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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Vital Signs: Essential Tool or Task?

Stethoscope green colorMr. Phillips is a 48 year old inmate with a history of schizophrenia who was admitted to the facility psych unit a week ago because of refusal to eat and potential for self-harm. On morning rounds, the nurse reports that his blood pressure is low (98/51 mmHg), although all of his other vital signs are within normal limits and he does not have any particular complaints. The primary care provider is contacted and asks that his vital signs be monitored closely. The provider is concerned that Mr. Phillips is dehydrated and asks that drinking water be readily available to him. During the remainder of the day he keeps to his cell and does not take any meals. That evening his vital signs are normal except for blood pressure, which is 88/51 mmHg. The night nurse makes a summary chart note at the end of the shift that Mr. Phillips appeared to sleep without complaint or distress. A few hours later he is found lying in bloody feces and barely responsive to verbal stimuli.

Florence Nightingale said “But if you cannot get the habit of observation one way or other, you had better give up the being a nurse, for it is not your calling, however kind and anxious you may be.” In this case example, the provider asked that Mr. Phillips’ vital signs be monitored closely and yet over the next 20 hours nursing staff only take them once. Taking vital signs is an independent nursing intervention (it does not require a provider order) and is considered an essential tool in the collection of information used by nurses to assess and monitor health status.

Monitoring of health status is described by the Institute of Medicine (IOM) as an important aspect of what nurses do in caring for patients. Monitoring or patient surveillance is defined as purposeful and ongoing collection, interpretation and synthesis of data for clinical decision making with the goal of early identification and prevention of potential problems. The practice includes skill in the use of monitoring devices to measure temperature, pulse, blood pressure, respiration, tissue oxygenation and neurological status. It also includes thinking critically about possible reasons for changes in a patient’s vital signs, to think beyond the obvious in constructing a diagnosis, then formulating a plan and intervening to achieve the identified patient outcomes.

In the correctional setting, the nurse is the initial and primary link a patient has to access care for medical and mental illnesses. Utilization of nursing process, including comprehensive assessment is critical to good patient outcomes in the correctional setting. The first practice standard is that correctional nurses collect comprehensive data in a systematic and ongoing process, using appropriate tools and techniques and then synthesizes the data to construct a coherent whole to plan, provide and direct subsequent care (ANA 2013, White & O’Sullivan 2012).

The function of using vital signs to monitor a patient’s physiological status is among the first subjects taught in nursing school along with the development of skill in using various measurement tools and techniques. However the ability to synthesize the information and come to a clinical judgment requires exposure to many clinical situations and the knowledge garnered from experience. It is only from reflection on clinical experiences that the expertise to form a nursing judgment develops (Rathbun & Ruth-Sahd 2009).

The patient safety and quality improvement literature have emphasized development of early warning systems using numerical parameters set for abnormal vital signs to help identify patients whose physiological status is deteriorating during hospitalization (Whittington et al. 2007). Reasons for establishment of these systems are that nurses fail to detect deterioration in patients because they don’t take vital signs as frequently as they should, nurses wait to take vital signs only when they recognize that the patient is deteriorating and they are overly reliant on their experience to alert them when a patient’s condition is deteriorating (Bunkenborg et al. 2012).

All three of these reasons played into the failure to recognize earlier deterioration of the patient in the case example at the start of this post. The next three posts will address best practices for taking vital signs, the interpretation and synthesis of data collected from vital signs and the concept of clinical triggers in patient care. In the meantime take a moment to conduct your own audit and reflect on the use of vital signs in your setting. Here are some questions to get you started:

  1. Are vital signs treated as a tool or a task?
  2. When do you take vital signs and why?
  3. When do you delegate taking vital signs?
  4. What is the significance of the information collected and how is patient care impacted?

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 (2nd Ed.) American Nurses Association. Silver Spring, MD.

Bunkenborg, G., Samuelson, K., Åkeson, J., Poulsen, I. (2012) Impact of professionalism in nursing on in-hospital bedside monitoring practice. Journal of Advanced Nursing 1466-1477.

Nightingale, F. (1860) Notes on Nursing: What it is, and what it is not. D. Appleton and Company, New York.

Page, A. (Ed) (2004) Keeping Patients Safe: Transforming the Work Environment of Nurses. Institute of Medicine. The National Academies Press. Washington, D.C.

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

White, K. M. & O’Sullivan, A. (Ed.) (2012) The Essential Guide to Nursing Practice. American Nurses Association. Silver Spring, MD.

Whittington, J., White, R., Haig, K.M., & Slock, M. (2007) Using an automated risk assessment tool to identify patients at risk for clinical deterioration. The Joint Commission Journal on Quality and Patient Safety 33(9): 569-574.

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Considering productivity in sick call

mature female nurseNurses at a medium security male facility have asked you to help them get a handle on nurse sick call. They don’t know what is wrong but are burdened by the number of sick call requests that they get every day. There are times during the week when inmates are not seen within the facility’s definition of timeliness. The average number written requests for health care attention that the nurses receive each day is 42. Approximately half of these involve physical symptoms that require a nursing assessment no later than the next day. The nurses see on average 26 patients each day; but only half of these are nursing assessments scheduled from triage of the written request. The other half are urgent walk-ins. There is a backlog of 30 patients who have yet to be assessed by a nurse.

What do the numbers tell: What is your first impression about how nurse sick call is being handled? Looking at the average statistics a backlog can be predicted. If an average of 21 patients each day have concerns that involve physical symptoms then the nurses will need to see that many patients every day to keep up. In this example the nurses are only seeing about 13 patients scheduled from triage of the written request each day so every day eight patients are added to the backlog. To catch up the nurses need to see more than 21 patients a day until the backlog is eliminated.

Underlying principles of sick call: Nursing sick call is considered one of the signature practices defining the specialty of correctional nursing. There are two legal principles underlying nursing sick call. The first is that inmates have daily, unimpeded access to health care. The second is that inmates are entitled to a professional clinical judgment regarding their health concerns. Simply put, inmates can request health care attention every day and their concerns must be addressed in a responsive, timely and clinically appropriate manner (Smith 2013). The failure to see patients, as in the example above, is a violation of these underlying legal principles and puts patients at risk of harm.

What gets measured gets done: Sometimes the never ending onslaught of requests for health care attention can overwhelm nursing staff and becomes a morale and staff retention issue in addition to a legal or risk management problem. Having performance benchmarks for nursing sick call can be helpful in identifying when practices deviate from the norm, considering root causes and developing solutions to improve performance. Based upon your experience how many patients can a proficient nurse see in sick call in an hour? What advice would you give to a nurse who wanted to become more efficient at sick call? Please share your opinion and advice by responding in the comments section of this post.

Next week’s post will include the consensus from nursing colleagues about how many patients nurses can see in an hour of sick call as well as their advice about how to manage sick call efficiently.

There is much more on the subject of Sick Call written by Sue Smith in Chapter 15 of the Essentials for Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

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Pustules, Furuncles and Petechia, Oh My!

human skin anatomy cross sectionI just spent a week at a correctional facility and while there was privileged to observe several nurses conducting sick call. I came away from these experiences appreciating that this process has become one of the signature practices of the correctional nursing specialty. Sue Smith referred to sick call when done well as “a thing of beauty” in her chapter on the subject in the Essential of Correctional Nursing (page 304). Reflecting on the experience of being with these sick call nurses over the week it occurred to me just how many patients were seen because of skin problems. Complaints included toenail fungus, dry skin, contact dermatitis and acne. Sound familiar? Most nursing protocols for problems related to the skin almost presume a diagnosis first. Here are some examples of these types of protocols: ectoparasite infestation, urticaria, dermatitis, candidiasis infection, bacterial infection, fungal infection, boils, jock itch, warts etc. In order to select the correct protocol the nurse should perform a more general skin assessment first. A thorough assessment and objective description of the condition also should accompany any referral to a primary care provider for more definitive diagnosis and treatment of those conditions not covered by a nursing protocol or that do not respond to nursing intervention.

Subjective description: The following subjects should be covered while gathering information from the patient about a skin problem.

  •      Duration: Is the onset sudden or gradual? Previous episodes or is this the first? Has the condition been persistent or does it fluctuate over time?
  •      Location: Where is it located? Where did it start? Has it spread and if so where?
  •      Provoking or relieving factors: What brought it on, makes it worse and makes it better?
  •      Associated symptoms: Itching, tenderness, bleeding, discharge, generalized or systemic symptoms of fever, pain, malaise?
  •      Response to treatment: What treatment has the patient tried and what was the result? Be sure to include consideration of prescription, over the counter and complementary (herbal, etc.) interventions.

The patient’s medical history and family history may be relevant (chronic or immunosuppressive disease, skin cancer etc.). Other areas to consider in gathering the patient’s subjective data include environmental exposures (work, leisure activity etc.); alcohol, drug and tobacco use, allergies and recent travel. Equipment for a dermatological exam: In terms of the tools of the trade, dermatologists recommend having a magnifying glass and measuring device available. Another recommendation is to ensure adequate lighting. Natural light is best; a hard thing to come by in some correctional facilities. If relying on artificial light, a high intensity, incandescent light is best. In addition a handheld light is helpful to provide lighting from the side when assessing a lesion. Finally, you have to have sufficient privacy for the examination and since the assessment will involve palpation, the hands need to be clean and for the patient’s sake warm. It is always best to tell the patient that you are going to touch them, where and why before you do. This is especially true for patients who have a history of having been traumatized or abused. Examination: The first step is to just look at the patient; do they seem well or ill? Is there any evidence of systemic illness (vital signs, flushing, jaundice, etc.). The next steps are to visually inspect and then palpate the lesion or effected area. Inspection includes the noting the following characteristics:

  • Location – is the lesion or effected area related to sexual contact, exposure to sun or other environmental conditions (chemicals etc.); is it in an area of friction or pressure from clothing, does it involve mucous membranes or areas of perspiration.
  • Number and Distribution – How many? How are they arranged?
Terminology Description
Annular Circular pattern
Confluent Merged or run together
Discrete Separated and distinct from each other
Generalized Scattered over an area
Grouped Clustered in multiples
Linear Line or snakelike shape
Polycyclic Concentric circles like a bull’s eye
Zosteriform Along a nerve root
  •  Characteristics – Size (measure the longest side first). Describe the color and any variation in coloring, including any areas of inflammation. Note whether edges are clearly defined and if the shape is regular or irregular.

Next palpate the affected area for tenderness and warmth. Palpate the lesion to determine where it is located within the three layers of skin (epidermis, dermis, subcutaneous tissue), how thick the lesion is and its consistency (hard, soft, firm, fluctuant). When pressure is applied does the color change or does it break down or bleed easily. Examine regional lymph nodes for tenderness or inflammation. The purpose of inspection and palpation is to obtain an accurate and objective description of the skin problem. There is a vast vocabulary of terms to describe skin conditions. A few of the most common are listed here. A great glossary of dermatological terms can be found at the American Academy of Dermatology.

Type of lesion Description
Atrophic Thin, wrinkled skin
Crust, scab Dried serum, blood or pus
Excoriation Hollowed out or linear area covered by a crust. Caused by scratching, rubbing or picking.
Lichenification Skin thickening
Macule, patch Flat, circumscribed, discolored spot. Macule less than 1 cm (ex. freckle). Patch is larger than 1 cm.
Nodule, papule Solid, palpable lesion. Nodule if greater than 1 cm, papule smaller than 1 cm in diameter.
Petechia, ecchymosis, purpura Extravasation of blood into skin. Petechia are less than 2 mm, ecchymosis larger than 2 mm. Pupura are confluent lesions.
Plaque Well defined plateau above the surface of the skin. As seen in psoriasis or eczema.
Pustule Superficial, elevated lesion containing pus.
Scales Dead skin that flakes or is built up
Scar Fibrous tissue formed after a skin injury
Vesicle, bulla or blister Circumscribed, bump containing clear fluid. Vesicle less than 5mm. Bulla or blister larger than 5 mm.
Wheal Transient, irregular, elevated, indurated, changeable lesion caused by local edema.

Documentation: Once you have taken the patient’s history, collected subjective information about the chief complaint and examined the patient review your documentation of findings to ensure that it is complete. A good description of the lesion will be important in comparing whether the patient’s condition is improving or getting worse with recommended treatment. A focused assessment of a skin condition assists in clinical decisions about which nursing protocol to use and/or the urgency of a provider referral. The key parts of an assessment include:

  • Presenting symptoms
  • History of the complaint
  • Examination
    • Location and size
    • Number and distribution
    • Characteristics of the lesion
  • Documentation of findings

For more about nursing assessment and sick call in the correctional setting go to our book, Essentials for Correctional Nursing. It is the only text published about the unique experience of correctional nursing practice. Order your copy directly from the publisher. Use promotional code AF1209 to receive a $15 discount and free shipping.  By the way, the title of this post, Pustules, Furuncles and Petechia, Oh My! is a riff on the Wizard of Oz, a holiday favorite of mine. Here is a clip from the movie. Enjoy!

References and Resources:

  1. Adult Decision Support Tools: Integumentary Assessment (2014). Remote Nursing Certified Practice. CRNBC Publication 743 at https://www.crnbc.ca/Standards/CertifiedPractice/Documents/RemotePractice/743IntegumentaryAssessmentAdultDST.pdf
  2. American Academy of Dermatology at https://www.aad.org/education/basic-dermatology-curriculum
  3. Hess, C.T. (2008) Practice points: Performing a skin assessment. Advances in Skin & Wound Care: The Journal for Prevention and Healing 21(8): 392-394.
  4. Jail Medicine by Jeffrey Keller at http://www.jailmedicine.com/. Select dermatology from the categories section for several blog posts on dermatology issues in the correctional setting.
  5. Johannsen, L.L. (2005) Skin Assessment. Dermatology Nursing 17 (2): 165-166.
  6. Pullen, R.L. (2007) Assessing Skin Lesions. Nursing 2007 (8): 44-45
  7. Tidy, C. (2014) Dermatological History and Examination. PatientPlus at https://www.patient.co.uk/print/2041

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Dealing with the Difficult Patient

Stressed manLast week I attended the fall meeting of the Oregon Chapter of the American Correctional Health Services Association. I have belonged to this organization for 30 years and have received a lot of professional support over the years, especially continuing education. These are my notes from an interesting presentation by Daryl Ruthven, M.D., CCHP, Director of Psychiatry for the Oregon Department of Corrections.

Demanding, non-compliant, whining, threatening, somatizing, malingering, drug-seeking, mentally ill, frequent flyer are some of the ways difficult patients are described. Their behavior can be so obstructive that it’s possible to miss important information or data about them and compromise our clinical work. Certain personality types are more likely to take up more time when seen at sick call or in clinic. These include people with antisocial, borderline, narcissistic, histrionic, dependent or organic personality types. The first thing to remember is that the patient’s behavior is consistent with their personality type and not likely to change just because they are seeking health care. Reduce the likelihood of missing important clinical information by remaining non-judgmental about their behavior and objective during assessment and evaluation of their condition.

The Angry Patient: Unless the patient is brain damaged or intoxicated, anger is a response to fear or threat. The patient is afraid of something that either is or is not going to happen as a result of the encounter. Anger sometimes is used as a display to intimidate others. In this situation the patient may need to vent a bit first. Then try to figure out what the patient is scared or anxious about. They may not be aware that their anger is a response to threat and so it may take a bit of dialogue to identify the problem. A good question to ask is “What do you fear will happen?” or “What are you most concerned about?” The encounter should be terminated if the anger is escalating or becomes abusive rather than defusing.

The Demanding Patient: Uses confrontation as a means to force a desired result. Demands are usually accompanied by a direct or indirect threat. Demanding behavior may be a result of fear, sociopathy, or poor assertive skills training or advice. Most patients are as interested in relief of a problematic symptom as they are in a specific outcome. With this in mind, remind the patient of the responsibilities each party has in the patient/provider relationship. The patient’s responsibility is to provide information about the problem and to decide whether to follow the plan of care suggested by the provider. The provider’s responsibility is to listen to the patient, assess the problem and determine the treatment options that are most appropriate to address the problem.

The Splitting Patient: Pits staff against each other to create chaos and in the midst of the confusion achieves a goal. When a nurse (or other provider) feels confused or at odds with other health care providers about a patient’s plan of care it is a good sign that splitting is taking place. The most important action to take with a splitting patient is to bring the team together to agree on a consistent plan to manage the patient’s care. This should include developing a comprehensive treatment plan (including custody and mental health staff) and reviewing it together at regular intervals.

The Threatening Patient: The facility or health care program should have no tolerance for physical threats and train staff in how this kind of behavior is addressed. The specifics of threatening behavior should be documented thoroughly in a report of the incident. Threatening legal action is very common. Suggestions here are to know enough about the law to appreciate how poor health care must be before a finding of “deliberate indifference” and “cruel and unusual punishment” can be made. Staying up to date with the literature and competent clinically along with thorough documentation protects nurses from tort liability. Basically providing and documenting good nursing care provides sufficient protection from legal threats.

Conclusions: Finally, don’t respond unprofessionally to the difficult patient by yelling, use of sarcasm, counter threatening or reacting emotionally. These responses undermine the power of the provider in the relationship with the patient and can destroy the reputation and authority of the clinician.

Difficult patients do have health problems that need to be identified, assessed and treated. These patients also have something that they are scared of or bothering them. Asking “What are you most concerned about?” or “What do you fear will happen?” may help identify this underlying problem so it can be addressed. Set limits that are appropriate to the responsibilities of each in the provider/patient relationship. Discuss the patient’s options calmly and clearly. Seek help from others to manage difficult patients. Take care to prevent becoming jaded, desensitized or overwhelmed by difficult patients by taking regular time off and developing interests and relationships outside of work.

What tips do you have to manage an encounter with a “difficult patient”? Add to the advice given here by responding in the comments section of this post.

There is much more on this subject in the Essentials for Correctional Nursing. Lorry Schoenly discusses working with difficult patients in Chapter 4 Safety for the Nurse and the Patient. Also Roseanne Harmon describes care of patients who have personality disorders in Chapter 12 Mental Health. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

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