Vital Signs in the Ambulatory Setting:
An Evidence-Based Approach
Project
Overview
Presentation
title
Cecelia
SUB TITLE HERE L. Crawford, RN, MSN
The Importance of Vital Signs
Foundation of clinical assessment
Basis for many clinical decisions
Accuracy 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 Signs
VS 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 Signs
Importance 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
 Speech
 Touch
 Physical 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
Temperature
Pulse
Respiratory Rate
Blood Pressure
Pulse Oximetry (5th VS)
Temperature
Glass Thermometers
 Associated with adverse
events
 Rectal/oral trauma
 Mercury exposure
Axillary Temps
 Great variation with no
“norm” found
Temperature
Oral Temps
 Position oral
thermometers in left
or right sublingual
pockets
 NOT influenced by
breathing patterns
 IS influenced by hot
& cold fluids
Temperature
Tympanic Thermometers
 Can be affected by
 Extremes in environmental temps
 Localized 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
•Pulse
Apical 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 Pressure
Procedure (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 Pressure
What 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 Preference
HCW 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 & Training
 VS Accuracy & Communication of Data
 Competencies
 Annual Review of Skills
Recommendations - Equipment
Automated BP devices
(Welch-Allyn)
Vital Sign Monitor
Tympanic 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 Conclusions
An 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!
References
American 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.
References
Pickering, 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.
References
Schell, 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),
For more information:
Cecelia L. Crawford, RN, MSN
Project Manager for Evidence-Based
Nursing Practice
So. Calif. Nursing Research Program
626-405-5802
Cecelia.L.Crawford@kp.org