steve mercado, md staff physician utmb/correctional managed care putting the vital in vital signs 1
TRANSCRIPT
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STEVE MERCADO, MDSTAFF PHYSICIAN
UTMB/CORRECTIONAL MANAGED CARE
Putting the Vital in Vital Signs
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Overview
INTRODUCTIONTEMPERATUREBLOOD PRESSUREHEART & RESPIRATORY RATE (discuss
together)PULSE OXIMETER (discuss briefly)MEDICAL/LEGAL ISSUES“OFF THE RECORD” (ACLS, HIV, Hep C)
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Who is this?
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Introduction
1. Definition of Vital= (adjective) critical; urgently needed; absolutely necessary in order for something to succeed or exist.
2. “Tee Shot”
-no ETOH, tobacco, caffeine, or vigorous exercise within 30 minutes of taking vitals.
3. Technology
-more accurate?
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Temperature
5 Methods Obtain TemperatureOralRectalAxillaryEarForehead
Normal range 97.8-99.0 degrees:-dependent on gender/stage of menstrual cycle-recent activity-food/fluid consumption-time of day
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Temperature-Methods
1. Oral-normal 98.6-mercury thermometers have been replaced by digital technology (mercury can vaporize; toxic inhalation)
2. Rectal
-normal 99.6 (0.5-0.7 higher than oral)-closest to “true” core body temperature-infants/toddlers; not “convenient” for school age kids
3. Axillary
-normal 97.6 (0.3-0.4 lower than oral)-least accurate???
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Temperature-Methods
4. Ear-normal 99.6 (same as rectal-infrared light measures heat/body temp of tympanic membrane-variables can affect accuracy (ear infection, cerumen, curved ear canals)-least accurate??? Probably accurate enough for most clinical settings but
don’t rely on for major medical decisions (lumbar puncture, hospital admission). 5. Skin/forehead (temporal artery thermometers)
-normal 99.0 (slightly higher than oral; slightly less than rectal. Check with manufacturer)
-introduced in 2000; infrared scanner measures temperature of arterial artery in forehead (?)
-highly heat sensitive (hot/sweaty, nearby lights, office/room temperature) -$$$
-Forehead strips; get rid of! Highly inaccurate.
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Temperature - Studies
Study: “Accuracy and Precision of non-invasive temperature measurements in adults ICU patients”. American Journal of Critical Care, Sept. 2011.
-60 ICU patients-compared 4 non-invasive methods (oral, ear, axillary, temporal artery thermometers)-outpatient clinical implications (no rectal thermometers)-comparing temperature of non-invasive methods to pulmonary artery catheter temperature ( true core temp)-oral and temporal artery thermometer readings closest to pulmonary artery core temperature.-axillary better than ear!!!
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Blood Pressure
American Heart Association:-take BP twice (sitting) on each arm and take average of each arm. Use arm with higher reading.-slight difference between arms is normal but >15 point difference is significant.
Normal BP (Nelson’s Textbook of Pediatrics, 17th
edition):Age 3-6 yrs= 95-110/60-75Age 6-12 yrs= 100-120/60-75Age 12-18 yrs= 110-135/65-85
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Blood Pressure-Sources of Error
1. Equipment-straightforward; if its broke, fix it or get new one
2. Patient
-talking-pain-anxiety/emotions-time of day (peak BP in mid afternoon)-office temperature (cold room; peripheral vasoconstriction; LOW BP)
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Blood Pressure-Sources of Error (continued)
3. YOU! -cuff size (“too small too high; too big too
low”) -sitting/back supported/feet flat on floor (not
trivial; supported by studies) -arm supported at heart level (“too high too
low; too low too high”) -bell vs diaphragm? Bell best (low frequency
s ounds)
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Blood Pressure - Technology
Wrist Machines-very accurate when used correctly-cuff size not really an issue-again, must be at heart level-easier to get erroneous readings because of
increased sensitivity to movement (“hand talkers”)
-Mount Sinai Hospital study…..”more accurate than arm cuff”
-great for home monitoring
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HEART & RESPIRATORY RATE
Nelsons Textbook of Pediatrics, 17th edition HR RRAge 3-6: 65-110 20-25
Age 6-12: 60-95 14-22 Age >12: 55-85 12-18
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Rosens Emergency Medicine Text, 5th edition HR RRAge 2-5: 80-140 22-34Age 6-12: 70-120 18-30Age >12: 60-100 12-16
HEART & RESPIRATORY RATE
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HEART & RESPIRATORY RATE
Emergency Care, 11th edition HR RRAge 3-5: 80-120 20-30Age 6-10: 70-110 15-30Age 11-14: 60-105 12-20
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Advanced Pediatric Life Support HR RRAge 2-5: 95-140 25-30Age 5-12: 80-120 20-25Age >12 60-100 15-20
HEART & RESPIRATORY RATE
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Saunders Comprehensive Review for the NCLEX- RN exam, 3rd edition
HR RRPreschooler 70-110 16-22School age 60-100 16-20Adolescent 55-90 12-20
HEART & RESPIRATORY RATE
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Pediatric Basic & Advanced Life Support (AHA) HR
Age 2-10: 60-140 (awake), 60-90 (sleeping)Age >10: 60-100 (awake), 50-90 (sleeping)
RRPreschooler 22-34School age 18-30Adolescent 12-16
HEART & RESPIRATORY RATE
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What’s My Point?!
-Study: “Normal ranges of HR and RR in Children from birth to 18 yrs of age; a systematic review of observational studies”. The Lancet, vol. 377, issue 9770, March 2011
*meta-analysis and statistics applied to numerous studies around the world that mentioned heart or respiratory rate ranges in children
*conclusion- “comparison of our percentile charts with existing published reference ranges for HR & RR show striking disagreement”.
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What’s My Point?!
- Study: “Age related reference changes for HR & RR in children age 4-16”. Archives of Disease in Childhood, vol. 90, issue 11, 2005. South Africa
*conclusion- “this study has shown that the range of published “normal” values for HR & RR varies widely depending on the source referred to, and has shown the lack of evidence behind these values”.
-Expert panels agree on what is “normal”; not backed by
evidence-Problems? Rewriting/standardizing texts. “Fringe” values for
vital signs.-Discuss with your provider.
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PULSE OXIMETRY
-Pulse ox <95% on room air is significant (patient is hypoxic); needs provider intervention.
-O2/Hgb dissociation curve
-“The 90’s”
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MEDICAL/LEGAL ISSUES
-Nursing accountability and documentation (school nurses)”don’t let the sun set on abnormal vital signs”
-Nurse/Provider communication (office nurses)
*inform providers of abnormal vital signs*providers get busy/careless
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“OFF THE RECORD”
-March 2010 AHA ACLS guidelines-March 2012 Infectious Disease
recommendations (HIV, Hep C)