Continuity of medication and solving problems unique to the correctional setting

preso FATMany of the issues that nurses confront in the correctional setting while advocating for patients and their treatment are because health care is not the main goal, the burden of disease is great, and the population is transient with high turnover among inmates.

Problems with medications that arise from the setting: The most common problem in this category are inmates who do not show up to take medication at the prescribed time. While patients have a right not to take a medication in the correctional setting the patient must communicate this to the nurse by stating their refusal. The mere absence of a patient is not a refusal but a “no show” instead. There are many reasons why an inmate doesn’t appear to take their medication; it could be that they are at an appointment, in court or attending a program. It could also be that they have been moved to another part of the correctional facility or transferred to another institution entirely. It could be that no officer has let the inmate out of the cell or the housing unit. The nursing action to a “no show” is to follow up to find out where the inmate is and determine if the dose can be given later. Repeated instances of “no shows” need to be reported to the supervisor so that a systemic correction can be ma

Another problem is having the wrong medication delivered. Because there are so many inmates and they may have very similar names the pharmacy may dispense the wrong medication or staff may incorrectly identify the patient’s and put their medication in the wrong place in the med room or on the cart. This is one of the reasons for insisting upon two forms of identification and checking the medication against the MAR. When inmates have similar names, use of capital letters, color coding or some other way to easily distinguish one from the other is a practical solution.

Nurses who work in hospitals and other major health care settings have the advantage of quick access to the pharmacy for stat or urgent orders. Correctional nurses most often work in facilities that do not have an on-site pharmacy and in fact may use a mail order pharmacy located miles away. And yet there are times when an inmate arrives or an incident happens and a medication is needed quickly. Many of these types of situations can be anticipated (anaphylaxis, for example and medication epinephrine) and the medication stocked at the facility. Imagine though, an inmate arrives who is on the newest HIV medication and no other medication is a clinically appropriate substitution. It doesn’t make sense to stock some of every medication just in case there is a need. Instead, most facilities have made arrangements with a local pharmacy with 24 hour – seven day a week service to provide medications that cannot be obtained timely from the regular dispensing pharmacy. The nurse will be the one responsible for contacting the pharmacy and making arrangements for delivery once the provider has given the medication order. Correctional facilities without access to a backup pharmacy to fill urgent and stat orders jeopardize the health and safety of inmates.

Problems with medications arising from the burden of disease: Inmates as a population are sicker than the general community. There are many studies which have demonstrated the burden of disease among correctional populations. The majority take prescription medications, not only for one or more chronic medical diseases but often for a mental health disorder as well. Polypharmacy is a problem in correctional settings. The impact on nurses is an explosion of inmates on med line or who need KOP meds delivered, lengthy MARS that need to be transcribed and kept updated, and an increasingly complex patient care situation that can produce adverse events. Also the patients themselves, in this case, inmates, expect providers to treat conditions that many of us who live in the community would either not experience, ignore or treat ourselves without use of prescription medication. Because patients in correctional facilities see different providers, medications may be prescribed by one without being aware of what else the patient is receiving. A solution to this is to bring patients on multiple medications to the attention of the medical director or senior medical professional for review. These are patients perhaps better assigned to see one provider and for medical and mental health providers to collaborate when making treatment decisions. These are also patients whose treatment would benefit from pharmacy consultation.

Because of the presence of so many mentally ill persons in prisons and jails nurses are also likely to be involved in administration of involuntary medication to patients. State law and other aspects of law will govern the use of involuntary medication in your facility and you need to familiarize yourself with these requirements; hopefully your facility will have a policy and procedure. Many patients who have gone through the process of having an involuntary medication order put in place are very cooperative with the process. Medication may also be administered involuntarily in a psychiatric emergency; again, be familiar with your facility’s policies and practice as well as state law so that you are prepared if this becomes necessary.

Problems with medications arising from inmate movement: Missing medications are a huge problem, especially in large jails and prisons with multiple locations where medications are administered. If an inmate is moved from housing block A to D block, and a different medication cart is used for these two housing units, the nurse administering medication in block D isn’t going to have the inmate’s medication when it is time to administer it, unless the nurses are informed that the inmate has been moved before the next med administration and someone moves the medication from one cart to another. In this same scenario, if the inmate takes the medication KOP, it gets put into his property when he is moved and he cannot access it until the property is inventoried and returned to him. Solutions to this problem center on improving the timeliness of notification by custody to health care and nursing accountability to put the medication in the new location. For KOP a solution is to ensure prompt processing of property or providing a way for the inmate to bring the medication with them to the new location.

The problem of transfers is even more profound when an inmate is transferred from one correctional jurisdiction to another, from a county jail to a state prison and visa versa, from one county jail to another or one prison to another, from a jail to the Marshall’s Service to a series of jails for brief stays while being transported across country to another correctional facility. Nurses play a key role in providing a written transfer summary that includes a list of the inmate’s medical problems, the medications they are taking, recent labs and pending appointments. When this is not done it may be because the nursing staff did not receive timely notice of the transfer. If you receive an inmate from another facility who reports that they were taking medication it is best to contact the facility to verify the information and follow up until you succeed in receiving it.

Discharges is another problem area. When inmates return to the community, it is a well-established standard that they receive a supply of medication sufficient to ensure continued treatment until they are seen by a provider in the community. Again lack of timely notice that the inmate is being discharged is the culprit. Solutions to this problem are to work with classification officers to anticipate the probable discharge date. Inmates can also be good sources of information about probable discharge dates and provide information about the resources they use for health care while in the community. Some jails initiate discharge planning at the time of intake and provide inmates with information about how to obtain bridge medication until they see a community provider. Most facilities have processes in place to let inmates take the medication already dispensed, to provide a container of especially prepared discharged medication or for the inmate to go to a local pharmacy to pick up medication prescribed by the provider at the correctional facility within a couple days of discharge. The nurse’s role usually is to ensure the discharge prescription has been written, the patient has their medication upon release or has been provided with information about how to obtain the medication from a community pharmacy.

Managing and monitoring continuity of medication

One of the most important factors affecting patients’ willingness to follow the treatment plan is whether their symptoms are relieved and new ones not experienced (Ehret et al. 2013, Mills et al. 2011). If patients don’t feel better, they are not going to continue following treatment recommendations. Increasing adherence to prescribed medication has greater impact on health outcomes than any other specific form of medical treatment (Brown & Russell 2011, Sabaté 2003). Monitoring patients closely for symptom response, addressing side effects promptly and eliminating barriers and other reasons for medication discontinuity increase the likelihood of treatment success (Vellegan et al. a. & b. 2010). These three interventions are within correctional nurses’ independent scope of practice and can therefore be implemented without provider orders.

Specific steps correctional nurses can take to support the patient’s continuity of care in medication treatment are to:

  1. Notify custody staff of patients whose medication requires:
    • Dietary restrictions or a special diet for patients with diabetes or those taking MAO inhibitors for example.
    • Work restrictions such as not driving or using machinery when a patient is taking medication that causes sedation.
    • Canteen restrictions when for example a patient’s salt intake or carbohydrates must be limited.
    • Housing restrictions such as a lower bunk for a patient taking medication that causes dizziness or medically supervised housing for patients on medication that needs close monitoring (rehydration for example)
    • Environmental precautions: such as limiting exposure for patient’s taking heat or light sensitive medication.
  2. Schedule Follow up appointments with:
    • Nursing to check adherence by review of the MAR or the patient’s own medication if on KOP, to collect serial data such as blood pressure, weight, blood glucose and to find out from the patient if they are feeling better (intended effects) or experiencing side effects (unintended effects). Patients with poor adherence should be seen weekly while those with better adherence can be seen monthly or quarterly.
    • The patient’s provider(s) to review labs, discuss progress, symptom relief, side effects, adherence and adjust prescribed treatment as necessary. Provider appointments should be scheduled to coincide with the availability to lab and other monitoring measures as well in time to see the patient to re-order medication.
  3. Schedule lab and other monitoring measures to coincide with and take place in advance so that the data is available for review and discussion with the patient at provider appointments. Be familiar with common lab work recommended for medications you are responsible for providing to patients and help providers remember to order these when appropriate.

What problem areas do you experience with medication treatment that you believe are unique to the correctional setting? Do you have solutions to any of these problems that haven’t been discussed in this post? Please share your comments by replying in the comments section of this post.

For more about supporting medication treatment and continuity of care see Chapter 6 Chronic Conditions and Chapter 12 Mental Health in our book the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

References

Brown, M. T. & Bussell, J.K. (2011) Medication adherenace: WHO cares? Mayo Clinic Proceedings 86 (4) 304-314.

Ehret, M.J., Barta, W., Maruca, A., et al. (2013) Medication adherence among female inmates with bipolar disorder: results from a randomized controlled trail. Psychological Services, 10 (1), 106-114.

Mills, A., Lathlean, J., Forrester, A., Van Veenhuyzen, W. & Gray, R. (2011) Prisoners’ experiences of antipsychotic medication: influences on adherence. The Journal of Forensic Psychiatry & Psychology, 22 (1) 110-125.

Sabaté, E., ed. (2003) Adherence to Long Term Therapies: Evidence for Action. Geneva Switzerland: World Health Organization. Accessed January 24, 2015 at http://www.who.int/chp/knowledge/publications/adherence_report/en/

Velligan, D.I., Weiden, P.J., Sajatovic, M. et al. (2010 a.) Assessment of adherence problems in patients with serious and persistent mental illness: recommendations from the Expert Consensus Guidelines. Journal of Psychiatric Practice, 16 (1) 34-45.

Velligan, D.I., Weiden, P.J., Sajatovic, M. et al. (2010 b.) Strategies for addressing adherence problems in patients with serious and persistent mental illness: recommendations from the Expert Consensus Guidelines. Journal of Psychiatric Practice, 16 (5) 306-324.

Photo credit: © mag – Fotolia.com

Intake Health Screening-Making the most out of this brief encounter

Rear view of nurse assisting man while working at reception desk in hospital

 

Receiving or intake health screening is done whenever someone is brought to a jail or prison for admission. These individuals are being detained for any number of reasons including having been arrested for an alleged illegal activity, involved in an altercation or other suspicious activity that the police were called for, having been tried, found guilty and sentenced to serve a term of incarceration, having violated conditions of parole or probation, or are being deported for being in the country illegally or are being transported by the Federal Marshall.

Persons may be held in custody for only a brief time (hours) or for very long periods of time (life). The length of time people generally spend in jail is considerably less than in prison. Therefore, jails have very high rates of turnover and intake health screening is a very high volume activity. Furthermore, people admitted to jail have been in the community immediately before, perhaps living in conditions that were a risk to their health and wellbeing or they may have been injured during the arrest or while in police detention. The volume of people admitted to prisons is not as great but because they have been in custody for a while their condition may have deteriorated if it was not identified or treated at facilities which held the person previously. Because of the potential to miss identifying a serious medical or mental health condition and delay necessary treatment, intake receiving screening is also a considered a risk prone process.

Chart audit of intake health screening is one way to monitor the quality and effectiveness of the process. I just finished an audit of 25 charts using these three questions.

  1. Were conditions that warranted referral to a provider identified?
  2. Were patients seen timely by a provider when referred?
  3. Were records of previous care requested when the patient reported ongoing or recent treatment?

Several problem practices were identified that would be good to review further so that corrections can be put in place. I have seen these same problems with intake screening before and so wanted to share them with you to see if your experience is similar and if you have found ways to improve? The following paragraphs describe these findings and suggest possible corrective action.

  1. Practices that reduce the likelihood of identifying a medical or mental health condition that should be referred include:
  • Not collecting serial assessments when abnormal results are found initially. There are many things that can cause elevated blood pressure, including stress, agitation and withdrawal. The same with pulse, blood glucose and peak flow readings. Repeating tests that were abnormal at the end of the assessment or having the inmate wait a bit to reassess adds important information. Results that don’t improve or worsen need to be followed up and a nurse cannot depend on the next person down the line to pick it up. Consideration should be given to removing the barriers that get in the way of obtaining serial assessment data at intake screening.
  • Not inquiring further to yes answers or when the patient reports a medical or mental health condition. For example, if the patient says that they have seizures follow up questions should elicit a description of the type of seizure, when the last one took place, how often they happen and what treatment did the patient receive. Another example was a woman who reported in response to the social history questions that she had been forced to have sex and did not feel safe living at home. Maybe the nurse expected the social worker to pick up on this later but the absence of any additional inquiry or explanation on the part of the nurse indicated that this information was ignored in considering possible health problems. Developing question prompts may help nurses follow up on positive answers.
  • Not going further to establish rapport with patients who give minimal answers or deny obvious problems. An example I see frequently is a patient who denies alcohol or drug use when either their current condition or history of arrest suggest it is likely untrue. A follow-up question or statement to challenge the answer in a non-threatening manner may yield better information. Receiving screening is a dialogue not just rote fact finding using a standardized questionnaire. When the patient’s answer is no to every question you have to consider if language or some other barrier is effecting the patient’s disclosure. Here are some techniques that build rapport during intake screening:
      • Professional appearance of the nurse
      • Focus on the patient
      • Have a neutral or friendly facial expression
      • Allow silence so the patient can reflect and respond
      • Eye contact that is neither too much or not enough
      • Ask questions without reading verbatim
      • Avoid use of leading or biased questions
      • Avoid body language that is perceived as superior or judgmental
      • Do not be distracted, preoccupied or rushed
      • The setting provides privacy

2. Practices impacting timely referrals to providers include:

  • Not following up when nurses make urgent or priority referrals to a provider to make sure the patient is seen timely. We all get busy during the shift and it may be that something is preventing the provider from seeing the patient within the timeframe the nurse requested. Or it may be that the communication about the patient’s priority was missed. The person making the referral bears responsibility to follow-up to make sure that it is accomplished or an acceptable alternative put in place. This is the sixth step in the nursing process; evaluation and revision of the plan of care.
  • Not ensuring that patients are seen by a provider promptly when they return to the facility after diversion to the emergency room. When the ED clears an arrestee for jail it simply means that their condition is not urgent enough to require further monitoring in the ED or admission to the hospital. It does not mean the person was medically cleared and therefore intake health screening is not necessary. Instead information from the ED should be collected and reviewed by the nurse, other intake screening data collected and the patient referred promptly to a provider. If not immediately, the provider should see these patients no more than a couple hours of their return to jail and the nurse should follow up to ensure that this takes place.

3. Not requesting health records of recent or ongoing treatment at intake may delay initiation of appropriate medical or mental health care. Examples of conditions where the previous treatment record should be requested include HIV disease, seizure disorder, heart disease and other acute or chronic conditions. Nurses are in the best position to get prior records; the patient is right there and can sign the consent forms and the nurse knows how to navigate the local health community. These records can be very important to the provider’s decisions about treatment. Many times the reason given for not requesting records is that the patient will be gone before the record arrives or that the patient’s information is so vague that tracking down the provider isn’t efficient use of time. Examining barriers to requesting previous records should be explored and efforts to eliminate or develop sources to get the information made. Making specific arrangements for transfer of information with specific providers who see a majority of the same population may reduce the time it takes to get information. Examples would be the state prison system and jails, major community based providers of indigent care, and the mental health system in the state or county. With the advent of electronic records, the timeliness to request and receive information is vastly improved.

Conclusion: Intake health screening is an activity unique to jails and prisons, that involves nurses’ collection and review of information about the health of every person admitted to the facility and nursing decisions about patients’ immediate needs for medical attention, ongoing treatment and protection from harm. It is a high risk, problem-prone aspect of correctional health care and should be regularly reviewed by the Quality Improvement Program and studied to identify opportunities to improve practices. This blog post described the findings from a chart audit that used just three criteria and only took a couple hours to complete. Six areas of possible improvement in nursing practice were identified. Further study to identify and eliminate barriers to best practices is the next step to an improved intake process.

What are the most common problems you have identified when monitoring the nurses’ role in intake or receiving screening? What barriers were addressed which improved intake screening practices? Please share your answers to these two questions by replying responding in the comments section of this post.

For more about the nurse’s role in intake or receiving screening see Chapter 14 Health Screening in our book the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

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What would you do in this situation? Comparing clinical judgement.

Last week’s post was an opportunity to exercise your skill in making clinical judgments about patients who present with possible mental health issues. This week the best clinical option in each case is described along with the rationale. Compare each answer to the conclusion you drew about what to do next with the patient. If your answer is different it is important to reflect on the reasons; it may be that you perceived the symptoms differently or that you had a past experience that influenced your decision. If your answer is the same did you have the same rationale or another?

Case # 1. Willie is a 46 year old man with a history of seizures, suicide attempts and has a mental health diagnosis of “psychotic disorder, not otherwise specified”. He is followed regularly in chronic care clinics for both the seizure disorder and mental health. Dilantin and Haldol are prescribed for him to take twice daily and he is for the most part adherent in taking the medication. This evening while administering medication cell side he will not come to the door to take his medication. He is responsive to you but his conversation is making no sense. His cell is messy and there are cartons of partially eaten food strewn about on the cell floor. What action do you take?

  1. Document your observations in the medical record.
  2. Take his vital signs.
  3. Call the medical provider.
  4. Make a referral to mental health.
  5. All of the above.

Rationale: There are both medical and psychiatric concerns here. Always consider medical reasons for disordered behavior first. This is because if diagnosed and treated early the consequences of delayed treatment are avoided (permanent disability, death, adverse events and stigma). Both medical and mental health staff need to be notified so that care of the patient is coordinated. Taking vital signs and initiating periodic monitoring as well as the description of symptoms by way of observation contribute important information to the patient’s evaluation by medical and mental health staff.

Case #2. Norma is a 55 year old woman with a history of bipolar disorder. She was taken off the mental health caseload several months ago because she was doing well. Recently she displayed threatening behavior to several other inmates and as a result has been put into administrative segregation. It is early in the morning and the officers complain to you that she has been awake all night, singing and prancing about the cell. You should do all of the following except:

  1. Try to speak with her and make your own observations of her condition.
  2. Document your assessment in the medical record.
  3. Join in her song to initiate a therapeutic alliance.
  4. Make an urgent referral to Mental Health.
  5. Call the Mental Health Clinical Supervisor to report that you have made the referral.

Rationale: While Norma is not imminently a danger to self or others right now, it is unusual behavior that needs to be addressed promptly. By trying to speak with her you can assess her ability to respond to others and the extent to which she is able to communicate. Obviously you will document your assessment in the record because otherwise “it never took place”, right? Communicating directly with the mental health supervisor about the urgent referral is recommended so that he or she has an opportunity to clarify information about your observations of the patient and has the information to follow up and ensure the patient is seen timely. Joining the patient in her song may not be interpreted by the patient as therapeutic (it could be viewed as demeaning, threatening or confusing) and it serves no therapeutic purpose.

Case # 3. Geraldo is a 35 year old man with diabetes. He is followed regularly in the chronic care clinic and his diabetes has been in fair control the last six months. At today’s insulin line you notice that he appears to be upset and say something to him about it. He says that he just got an additional 20 months on another sentence. He thanks you for your concern. What should you do next?

  1. Immediately contact the on call mental health provider.
  2. Make a supportive comment and provide information about how to access mental health services.
  3. Place him on suicide watch.
  4. Give him the insulin he needs and move on to the next patient in line.
  5. Suggest that he order some Honey Buns, a favorite comfort food, from the commissary.

Rationale: The other choices range from too much to too little, to counter-therapeutic, don’t they? He isn’t expressing actively suicidal intention so there is no basis for contacting the on call mental health provider or placing him on suicide watch. But he did just get “bad news” and looks upset about it. Don’t assume that every inmate is going to know how to access mental health services; they may not remember because it wasn’t something that was important at the time of explanation. Providing information about access also indicates that it is normal to be upset about bad news and that people can benefit from “help” in coping with these challenges. Suggesting that he eat “comfort food” undermines the management of his diabetes and is counter-therapeutic.

Case # 4. Tammy is a 23 year old woman received at the jail for the first time 72 hours ago on a charge of reckless driving. The officers have contacted you this evening because “she is going crazy” and has not rested or eaten over the last 24 hours. You check her medical record and note that on intake she gave no history of mental health treatment and denied use of drugs or alcohol. On interview she doesn’t make any sense, does not respond to requests and seemed to get increasingly agitated. She also was picking at things in the air and rolling her fingers. What would you do next?

  1. Have a drug urinalysis done.
  2. Place her on medical observation.
  3. Complete a CIWA-Ar evaluation.
  4. Contact the provider for orders.
  5. Follow up with the officer later in the shift.

Rationale: Even though Tammy denied use of drugs at intake screening and gave no history of mental health treatment these certainly are possibilities now. An earlier post commented that we should expect patients to under-report at intake use of alcohol and drugs and include possibility of withdrawal in our differential diagnosis. While you most certainly will contact the provider and place her on observation, the next step is to do a more focused assessment for withdrawal. The CIWA-Ar is a standardized assessment tool that many correctional health care programs use to manage patients in withdrawal. The data collected from an assessment with this tool will provide the clinician with important information to use in determining treatment and follow up of this patient.

Case # 5. Jamie is a 17 year old brought to jail on a charge of burglary. He has a history of several other detentions as a juvenile. Currently he is in segregation for failure to follow orders. He has multiple complaints of chest pain and indigestion because of the food served with the religious diet. He is brought to the clinic because he has cut himself. He has four superficial lacerations on his left forearm. You treat each of the wounds and after a brief examination release him to return to his cell. This is his fourth cutting episode. What would you consider the best next step to be?

  1. Schedule him for a nursing visit the next day?
  2. Make a referral to the mental health staff.
  3. Ask the dietician to see him about the religious diet.
  4. Suggest an interdisciplinary meeting to discuss his care.
  5. Report the cutting episode to the next shift.

Rationale: Repeated cutting, even when not severe, is considered self-harm. Self-harm is a form of psychological distress, even in the absence of a diagnosed mental illness. Since this is his fourth episode, we can expect to see more episodes of cutting or other forms of self-harm with accidental or intentional suicide a real possibility. Since his maladaptive behavior effects everyone (security, medical, food service, religious services and mental health) an interdisciplinary plan of care is going to be the most effective. Nursing staff are in the key position to make this recommendation because we see the constellation of problems he presents (segregation, physical complaints about the diet, self-harm etc.).

Learning from case examples

Exercising good clinical judgement is one of the most essential features of correctional nursing. The right to a clinical judgment is one of the three constitutional rights that inmates have while incarcerated and nurses are most often the first health care professional to make a clinical judgement about an inmate in the correctional setting. Comparing decisions about cases is one way to increase information and build skill in making clinical judgments.

So how do your clinical judgments compare to these recommendations? In what way do they differ and why? For example if mental health services are limited only to those with the most severe symptoms you may not provide information to Geraldo in Case # 3 about accessing mental health for help coping with “bad news”. But what if he has trouble coping? Suicide is a risk resulting from “bad news” so what is an alternative clinical judgement? Schedule him for a nurse follow up visit? Are there other programs at your facility to help…such as the chaplain or a volunteer group? Examining your answers in this way may lead to identification of additional resources that you may want to use or develop further.

You may want to discuss each of these cases with other nurses at your facility to find out what others would do. If you do this as a group you may find that there are more resources than any one individual knew were available. These cases also would be great for an interdisciplinary discussion. If each member discusses what is their most important next step and why, other disciplines will know more about each program and its operation so that work with the inmate is coordinated rather than at cross purposes. These discussions will also identify opportunities to improve the management of inmates or eliminate gaps or barriers in service that are a liability risk.

We are interested in hearing your comments about what you think is the best clinical judgement in these cases. To do so please respond in the comments section of this post. To learn more about correctional nurses’ assessment of mental illness, response to suicide, self -harm and withdrawal, see our book, Essentials of Correctional Nursing. Order your copy directly from the publisher or from Amazon today!

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Clinical judgment resulting from the mental health assessment

Man Woman face people problem puzzle

Previous posts have described the prevalence of mental disorder among inmates in our prisons and jails today. Every correctional nurse has witnessed the incredible suffering that the mentally ill experience during incarceration. In addition to the illness itself, mentally ill inmates are more likely to be stigmatized and perhaps victimized by other inmates, housed in isolated areas to prevent harm to themselves or others, receive long segregation sentences for rule infractions, and have difficulty finding safe housing and employment once released to the community. We also know that serious medical problems can mimic psychiatric problems and that an astute nursing assessment can prevent adverse patient outcomes.

Finally just because an inmate was not identified at intake as having a mental illness does not mean that a mental health problem cannot occur at any time later during incarceration. Stressful situations that increase the risk for developing or worsening mental illness include:

  • Recent changes or loss of privileges
  • Isolated housing assignments such as disciplinary or administrative segregation or protective custody
  • Environmental changes such as a change in cell mate, transfers within the facility or transfer to another facility
  • Assault (sexual, physical, intimidation)
  • Bed news about a death in the family, unfavorable legal decision, new medical diagnosis, divorce, loss of job, etc.
  • Pain (acute or chronic)
  • Conflict within own family or among peers

Correctional nurses may be the first health professional to identify a patient in need of mental health treatment. Even when an inmate is seen regularly by mental health staff, nurses still see the patient more frequently (during sick call, medication administration and segregation rounds) and can identify changes in condition earlier resulting in a referral for additional evaluation and treatment.

How nurses assess a patient’s mental health assessment was discussed in a three part series of posts in October 2012. Briefly the process involves observing the appearance of the person and their cell, their behavior during your interaction with them, their affect, thought process and content and cognition. It is more important to give a description of the symptoms or behavior rather than use diagnostic labels. The use of a standardized assessment process and screening tools will yield more accurate clinical judgments when determining if a referral is necessary and if so to whom and by when.

The following are five case examples to test your clinical judgement in deciding the next steps to take. Make a note of what answer you think is the best next step for the nurse to take. If you think an option other than those listed is better please write it down.

Case # 1. Willie is a 46 year old man with a history of seizures, suicide attempts and has a mental health diagnosis of “psychotic disorder, unspecified”. He is followed regularly in chronic care clinics for both the seizure disorder and mental health. Dilantin and Haldol are prescribed for him to take twice daily and he is for the most part adherent in taking the medication. This evening while administering medication cell side he will not come to the door to take his medication. He is responsive to you but his conversation is making no sense. His cell is messy and there are cartons of partially eaten food strewn about on the cell floor. What action do you take?

  1. Document your observations in the medical record.
  2. Take his vital signs.
  3. Call the medical provider.
  4. Make a referral to mental health.
  5. All of the above.

Case #2. Norma is a 55 year old woman with a history of bipolar disorder. She was taken off the mental health caseload several months ago because she was doing well. Recently she displayed threatening behavior to several other inmates and as a result has been put into administrative segregation. It is early in the morning and the officers complain to you that she has been awake all night, singing and prancing about the cell. You should do all of the following except:

  1. Try to speak with her and make your own observations of her condition.
  2. Document your assessment in the medical record.
  3. Join in her song to initiate a therapeutic alliance.
  4. Make an urgent referral to Mental Health.
  5. Call the Mental Health Clinical Supervisor to report that you have made the referral.

Case # 3. Geraldo is a 35 year old man with diabetes. He is followed regularly in the chronic care clinic and his diabetes has been in fair control the last six months. At today’s insulin line you notice that he appears to be upset and say something to him about it. He says that he just got an additional 20 months on another sentence. He thanks you for your concern. What should you do next?

  1. Immediately contact the on call mental health provider.
  2. Make a supportive comment and provide information about how to access mental health services.
  3. Place him on suicide watch.
  4. Give him the insulin he needs and move on to the next patient in line.
  5. Suggest that he order some Honey Buns, a favorite comfort food, from the commissary.

Case # 4. Tammy is a 23 year old woman received at the jail for the first time 72 hours ago on a charge of reckless driving. The officers have contacted you this evening because “she is going crazy” and has not rested or eaten over the last 24 hours. You check her medical record and note that on intake she gave no history of mental health treatment and denied use of drugs or alcohol. On interview she doesn’t make any sense, does not respond to requests and seemed to get increasingly agitated. She also was picking at things in the air and rolling her fingers. What would you do next?

  1. Have a drug urinalysis done.
  2. Place her on medical observation.
  3. Complete a CIWA-Ar evaluation.
  4. Contact the provider for orders.
  5. Follow up with the officer later in the shift.

Case # 5. Jamie is a 17 year old brought to jail on a charge of burglary. He has a history of several other detentions as a juvenile. Currently he is in segregation for failure to follow orders. He has multiple complaints of chest pain and indigestion because of the food served with the religious diet. He is brought to the clinic because he has cut himself. He has four superficial lacerations on his left forearm. You treat each of the wounds and after a brief examination release him to return to his cell. This is his fourth cutting episode. What would you consider the best next step to be?

  1. Schedule him for a nursing visit the next day?
  2. Make a referral to the mental health staff.
  3. Ask the dietician to see him about the religious diet.
  4. Suggest an interdisciplinary meeting to discuss his care.
  5. Report the cutting episode to the next shift.

Next week we will discuss the preferred next steps for each case and the rationale. If you disagree or have a better option we want to hear from you in the comments section. In the meantime to read more about mental health care in correctional nursing see Chapter 12 of our book the Essentials of Correctional Nursing. Order your copy directly from the publisher today.

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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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