ambulatory setting
TRANSCRIPT
Presentation titleSUB TITLE HERE
Vital Signs in the Ambulatory Setting:An Evidence-Based Approach
Cecelia L. Crawford, RN, MSN
Project
Overview
The Importance of Vital Signs
Foundation of clinical assessmentBasis for many clinical decisionsAccuracy of VS
Influences the patient’s clinical course Impacts patient outcomes
Therefore, VS should be based on evidence, rather than ritual, routine, & tradition!
Frequency of Vital Signs
Trends more important than any single measurement
Should NOT be used as a method of ensuring Health Care Worker (HCW) visits
Standardize methods of VS measurement
Frequency of Vital SignsVS parameters do NOT guarantee normal physiological status
Have VS become routine & unrelated to patient needs?
Is visual observation more important than routine VS?
Couple visual patient observation with VS
The HCW & Vital SignsImportance of communication
What happens to VS data after it is collected is as important as the accuracy of the VS themselves!
Educational programs CAN improve HCW vital sign measurement techniques
The HCW & Vital Signs
HCW has a definite influence on VS
SpeechTouchPhysical presence
The HCW & Vital Signs
Most influence seen with auscultated blood pressure
White coat HTN may contribute 20% towards misdiagnosis of Stage 1 HTN Higher BPs in clinic/work settings
Vital Sign Technology
Automated machines Electronic/infrared
thermometers BP & Pulse Oximetry Convenient May save time & labor
not confirmed by current studies
Vital Sign Technology
Noninvasive Automatic BP is the most favored method
Reduction in measurement errors
Standardized & calibrated device vs. many HCWs & different techniques
Vital Sign Techniques & Methods:An Overview
TemperaturePulseRespiratory RateBlood Pressure
Pulse Oximetry (5th VS)
Temperature
Glass Thermometers Associated with adverse
eventsRectal/oral traumaMercury exposure
Axillary Temps Great variation with no
“norm” found
TemperatureOral Temps
Position oral thermometers in left or right sublingual pockets
NOT influenced by breathing patterns
IS influenced by hot & cold fluids
TemperatureTympanic Thermometers
Can be affected byExtremes in environmental tempsLocalized heating/cooling measures
Ear tug positively affects accuracy Impacted cerumen adversely
influences accuracy
Temperature
Tympanic Temps - Patient Perceptions
Parents prefer re: speed, ease, cleanliness, & safety
Peds patients reacted more positively
Pulse
Count for 60 sec
Count for 30 sec and multiply X2 Shorter time counts = inaccurate data
•PulseApical pulse via stethoscope
Abnormal pulse Difficult to palpate pulse
Pulse rates via automatic devices not discussed in the literature, but often used in the clinical practice setting
Respiratory Rate
Count for 60 sec
Count for 30 sec and multiply X2 Shorter time counts = inaccurate data
Respiratory Rate
Pediatric patients If panting, use
stethoscope to count
Agitation can result in inaccurate RR
Respiratory Rate
RR is NOT a reliable screen for oxygen desaturation states!
RN and MD assessment is needed
Blood Pressure
Use a consistent & standardized method to minimize inaccuracies
Machine or auscultation Functional & calibrated
machine Korotkoff’s sounds Properly trained HCWs
Blood PressureProcedure (Any Method)
Upper arm properly supported at
level Proper arm cuff size Patient sitting & at rest for 5
minutes Back supported, legs uncrossed No talking or gestures by patient
or HCW Repeat BPs – 2 minutes apart
Blood PressureWhat if a BP cannot be obtained?
What if the cuff doesn’t fit?
What if a right-sized cuff isn’t available?
HCW should consult with RN or MD for all troubleshooting issues
Pulse Oximetry
Possible consideration as the 5th VS
Use in situations where patient assessment & monitoring is critical
VS – It’s All About The Numbers!
Terminal Digit PreferenceHCW may show a preference for certain numbers in
Pulse, Respirations, & auscultated BP readings* Zeros, even numbers, odd numbers Research study on BP revealed 99% of auscultated SBP/DBP
readings ended in zero, demonstrating lack of adherence to AHA recommendations*
HCW should be aware of this possible tendency
(*Roubsanthisuk, W., Wongsurin, U., Saravich, S., & Buranakitjaroen, P., 2007)
Final Thoughts on VS
Tempting to view VS as a routine & static piece of data
VS are fluid, dynamic, & ever-changing, just like our patients!
Final Thoughts on VS
Crucial Vital Sign Decisions Base on the Evidence! Equipment & Technology Technique & Methods HCW Education & Training Frequency Protocols
Influences P&Ps & Clinic Setting (and visa versa!)
Final Thoughts on VS
HCW Education & TrainingVS Accuracy & Communication of DataCompetenciesAnnual Review of Skills
Recommendations - Equipment
Automated BP devices (Welch-Allyn)
Vital Sign MonitorTympanic thermometers
(Kendall Healthcare) Genius tympanic thermometer
Recommendations – Reference Texts
American Academy of Ambulatory Care Nurses (2006): Core Curriculum of Ambulatory Care, 2nd Ed., Elsevier
Perry & Potter (2006): Clinical Nursing Skills & Techniques, 6th Ed., Mosby
Perry & Potter (2006): Skills Performance Checklists: Clinical Nursing Skills and Techniques, 6th Ed., Mosby
Recommendations - Procedure
Base Policy & Procedures on AAACN Core Curriculum and Perry & Potter
Use AAACN Core Curriculum and Perry & Potter as a daily clinical reference
Checklists to instruct and validate clinical competence & skills
Personal Stories Make it Real!
Use real life stories to illustrate how the proper use of vital sign equipment can
positively impact the care of your patients…
Remember these stories as they happen and pass them along!
Vital Signs ConclusionsAn evidence-based vital sign measurement method provides a foundation for:
Patient-HCW Relationships Patient Assessment Patient Treatment Quality Patient Outcomes
Shift the paradigm from
ritual to science!
ReferencesAmerican Association of Critical Care
Nurses (AACN) (2006). Practice alert: Noninvasive blood pressure monitoring. AACN Newsletter, June 2006, 4-5.
Lockwood, C., Conroy-Hiller, T., & Page, T. (2004). Vital signs: Systematic review. Joanna Briggs Institute Reports, 2, 207-230.
ReferencesPickering, T.G., Hall, J.E., Appel, L.J., Falkner, B. E., Graves, J., Hill, M. N., Jones, D. W., Kurtz, T., Sheps, S. G., & Roccella, E. J. (2005). Recommendations for 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.
References
Roubsanthisuk, W., Wongsurin, U., Saravich, S., & Buranakitjaroen, P. (2007). Blood Pressure Determination By Traditionally Trained Personnel Is Less Reliable And Tends To Underestimate The Severity Of Moderate To Severe Hypertension. Blood Pressure Monitoring, 12 (2), 61-6.
ReferencesSchell, K., Bradley, E., Bucher, L., Seckler, M.,
Lyons, D., Wakai, S., Bartell, D., Carson, E., Chichester, M., Foraker, T., & Simpson, K. (2006). Clinical comparison of automatic, noninvasive measurements of blood pressure in the forearm and upper arm. American Journal of Critical Care, 14(3), 232-241.
Thomas, S. A., Liehr, P., DeKeyser, F., Frazier, L., & Friedmann, E. (2002). A review of nursing
research on blood pressure. Journal of Nursing Scholarship, 34, 313-321.
For more information:
Cecelia L. Crawford, RN, MSNProject Manager for Evidence-Based
Nursing PracticeSo. Calif. Nursing Research [email protected]