in the context of the particular circumstances of the patient that define the practice of nursing. Clearly the inmate’s vital signs are abnormal at 10:30 pm after being found lying, unresponsive, on the floor of his cell. Can you explain what is going on physiologically with this inmate? What do you think his vital signs would have been at the time of the nurse’s initial assessment and what do you think they would have been an hour later? Can you explain why?

Body temperature is the difference between the amount of heat produced as a byproduct of metabolism and the amount of heat lost. The hypothalamus is the control point that maintains our body temperature between 96.8°F and 100.4°F. The body reduces core temperature by sweating, vasodilation and inhibiting heat production. Vasoconstriction and shivering increase or preserve core temperature. Heat loss is controlled by radiation, conduction, convection, and evaporation. The skin provides insulation, senses temperature and is the site of vasoconstriction or dilation. Factors affecting body temperature include age but also exercise, hormones, time of day, stress and the environment.

Abnormal temperatures are those over 100°F or repeated temperatures under 99°F or a 1°F increase over the patient’s baseline temperature. Temperatures in children are more labile until puberty. The elderly may run lower body temperatures and they have less ability to regulate their body temperature in extremes of cold and warmth.

Higher than normal temperatures can be the result of excessive heat production as in infection and/or the inability to promote heat loss. For example in hot weather the elderly, and those with cardiovascular disease, diabetes, alcoholism, hypothyroid conditions as well as those who take certain medications are less able to rely on the hypothalamus to produce heat loss and so are at greater risk of heat stroke when environmental temperatures are high. Diaphoresis which promotes heat loss by evaporation can result in dehydration and electrolyte imbalance from a deficit in fluid volume. Lower than normal temperatures result from the inability to control heat loss and/or the body’s ability to produce heat is overwhelmed (Fetzer 2013, Rathbun & Ruth-Sahd 2009). The patient’s low temperature in the case example is most likely related to his head injury and an inability to control heat loss.

Respiration is the body’s mechanism to exchange oxygen and carbon dioxide between the atmosphere, blood and cells and involves three processes:

  1. Ventilation, which is the movement of air in and out of the lungs. When we assess the rate, depth, rhythm and symmetry of respiration we are evaluating the patient’s ventilation.
  2. Diffusion is the exchange of oxygen and carbon dioxide between the lungs and the red blood cells. Oxygen saturation and blood gasses are means of assessing diffusion
  3. Perfusion is the distribution of red blood cells carrying oxygen and carbon dioxide throughout the body and back to the lungs. Capillary refill and oxygen saturation are methods used to assess perfusion.

Respiratory control lies in the brain and responds to levels carbon dioxide, oxygen and the pH level in the arterial blood by changing the rate of ventilation. Ventilation also requires muscular effort to move the diaphragm, abdominal organs and rib cage so that air moves into and out of the lungs.

A normal respiratory rate for adults is between 12 and 20 breaths per minute and for adolescents between 16 and 20 breaths per minute. Oxygen saturation rates are normally between 95 and 100%. A change in the character of respirations is as important as the rate (Fetzer 2013). Abnormal respirations should be further evaluated by listening to chest sounds. Critical thinking about abnormal respiration will consider conditions which:

  1. reduce the capacity of the body to carry oxygen (e.g. anemia, carbon monoxide poisoning, shock or dehydration).
  2. reduce the concentration of oxygen (e.g. airway obstruction, overdose, or altitude).
  3. cause an increased metabolic rate (e.g. pregnancy, exercise or wound healing).
  4. affect movement of the chest wall (e.g. pregnancy, obesity, trauma, neuromuscular disease and injury to the central nervous system. Archer, 2013).

Respiration is easiest vital sign to take but least likely to be assessed and yet is the most sensitive and earliest indicator of an impending adverse event (Chua et al. 2013, Elliott & Coventry 2012). Consistent with this finding, the nurses in the case example did not assess the inmate’s respirations. Given the description of the incident what effect do you think there would be on the inmate’s respirations and why?

Pulse is the rhythmic flow of blood pushed into the peripheral artery caused by the contraction and relaxation of the heart. It provides information about cardiac output including:

  1. the conduction of electrical stimuli in the heart (rhythm),
  2. the volume of blood ejected from the heart (strength) and
  3. distributed through the peripheral arteries (equality).

A normal pulse rate for adults is 60 to 100 beats per minute and for adolescents is 60 to 90 beats per minute (Fetzer 2013). Mechanical, neural and chemical factors regulate the heart’s contraction and flow of blood. Cardiac output is affected by hemorrhage and dehydration but also by coronary artery disease, pulmonary disease and diseases of the heart valves (Archer 2013). Heart rate will adjust to maintain cardiac output but only to an upper limit of 140-150 beats per minute (Dickenson E.T. & Lozada K.N. 2010). Conduction (heart rate) is affected by ischemia, abnormal heart valves, anxiety, drugs, caffeine, alcohol, tobacco, electrolyte and acid-base imbalances. Heart rate will be higher during exercise, pregnancy, and with fever (Archer 2013). The heart rate in the elderly is slower to change in response to cardiac output (Fetzer 2013).

In the case example the inmate’s pulse was 106 beats per minute, which is high. It is hard to judge the significance of the finding because we don’t know to what extent this is a change from his baseline vital signs or when he was first evaluated earlier in the evening. This rate could reflect hemorrhage but it could also be an outcome of head injury.

Blood pressure reflects the hemodynamic variables that maintain blood flow and oxygenation in the body. The systolic blood pressure reading is the point at which the ventricles contract and blood is ejected into the aorta at the highest pressure. The diastolic reading is the moment that the ventricles relax and the artery wall is at the lowest pressure. Cardiac output, peripheral resistance, blood volume, blood viscosity and elasticity of vessel walls all affect each other and ultimately affect blood pressure (Fetzer 2013).

Normal blood pressure for adults is considered 120/80 mm Hg and for adolescents 14 to 17 years of age normal is 119/75 mm Hg. Knowing the patient’s usual blood pressure is helpful in identifying if the problem is chronic or acute in nature. Factors that influence blood pressure include age, stress, ethnicity, gender, medications, activity level, weight and smoking.

Additional steps to be taken with abnormal readings steps include finding out the patient’s usual blood pressure and considering whether the blood pressure was taken incorrectly. Other possible causes for high or low blood pressure are listed in the table below.

Possible causes for abnormal blood pressure
Low blood pressure High blood pressure
Medications: opiates, diuretics, cardiac, hypertensive Medications: vasoconstrictors, IV fluids
Pain, dehydration, blood loss, other volume depletion Fluid overload, pain, anxiety
Anaphylaxis, neurogenic or septic shock, trauma, MI, aortic aneurysm Hypertension, renal failure, stroke, TIA, MI, toxemic pregnancy, aortic aneurysm

(Rathbun & Ruth-Sahd 2009)

The patient’s blood pressure in the case example were elevated (166/94) but we don’t know if he has hypertension that has been untreated or poorly controlled. This blood pressure in the context of rapid pulse, hypothermia and his subjective complaint of a headache three hours after an assault make traumatic injury a strong possibility. A CT scan done at the hospital showed a subdural hematoma.

Summary

Because the body has so many mechanisms to maintain homeostasis a full set of vital signs and serial readings will provide more information about the patient’s condition than a single vital sign or a single set of readings. When vital signs are considered a task, rather than a tool, simply collecting the information is sufficient. Nurses who use vital signs as a tool, integrate the information with other information they have about the patient, interpret their meaning and develop a plan that takes into account the likely scenarios that may take place. An essential step in nursing process is the evaluation and reassessment of a patient’s condition so that the plan of care can be adjusted to prevent harm and promote healing (ANA 2013).

  1. What criteria do you use to clear an inmate after an assault?
  2. What should the plan of care for the inmate in this case example have included and why?
  3. What are the ways nurses can evaluate their plan to return an inmate to general population?
  4. How often do you have a full set of vital signs when making this decision and are you able to compare it to a baseline for the particular patient?
  5. How often are you able to consider the full range of possible reasons for abnormal vital signs (reflective thinking) and how often do you rely on pattern recognition?

For more on the professional practice of nursing in the correctional setting get a copy of our book Essentials of Correctional Nursing. If you order directly from the publisher you can get $15 off and free shipping. Use code AF1209.

References:

American Nurses Association. (2013). Correctional nursing scope and standards of practice. Silver Spring, MD: American Nurses Association.

Archer, P. M. (2013) Oxygenation in Potter, P.A., Perry. A.G., Stockert. P.A., & Hall, A.M. (Ed.) Fundamentals of Nursing. Elsevier St Louis, MO.

Chua, W.L., Mackey, S., & Liaw, S.Y. (2013) Front line nurses’ experiences with deteriorating ward patients: a qualitative study. International Nursing Review. 60(4): 501-509.

Dickenson, E.T., & Lozada, K. N. (2010) Tend Alert: The trending and interpretation of vital signs. Journal of Emergency Medical Services (March).

Elliot, M. and Coventry, A. (2012) Critical care: the eight vital signs of patient monitoring. British Journal of Nursing. 21 (10): 621-625.

Fetzer, S.J. (2013) Vital Signs in Potter, P.A., Perry. A.G., Stockert. P.A., & Hall, A.M. (Ed.) Fundamentals of Nursing. Elsevier St Louis, MO.

Rathbun, M. C. & Ruth-Sahd, L. A. (2009) Algorithmic tools for interpreting vital signs. Journal of Nursing Education. 48(7): 395-400.

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Vital Signs: Best Practices

Spotlight on Best Practices Words Great Concepts Successful IdeaThe summer before entering college I got a job as an assistant at a retirement home. One evening I was taking an elderly gentleman’s pulse, while together we watched Neil Armstrong’s first walk on the moon. It was in that moment; feeling his strong, steady heartbeat, while sharing the wonder of our Nation’s achievement with him that I decided to become a nurse. I have taken a lot of vital signs since then and they still help me make a connection with the patient.

These tools have been around for more than 100 years. Pulse and respirations were the original vital signs because they only required a timepiece to measure. Although the thermometer was invented by Galileo, its clinical use did not began until the late 1800’s, followed shortly thereafter by blood pressure measurement. With the introduction of the pulse oximeter in the 1980s oxygen saturation has been suggested as a fifth vital sign (Olsen 2012, Tierney, Whooley, and Saint 1997). There is much debate in the literature about the use of vital sign changes to predict decline in physiological status, when and how often vital signs should be taken, and the role of new technologies in monitoring patients. Problems with accuracy of vital signs are attributed to the failure of healthcare professionals to follow recommended practices for measurement (Lockwood, Conroy-Hiller and Page 2004).

The reasons we take our patient’s vital signs include:

  1. Establishing a baseline for each particular patient. These baseline measurements are important because they help us identify changes in the patient’s circulatory, respiratory, neural and endocrine systems.
  2. To diagnose and treat illness. Abnormal vital signs are often the initial indicator of illness or disease and along with subjective and objective data will suggest the next steps that should be taken clinically. We also use vital signs to monitor progress in managing diseases such as hypertension.
  3. To identify risk for and prevent physiological deterioration. Patients often have changes in vital signs six to eight hours before cardiopulmonary arrest or other major organ failure (Storm-Versloot et al 2014, Moldenhauer et al. 2009, Kyriacos, Jelsma and Jordan 2011). Monitoring of patients who are already medically compromised helps us to detect deterioration in physiological status so that measures to prevent an adverse event can be taken.

Summary of recommended best practices for taking vital signs:

Temperature: There are three dimensions to temperature- the core body temperature which is estimated by mechanical means using a thermometer. Another is the patient’s subject feeling of being hot or cold. Last the body’s surface temperature or how hot or cold the patient is to touch (Elliot & Coventry 2012). Touch is remarkably accurate in identifying the presence of fever (Lockwood et al. 2004). The patient’s subjective description “ I feel like I have a fever”, our objective sense of the patient’s surface temperature “feels warm to touch” as well as the mechanical measurement of temperature are all components of the assessment of a patient’s temperature (Elliot & Coventry 2012). Environmental temperature as well as localized heating or cooling of the patient impact the measurement of temperature and should be considered in the evaluation of results (Lockwood et al. 2004, The Joanna Briggs Institute 2005). There is considerable variation in results among the various devices and locations used to measure temperature (oral electric, oral disposable, tympanic etc.) therefore a recommended best practice is to record the type of device used and location temperature was taken when documenting temperature results. For serial monitoring of an ill patient the same device should be noted and used for all measurements (The Joanna Briggs Institute 2005).

Pulse: In addition to rate, important dimensions include strength, regularity or quality, and peripheral equality all of which can only be to be assessed by touch (Elliot & Coventry 2012, Goldberg 2009). I once witnessed a correctional nurse ask an inmate to take his own pulse and tell her what it was rather than touch him herself (?). Eighty six percent of nurses underestimate pulse rate. As the rate increases, the magnitude of error increases. (Lockwood et al. 2004). Best practices are to take the pulse for a full 60 seconds. This way it is more likely that irregularity will be identified and math errors in multiplying a 15 or 30 second count are eliminated (Elliot & Coventry 2012, The Joanna Briggs Institute 2005). A full minute count is especially recommended if the pulse rate is particularly slow or fast. Abnormal rates can be further assessed using a stethoscope to listen to the apical pulse for a full minute (Goldberg 2009, Lockwood et al. 2004).

Respirations: In addition to the rate, observation of respiration includes noting the pattern or rhythm, effort including use of accessory muscles, depth and equality of chest expansion (Elliot & Coventry 2012, The Joanna Briggs Institute 2005). Observing respirations for two 30 second periods or for one 60 second interval provides a more accurate measure of respiratory rate than shorter intervals. Respiratory rate is considered a sensitive indicator of critical illness or an impending adverse event and so should be included in the serial evaluation of any patients presenting in distress (Elliot & Coventry 2012, The Joanna Briggs Institute 2005, Goldberg 2009, Lockwood et al. 2004).

Tissue oxygenation: While this is an important tool in managing patients with cardio-pulmonary disease there is no evidence that routine measurement of pulse oxygen saturation (SpO2 ) makes any difference in managing patients or their clinical outcomes in the ambulatory care setting (Lockwood et al. 2004). Therefore the patient’s SpO2 should be considered part of the evaluation of respirations rather than a separate vital sign (Fetzer 2013). Factors that affect the accuracy in determining SpO2 include any condition that decreases peripheral blood flow (atherosclerosis, vasoconstrictors, peripheral edema, hypothermia etc.) as well as conditions that interfere with transmission of light (nail polish, artificial nails, dark pigmented skin, moisture, jaundice, motion, outside light). Studies show that nurses often lack knowledge of the factors that affect its accuracy (Elliot & Coventry 2012).

Blood pressure: This vital sign is one of the most inaccurately measured by health care professionals and yet is one of the most important in diagnosing, treating and managing disease (Elliot & Coventry 2012, Lockwood et al. 2004). One study reported by the American Heart Association (AHA) found that only two percent of nurses and three percent of physicians measure blood pressure according to the AHA guidelines. Errors were made in placement of the cuff, size of cuff, inflation pressure and placement of the stethoscope (Pickering et al. 2005). Automated blood pressure monitors save time but are considered less accurate than use of proper technique and a sphygmomanometer and stethoscope (Lockwood et al. 2004, Elliot & Coventry 2012, The Joanna Briggs Institute 2005, Pickering et al. 2005). The AHA recommends that clinicians be evaluated and re-coached in technique periodically (Pickering et al. 2005). Best practice recommendations include using the bell rather than diaphragm of the stethoscope, the patient should be sitting with back and legs supported, the patient’s arm should be at heart height and supported at the elbow, the upper arm should be bare or unencumbered by clothing and the width of the cuff should be 40-46% of the circumference of the arm. The cuff should be inflated to 30mmHg above the last systolic pressure or when sound disappears at the brachial artery in the antecubital fossa. Pressure should be deflated at a rate of 2-3 mmHg/second. When blood pressure measures either high or low of normal a second measurement should be taken after consideration of factors that may be affecting the rate (recent exertion, anxiety, position, poor technique, wrong cuff size etc.). Repeated measures are much more valuable in managing hypertension than a single measurement (Fetzer 2013, Lockwood et al. 2004, Elliot & Coventry 2012, The Joanna Briggs Institute 2005, Goldberg 2009, Pickering et al. 2005).

Summary: There is a lot more to taking a patient’s vital signs than simply measuring temperature, pulse, respirations and blood pressure. This review reminds me of how much data can be collected when getting vital signs and how rich it’s meaning becomes when done comprehensively rather than piece meal. I will say that I don’t think I have had my competency taking vital signs evaluated nor has my technique been peer reviewed as recommended by the AHA. Does anyone have a peer review tool or a competency evaluation for vital signs that they would recommend after reviewing the best practices in this post? If so please share by responding in the comments section of this post.For more on the professional practice of nursing in the correctional setting get a copy of our book Essentials of Correctional Nursing. If you order directly from the publisher you can get $15 off and free shipping. Use code AF1209.

References:

Elliot, M. and Coventry, A. (2012) Critical care: the eight vital signs of patient monitoring. British Journal of Nursing. 21 (10): 621-625.

Fetzer, S.J. (2013) Vital Signs in Potter, P.A., Perry. A.G., Stockert. P.A., and Hall, A.M. (Ed.) Fundamentals of Nursing. Elsevier St Louis, MO.

Goldberg, C. (2009) Vital Signs. A Practical Guide to Clinical Medicine. University of California, San Diego School of Medicine. Retrieved 1/8/2015 from http://meded.ucsd.edu/clinicalmed/vital.htm

Kyriacos, U., Jelsma, J., Jordan, S. (2011) Monitoring vital signs using early warning scoring sytems: A review of the literature. Journal of Nursing Management 19:311-330

Lockwood, C., Conroy-Hiller, T., and Page, T. (2004) Vital signs. International Journal of Evidence Based Healthcare 2(6): 207-230.

Moldenhauer, M. A., Sabel, A., Chu E. S., Mehler, P. S. (2009) Clinical triggers: An alternative to a rapid response team. The Joint Commission on Quality and Patient Safety 35(3) 164-174.

Olsen, S.J. (2012) Standard 1. Assessment in White, K. M. & O’Sullivan, A. (Ed.) The Essential Guide to Nursing Practice. American Nurses Association. Silver Spring, MD.

Pickering, T.G., et al. (2005) Recommendations for Blood Pressure Measurement in Humans and Experimental Animals: Part 1: 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.

Storm-Versloot, M.N., Verweij, L., Lucas, C., Ludikhuize, J., Goslings, J.C., Legemate, D.A, Vermeulen, H. (2014) Clinical relevance of routinely measured vital signs in hospitalized patients: A systematic review. Journal of Nursing Scholarship 46 (1) 39-49.

Tierney, L.M., Wholley, M.A., & Saint, S. (1997) Oxygen Saturation: A Fifth Vital Sign? Western Journal Medicine 166: 285-286.

The Joanna Briggs Institute (2014) Vital Signs (JBI2005). Evidence Based Recommended Practices. The Joanna Briggs Institute 1-8.

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