Rethinking vital signs. I know. Again.

Not unusual vital signs for me. You have to consider the patient!

Not unusual vital signs for me. You have to consider the patient!

Vital signs are important. That's why they're called vital. I know that isn't why, but it's catchy. Nurses take them a lot. Less often, we think about what we're doing with them.

Today my dad went to the ER and was hypoxic (89% on room air) with a hemoglobin of 6.1. He looked sick. This ER used the monitor to get an initial set of vital signs and then unhooked everything. A nurse came back and put some oxygen on him, but no pulse ox.

For his transfusion they used the monitor as one would a rolling stand: take the vitals. When 15 minutes have gone, take them again. All this time his SpO2 was around 90% on 2 L of oxygen.

I was filled with righteous indignation. This SICK PATIENT wasn't even ON THE MONITOR. I sniped and bitched passive-aggressively about it ("he should be oxygenating better now that he's getting blood...NOT THAT WE WOULD KNOW, since he's not on the monitor"). I twitched. I wanted to know his vital signs!

Before I go on, I should say I have fought this battle before in different battlegrounds. The frequency of vital signs should be a nursing decision, even though there should be some minimal facility standards. I just tilted at this particular windmill at my most recent job, where my boss said to reschedule any kid with a high blood pressure for a hypertension chronic care consult, or some such horseshit. What about if it's high because of pain, or the kid just got his face beaten in, or a thousand other obvious reasons that cause temporary changes in vital signs? Didn't matter. No room for judgment.

Anyway, today, finally I couldn't stand it anymore and asked the nurse why he wasn't on the monitor. Her points were as follows:

  • His vitals had remained unchanged for hours (they were bad, but stably so)
  • The cables increased his fall risk, and he was already dizzy and unsteady from the hypoxia
  • It is a far better idea to measure only the vitals you plan to chart and/or act on, rather than go back later to hours of q 15 vitals and realize you probably should have done something about that 190/110 blood pressure before
  • Nurses should match the way the patient looks with what the vitals are, which requires her to be in there anyway to have the numbers make any sense
  • His clinical condition was not one precariously riding on a change in vitals ("although we could," she said, "really get worked up every 15 minutes because his blood pressure is STILL HIGH, if you want")

I liked it. Maybe we SHOULD be reserving constant monitoring for people on vasoactive drips and other similarly dicey situations. My dad was extremely ill, and still after pondering the issue at some length, I agree with his nurse. The question we should be asking is not "how sick is the patient?" It is "what question am I answering with his vital signs?" Let's challenge ourselves to really think about this most basic of tasks. WHY are we doing it for THIS patient? WHAT are we looking for? And if we're delegating, we need to communicate things things too. Thoughts?