Most common (+ overlooked) reasons for abnormal vitals?

[SoCal student]

I was thinking a very useful thread for students, new nurses, etc., would be one in which everyone weighs in on most common and/or overlooked reasons for abnormal vitals.

I'm thinking along the lines of:

Hypertension: "white coat" anxiety, stress

Bradycardia: possible baseline for an athlete

Low temp: ensure pt. hasn't recently drank cold fluids

Also, maybe some more commonly seen combinations:

tachycardia and hypotension: dehydration.

Would love to see some of the responses from the seasoned nurses here, maybe see some stuff we never would have thought of.

[BrandonLPN, LPN]

Patients who get Tylenol around-the-clock for pain can mask a fever.

Patients lying on their side while the cuff is inflating leads to false lows.

Poor peripheral circulation can lead to false spo2 readings.

Alcohol wipes can give false highs with glucoscan checks if you don't allow the finger to dry.

I've seen improper technique and/or laziness on the part of caregivers render the vitals they obtain meaningless. Temps of 95.2F or so are common on my unit 'cause the aides use those stupid tympanic thermometers incorrectly. And don't even get me started on the respiratory rates....

I just get my own vitals.

[nurseprnRN, BSN, RN]

FWIW, oral temp is not affected by oral intake of hot or cold liquids or by smoking, after a period of ten minutes or less. There is such a high blood flow through the sublingual tissue that local tissue temp equilibrates really rapidly.

[nurseprnRN, BSN, RN]

Patients lying on their side while the cuff is inflating leads to false lows.

The most common cause of lousy BP is lousy BP technique. To increase chances of accuracy, the cuff should be at RV level (not above (false low) or underneath (false high), as in a side-lying patient), the cuff must be applied properly (look at the Index Line, goes over the artery. Don't know where the artery is? Hmmmm.....the microphone will now be far from what it's supposed to be listening for) and the cuff must fit symmetrically and evenly and snugly before it's inflated so it inflates with the minimum necessary volume of air.

Also, mechanical BP cuffs will never give you accurate BPs in atrial fib-- you need a live, experienced clinician's ears with a manual cuff and a stethoscope to evaluate the variable sounds that result from uneven ventricular filling with AF. And even then, if the CNA doesn't understand what AF is and why we care.... well, as I heard one seasoned CNA explain to a new one, "If I can't hear, I just write down 120/80, that's a good one."

[dirtyhippiegirl, BSN, RN]

Burns mess everything up. Even a relatively small burn can cause rebound tachycardia, fever, and hypotension without actual sepsis. (Although we get a lot of that, too.) It's always weird to get floated to another ICU and have to reset myself -- ie. a heart rate of 120 is NOT normal.

[nynursey_]

The most common cause of lousy BP is lousy BP technique. To increase chances of accuracy, the cuff should be at RV level (not above (false low) or underneath (false high), as in a side-lying patient), the cuff must be applied properly (look at the Index Line, goes over the artery. Don't know where the artery is? Hmmmm.....the microphone will now be far from what it's supposed to be listening for) and the cuff must fit symmetrically and evenly and snugly before it's inflated so it inflates with the minimum necessary volume of air.

Also, mechanical BP cuffs will never give you accurate BPs in atrial fib-- you need a live, experienced clinician's ears with a manual cuff and a stethoscope to evaluate the variable sounds that result from uneven ventricular filling with AF. And even then, if the CNA doesn't understand what AF is and why we care.... well, as I heard one seasoned CNA explain to a new one, "If I can't hear, I just write down 120/80, that's a good one."

^ THIS!

Our PCA's, who I am consistently reminded are UAP, take manual BP's for patient's having atrial fibrillation all the time. I hardly know whether or not most of the BP's are accurate, so in the event that a patient is on a cardiac medication requiring a BP check prior to administration (which is almost all the time), I take the BP myself (or if the patient is on q4 VS).

At one point during my last rotation on, I heard an RN gripe about how a UPA didn't share a low BP reading with her and she didn't notice it all shift. While I disagree that she didn't check the entire shift, I also disagree that the UAP shouldn't have been responsible to share the number. The rationale? The UAP cannot interpret a BP and/or whether or not it is "too low" or "too high." If that's the case … they should only be able to use dynamap's to read BP's and if someone has a complicated cardiac history, they shouldn't be taking vitals at all.

Human error on VS can be costly!

[Here.I.Stand, BSN, RN]

Huh? I was a hospital CNA for a couple of yrs and took all the VS. I was expected to notify the RN immediately of any abnormal VS. Normal ones I gave to them after I had finished rounding.

[nynursey_]

Huh? I was a hospital CNA for a couple of yrs and took all the VS. I was expected to notify the RN immediately of any abnormal VS. Normal ones I gave to them after I had finished rounding.

Our hospital doesn't have CNA's. We have PCA's and they are unlicensed. They go through a brief orientation training that goes over taking blood pressures, calculating I&O's, TRP patients, documenting in the computer, etc. And I believe it is for this reason why I was told that it is not the job of the CNA to interpret an abnormal vital sign, but the RN's responsibility to ensure that the vital sign documenting has been done and then determine whether or not it's abnormal. I'm still a little fuzzy on that whole conversation. I know PCA's are taught what an abnormal vital sign is for sure, but it appeared as if the person I was talking to was trying to absolve reporting that vital sign as a duty not just of the PCA.

[nynursey_]

By unlicensed, I should have used the word "not certified."

[Christy1019, ASN, RN]

Altered mental status/confusion in the elderly can be a symptom of UTI.

If pt presents with possible stroke symptoms, ALWAYS check a blood glucose! Hypoglycemia mimicks stroke symptoms. Actually had this happen last night, triage brought me a "stroke patient" with slurred speech, and weakness. No-one in triage, nor the MD who evaluated him thought to check his sugar, so I go get the glucometer and low and behold, BS 46mg/dl !! An amp of D50 and some ceftriaxone later (pt ended up with UTI too! Lol), pt was back to his normal self!

[Cuddleswithpuddles]

I will add that sometimes V/S are overlooked because they seem to be within normal range, but are abnormal for the patient.

Example: A young, fit patient with a baseline HR of 50-60 bpm suddenly sustains in the 90s at rest. Any sustained increase in baseline HR is suspect. I would not be alarmed but I would definitely investigate:

- Pain, nausea and general discomfort

- Infection. Fever

- Oxygenation issues, even if SpO2 seems OK

- Any issues affecting cardiac output like hypovolemia.

- Medications given recently

[Cuddleswithpuddles]

Ooh, GrnTea hit the nail on the head with her post about automated BP cuffs and atrial fibrillation.

Portable V/S machines often misread HRs that are calculated during BP cuff inflation too. Patients who have irregular HRs in the low 100s on the monitor can look like they have a HR of 55 when their V/S are taken by a machine.

Always, always, always have your own BP cuff. I don't know about your hospital but mine keeps their manual cuffs precisely where I DO NOT need them when I need them the most lol!

[Lev, MSN, RN, NP]

Also, mechanical BP cuffs will never give you accurate BPs in atrial fib-- you need a live, experienced clinician's ears with a manual cuff and a stethoscope to evaluate the variable sounds that result from uneven ventricular filling with AF. And even then, if the CNA doesn't understand what AF is and why we care.... well, as I heard one seasoned CNA explain to a new one, "If I can't hear, I just write down 120/80, that's a good one."

When I worked tele, we only took manual BPs. All the techs had stethoscopes.