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:
- Take and record vital signs frequently
- Recognize patient’s physiological deterioration and the urgency of the situation
- Summon appropriate assistance
- Communicate findings and recommended actions clearly, sensibly and with confidence
- 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.
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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