By Carol Moore PhD, ARNP, CNS and Linda Sanko MS, MN, RN

Introduction The skills of obtaining accurate vital signs have disintegrated to a routine task without regard to the significance of the results. If vital signs could speak, they would echo Rodney Dangerfield's lament "I can't get no respect." Hence, the reliability of what is recorded in the patient's chart is suspect. The results of vital sign measurements are a prime consideration in making a diagnosis or determining a plan of care. How confident are you that the information in your medical record is accurate? dans, LPNs, ADNs, BSNs, and a graduate student studying to become an FNP). The most common, deflating the blood pressure (BP) cuff too rapidly. The rate of deflation should be 2-3 mmHg per second. Placing the BP cuff over clothing, sometimes bulky clothing, or pushing up the sleeve and it becomes constrictive. Overinflating the BP cuff, over 200 mmHg when the patient has a documented history of systolic pressure of 140 mm Hg. Statement of the Problem Reinflating the BP cuff for repeat measurements withIt began as a coffee break conversation, concern about out waiting 30-60 seconds or pumping the cuff back up the frequency of incorrect techniques noted in obtaining viwithout completely deflating first. tal signs. What the authors found during the literature rePlacing the stethoscope head on the cuff tubing to take view is disturbing. The number of articles written about the the measurement (done in the ER) nonchalant manner of obtaining vital signs is staggering. It Overheard in a teaching situation, "the bell of the is obvious that the profession is lacking vital sign accountstethoscope is used for children, the diaphragm is for abilitythere is no sugar-coating the negligence apparent adults." in these incidents that occurred in Kansas and beyond her Respirations not obtained for cardiac patients during borders. office visits. The individuals from these examples represent a wide Radial pulse taken by placing the thumb on the radial variation in educational preparation (medical/nurse technipulse site in a cardiologist's office (occurs repeatedly). Radial pulse obtained with patient diagnosis of atrial fibrillation and bradycardia. WICHITA STATE 1845 Fairmount Vital signs obtained immediately after Wichita, KS 67260-0041 being seated in the exam room. UNIVERSITY (316)978-3610 Literature records incidents of dis(800)516-0290 COLLEGE OF cipline and litigation for the inaccurate HEALTH PROFESSIONS www.wichita.edu/nurs taking of vital signs and for not taking or School oj Nursing recording vital signs. The first case is a situation of the RN not knowing how to Bachelor of Science in Nursing use the equipment, failing to seek assis BSN (Traditional, Early Admission, and Accelerated Option) tance although a visual assessment clear. LPN to BSN ly indicated the patient was in trouble. . MICT to BSN The patient collapsed before she called RN to BSN On-line Program the physician. Subsequent investigation discovered the RN's recordings of many Master of Science in Nursing other patients' vital signs were inaccurate. RN-BSN to MSN Dual/Accelerated She was warned about her conduct and sent to a special training course to cor Clinical Nurse Specialist (Adult Health & Illness) rect/improve her technique (Castledine, Nurse Midwifery (in collaboration with KU) 2006). Nurse Practitioner (Acute Care, Family, Pediatrics, The second case, one that ended in Psychiatric/Mental Health) the court system, was based on an ab Elective Sequence in Nursing Education sent record of vital signs and the patient death due to internal hemorrhage from a Doctor of Nursing Practice MVA. He was treated for two hours in the Post Baccalaureate Entry or Post Master Entry ER before expiring, the medical records Individual/Family Focus (includes NP or CNS specialization area) did not indicate the ER nurse obtaining vital signs although she testified she had Innovation and Excetience in Nursing Education continued on page 4
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Vital Signs Get No Respect

Vital Signs Gel No Respect

By Carol Moore PhD, ARNP, CNS and Linda Sanko MS, MN, RN
every 5-10 minutes but recorded them on pieces of paper she placed in her pockets (Gorcey v. Jersey Shore Medical Center, 2006). The patient, an elderly 78 year old gentleman, was admitted with a history of CAD and hypertension after falling at home and fracturing his right arm is an example of treatment based on an inaccurately obtain blood pressure. His complaints of dizziness, lightheadedness, and being tired all the time were ignored because his BP readings were elevated. Antihypertensive medication dosages were increased until a student nurse selected the correct sized BP cuff and positioned the arm at the appropriate level to obtain his vital signs. Results of a correctly obtained reading, and verification by the nurse and instructor, revealed a very low blood pressure (Tomlinson, 2010). Discussion Vital signs are termed cardinal signs because they represent the homeostatic balance of the human body. The assessment that accompanies obtaining vital signs should be recognized by the nurse as an activity high on the list of priorities. How do nurses obtain correct assessment data? Vital signs include temperature, pulse, respirations and blood pressure. These basic skills are the tools nurses have to assess a person's health status. Measuring the vital signs accurately provide insight to the patient's physiological status. A recent article by Rauen, Chulay, Bridges Vollman and Arbour (2008) state "About 30% to 40 % of patients do not receive care consistent with current scientific evidence Are we doing what is the best for our patient with the current evidence available to us." (p. 118). Medical care and prescriptions, and nursing care are based on the results of vital sign measurements. Inaccurate data leads to inappropriate treatments. It is unprofessional to use the "Jewish Mother" method of obtaining the temperatureplacing the hand on the forehead and estimating (Streger, 2000). Accurate measurable techniques to determine the patient's temperature is the standard. Hyper/hypothermia each present with specific indicators and in the scheme of things, the temperature may be that one significant clue to an impending crisis. Atrial fibrillation is the most common cardiac dysrhythmia and is associated with uncontrolled elevated systolic blood pressure (Madoc-Sutton, 2009). Atrial fibrillation is an important risk factor for stroke, therefore obtaining an apical pulse is paramount as it is often symptomless. The National Institute for Health and Clinical Excellence states that health professionals are in an ideal position to screen for this condition when taking vital signs, particularly the pulse and blood pressure. They go on to recommend that an electrocardiogram be performed to confirm the diagnosis.
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The assessment data obtained when taking vital signs should not be taken for granted. Measurement of the vital signs is a quick and easy method of monitoring the patient's condition, identifying problems and evaluating the patient's response to intervention. The assessment data obtained is a critical part of clinical problem solving. Numerous factors must be considered when taking a patient's blood pressure. Medications the patient is taking Position of patient (seated, arm and body position, legs uncrossed) Noise levels in the area Temperature extremes Clothing worn by the patient (arm free of constrictive clothing, supported anticubital fossa at appropriate level) Properly functioning equipment White-coat effect Proper BP cuff length or width Proper placement of the BP cuff Proper inflation and deflation of BP cuff f Length of time between taking BP readings and eating, exercising, and smoking Neglecting to palpate pulse for pulse regularity and to estimate SBP Patient anxiety Attitude of person taking the blood pressure Nolan and Nolan researched the nurses' understanding of the basic principles of taking and recording a blood pressure. The intent of the study was to make nurses aware of the value of research, but the results demonstrated nurses' inability to obtain accurate BP measurements. The results of the 20 item questionnaire revealed the majority of the 65 nurses taking the survey scored between 7 and 9, indicating a limited knowledge regarding sources of error when taking a BP. All nurses participating in the study indicated they were proficient in the skill of taking a BP. Readers who complete the questionnaire may compare their answers in the next issue of The Kansas Nurse. Can Nurses Take an Accurate Blood Pressure? 1. Before taking a routine measurement how much time should be allowed to elapse after the patient has: (a) Eaten, (b) Exercised, (c) Smoked For how long before taking a BP reading should the patient be advised to sit and relax? What is the recommended service interval for the sphygmomanometers? On average, what percentage of sphygmomanometers do you think are accurate?
The Kansas Nurse July-August 2010 Vol. 85 No. 5

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By Carol Moore PhD, ARNP, CNS and Linda Sanko MS, MN, RN
5. To the best of your knowledge when was the last time that the sphygmomanometers on your ward/unit were serviced? If someone were to ask you, what would you say were the upper limits of a normal BP in a healthy young adult? (a) Systolic (b) Diastolic Using a cuff which incorporates a bladder which is too small for the arm (too short, too narrow or both) is likely to result in: (a) An underestimation of BP, b) An overestimation of BP, or (c) It makes no difference. sible to record the BP to the nearest (a) 10 mmHg, (b) 5 mmHg, (c) 2 mmHg, or (d) 1 mmHg. 20. In a normal healthy adult the most accurate point at which to record the diastolic pressure is: (a) When the sounds muffle, (b) When the sounds disappear, or (c) The two are so close it doesn't really matter. 21. Bonus: Critique the photo on the cover based on the information in this article, listing the right/wrong techniques of obtaining a BP reading. Figure 1. From "Can nurses take an accurate blood pressure?" by J. Nolan and M. Nolan, (1993) British Journal of Nursing. 2(14), pp 724-729. Reprinted with permission from the authors. Data indicate that professional nurses may not take a BP accurately. Unfortunately, the "task" of taking vital signs is frequently delegate to the lowest paid and least educated member of the nursing staff. Hence, the reading obtained becomes just a number without regard to the quality characteristics that the number represents. Accuracy of the number is also suspect given the technique utilized in obtaining the reading. The professional nurse is responsible for assessing the skill and competency of the adjunct nursing staff. There are certain basic physical requirement competencies that are required. The first competency is vision. The dial of the monometer or meniscus of the mercury column must be at eye level and dearly seen by the observer without straining or stretching. The second competency is hearing. The observer must be able to hear the appearance and disap-

vital Signs Get No Respect

6.

7.

No one should underestimate the power of accurately obtained vital signs and the consequences of appropriate interpretation of those results.
8. Most modern BP cuffs contain a bladder which does not completely encircle the arm. When using such a cuff it is still possible to take an accurate reading providing the cuff is positioned so as to ensure that. . . What is the suggested time required to take and record an accurate BP reading? How high (in mmHg) should the cuff be inflated above the palpated systolic pressure? What is the suggested maximum distance that the nurse should be from the sphygmomanometer when taking a BP? The best way to ensure an accurate BP reading is to: (a). Inflate the cuff quickly and deflate it slowly, (b) Inflate the cuff slowly and deflate it quickly, or (c) Inflate and deflate the cuff at roughly the same speed. What is the recommended speed (in mmHg/second) at which the cuff should be deflated? When taking a BP it is important to ensure that the antecubitalfossa is level with . . . Ina healthy patient, providing the arm is positioned correctly, there should be little or no difference between the BP when lying, sitting, or standing? (a) True (b) False Rushing the procedure and taking a BP too quickly is likely to result in: (a) An overestimated systolic and underestimated diastolic reading, (b) An underestimated systolic and overestimated diastolic reading, (c) Roughly equal errors to both systolic and diastolic readings. Patients who have their BP taken while their legs are crossed are likely to have a recording which is: (a) Falsely low, (b) Falsely high, (c) It makes no difference Approximately how much gap should be left between the bottom of the cuff and the antecubitalfossa? When using a mercury sphygmomanometer it is pos-

9. 10. 11.

12.

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"Measuring blood pressure is a complex task, requiring careful work to avoid observer error, instrument error and to minimize individual variations."
pearance of the Korotkoff sounds. The third competency is eye/hand/ear coordination. The observer must be able to manipulate the equipment at the same time as listing to sounds and visually reading the equipment (Pickering et al., 2005). Patients who suffer an adverse event (AE) are more likely to suffer permanent disability or die. Many of these AEs are preventable and nurses have long played a pivotal role in their prevention. The ongoing physiological assessment of patients is a nursing responsibility and these assessment findings by nurses underpin many patient care decisions. Early recognition and correction of abnormalities can improve patient outcomes (Nolan & Nolan, 2004). No one should underestimate the power of accurately obtained
continued on page 6

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Vol. 85, No. 5 July-August 2010 The Kansas Nurse

visit us at www.nursingworld.org/snas/ks

Vital Signs Get No Respect

By Carol Moore PhD, ARNP, CNS and Linda Sanko MS, MN, RN
vital signs and the consequences of appropriate interpretation of those results. No one should underestimate the importance of using properly functioning equipment to obtain vital signs. The use of an inaccurate sphygmomanometer is a blatant violation of professional duty and acting in a nonethical manner. These healthcare workers could be sued for negligence by patients who believe the use of malfunctioning equipment had adverse consequences for their health (Plante, 2005). McKay, (2008) discussed the differences and benefits of the auscultation and oscillometry methods of taking a BP and whether the cuff should be used on a bare arm or sleeved arm. The results were inconclusive. The author suggested using the auscultation method with bare arm until more evidence was obtained. Madoc-Sutton, Pearson and Upjon (2009) conducted a study of nurses who measured BP with an electronic devise who also palpated the pulse. The conclusion indicated that one quarter of nurses surveyed did not take a pulse, thus missing the assessment of atrial fibrillation or other dysrhythmias. Conclusion A patient's needs and condition determine when, where, how and by whom vital signs are measured. It is important that the nurse is able to measure the vital signs correctly, understand and interpret the values, communicate the finding appropriately and begin intervention if needed. Taking the BP seems a simple task, yet it is one of great medical importance" (Plante, 2005, p. 35). There must be an attitude adjustmentthis ability to obtain vital signs correctly is not "high tech stuff' but high level cognitive function! It is time to finesse the skills learned in Fundamentals of Nursing class and incorporate pathophysiology and assessments skills to the interpretation and evaluation of what the vital signs indicate. There are absolutely no excuses for this shabby nursing care. The profession voted most trusted should not tolerate this lack of accounability to patients and colleagues.
References Castledine, G. (2006).The importance of measuring and recording vital signs correctly. British Journal of Nursing, 15(5). Considine, J., & Botti, M. (2004). Who, when and where? Identification of patients at risk of an in-hospital adverse event: Implications for nursing practice. International Journal of Nursing Practice. 70:21-31. Gorcey v. Jersey Shore Medical Center, 2006 WL 533379 (N.J. Super., March 6, 2006). Foster-Fitzpatrick, L., Ortiz, A., Sibilano, H., Marcantonio, R., & Braun, L. T (1999). The effects of crossed legs on blood pressure measurement. Nursing Researc/i.March/April, (2)48. Madoc-Sutton, H., Pearson, E, & Upton J. (2009). Pulse check as a screen for atrial fibrillation. Practice Nursing. 20{6). McKay, D. (February 26, 2008). Measuring blood pressure: A call to bare arms? Canadian Medical Association Journal. 178(5). Nolan, J., & Nolan, M. (1993). Can nurses take an accurate blood pressure? British Journal of Nursing. 2(19) 724-729. Martin, B. (April 2010). Noninvasive blood pressure monitoring. AANC Practice Alert. Potter, P., Perry, A., Stockert, P., & Hall, A. (2010. Basic Nursing, (7th ed.). St. Louis, MO: Mosby Elsevier .Pickering, T G., (2002). Principle and techniques of blood pressure measure measurement. Cardiology Clinics. (20)207-223. Pickering, T G., et al. (2005). Recommendations for blood pressure measurement in humans and experimental animals; Part I blood pressure measurement in humans. Hypertension. 45:142-161. Plante, C. (2005).Blood pressure measurement: Aworthy technique for nurses! Outlook. 28(2). Rauen, C , Chulay, M., Bridges, E., Vollman, K., & Arbour, R. (2008). Seven evidence-based practice habits: putting some sacred cows out to pasture. Critical Care Nurse. 28(2). Streger, M. (2000). Back to basics: Taking accurate vital signs. Emergency Medical Sen/ices. 29(8) 2000. Tomlinson, B. (March/April 2010). Accurately measuring blood pressure: Factors that contribute to false measurements. Medsurg Nursing. 19(2).

There must be an attitude adjustment this ability to obtain vital signs correctly is not "high tech stuff" but high level cognitive function!
The ability to use appropriate skill when taking a BP and correctly recording and analyzing the data continues to be a problem. Technology may be helpful, but evidence questions the accuracy of the reading. Recommendations in the literature indicates that the skill of taking a BP and other vital signs should be evaluated on a regular basis and be included as part of a competency check-off (Tomlinson, 2010). She goes on to state that "accuracy when assessing blood pressure has a profound effect on the medical management decisions and nursing care that directly impact the patient's ability to achieve positive health outcomes" (p. 94). Measuring blood pressure is a complex task, requiring careful work to avoid observer error, instrument error and to minimize individual variations" (Noland & Nolan, 1991, p. 729). "In an era in which medical technology abounds and research explores myriad pathways, it is ironic that BP monitoring is still the most effective indicator of life expectancy.
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The Kansas Nurse July-August 2010 Vol. 85 No. 5

Vital Signs Get No Respect

Carol Moore PhD, ARNP, CNS & Linda Sanko MS, MN, RN
Carol Moore PhD, ARNP, CNS is an Assistant Professor of Nursing at Fort Hays State University. She received the BSN from Eastern IVIennonite University, a Masters degree in nursing from Wichita State University, and a PhD in Education from Kansas State University. She is the Coordinator of Graduate Studies in the Nursing Department at FHSU and teaches graduate nursing courses. Linda Sanko, MS, MN, RN is an Assistant Professor of Nursing at Fort Hays State University. She graduated from Fort Hays State University with a BSN and a Masters degree in education and a Masters degree in nursing from the University of Kansas. She has taught nursing at ail levis, LPN, BSN and Graduate ievel nursing courses.

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