Mr. 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:
- Are vital signs treated as a tool or a task?
- When do you take vital signs and why?
- When do you delegate taking vital signs?
- 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.
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.
Photo credit: © pakphoto – Fotolia.com