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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 assessment Basis for many clinical decisions Accuracy of VS Influences the patient’s clinical course

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vital signs in the ambulatory setting an evidence based approach

Vital Signs in the Ambulatory Setting:An Evidence-Based Approach

Cecelia L. Crawford, RN, MSN



the importance of vital signs
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
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 signs4
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
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 signs6
The HCW & Vital Signs

HCW has a definite influence on VS

  • Speech
  • Touch
  • Physical presence
the hcw vital signs7
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
Vital Sign Technology

Automated machines

  • Electronic/infrared thermometers
  • BP & Pulse Oximetry
  • Convenient
  • May save time & labor
    • not confirmed by current studies
vital sign technology9
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
Vital Sign Techniques & Methods:An Overview



Respiratory Rate

Blood Pressure

Pulse Oximetry (5th VS)


Glass Thermometers

  • Associated with adverse events
    • Rectal/oral trauma
    • Mercury exposure

Axillary Temps

  • Great variation with no “norm” found

Oral Temps

  • Position oral thermometers in left or right sublingual pockets
  • NOT influenced by breathing patterns
  • IS influenced by hot & cold fluids

Tympanic Thermometers

  • Can be affected by
    • Extremes in environmental temps
    • Localized heating/cooling measures
  • Ear tug positively affects accuracy
  • Impacted cerumen adversely influences accuracy

Tympanic Temps - Patient Perceptions

  • Parents prefer re: speed, ease, cleanliness, & safety
  • Peds patients reacted more positively

Count for 60 sec

Count for 30 sec and multiply X2

  • Shorter time counts = inaccurate data

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
Respiratory Rate

Count for 60 sec

Count for 30 sec and multiply X2

  • Shorter time counts = inaccurate data
respiratory rate18
Respiratory Rate

Pediatric patients

  • If panting, use stethoscope to count
  • Agitation can result in inaccurate RR
respiratory rate19
Respiratory Rate

RR is NOT a reliable screen for oxygen desaturation states!

  • RN and MD assessment is needed
blood pressure
Blood Pressure

Use a consistent & standardized method to minimize inaccuracies

  • Machine or auscultation
  • Functional & calibrated machine
  • Korotkoff’s sounds
  • Properly trained HCWs
blood pressure21
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 pressure22
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
Pulse Oximetry

Possible consideration as the 5th VS

Use in situations where patient assessment & monitoring is critical

vs it s all about the numbers
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
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 vs26
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 vs27
Final Thoughts on VS

HCW Education & Training

  • VS Accuracy & Communication of Data
  • Competencies
  • Annual Review of Skills
recommendations equipment
Recommendations - Equipment

Automated BP devices (Welch-Allyn)

Vital Sign Monitor

Tympanic thermometers (Kendall Healthcare)

  • Genius tympanic thermometer
recommendations reference texts
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
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
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
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!


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.


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.


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.


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), 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
For more information:

Cecelia L. Crawford, RN, MSN

Project Manager for Evidence-Based Nursing Practice

So. Calif. Nursing Research Program