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.

[RNGriffin]

The actual cuff not aligned to detect the korsakoff sound. I've seen many CNAs bring in a bariatric or thigh cuff for my tiny 95lb patient.

[1fastRN]

Very sick febrile CA pt was was admitted to onc floor... No bed yet so he was being held in the ETD. When i got report on him he was at xray. He came back and he was AMS but i didnt think much of it bc the nurse before me told me he was altered. So i didnt have much of a baseline to compare to.

All of a sudden hes in extreme pain and HR shoots to 160 (it was 105ish earlier). I get an ekg and call the admitting doc to get a dilaudid order. As im medicating him his eyes roll back and he starts seizing. Family watches in horror bc hes never had a seizure. 2mg of ativan later the seizures stop. I run him to CT for a head scan to r/o anything traumatic. Pt is restless and just generally unstable. I bring him back to the ER and we end up intubating him.

I thought he was tachy due to pain, which may be the case.... But in retrospect it may have been an aura to a seizure. Now thats always in my mind wuth sudden onset tachy patients!

[amygarside]

This thread would be helpful for new nurses. Sometimes, we really need to double check the patient's current condition prior to taking vital signs.

[Dazglue, ADN, BSN, MSN, RN]

When I worked tele we only took manual BPs. All the techs had stethoscopes.[/quote']

At least your tech's know how to take a manual. Even though it's a class check-off when they are first hired, I always get that "deer in the headlight" look when I ask the tech to do a manual re-check. That was when I first started as a nurse. Now, I always do my own manual re-checks if anyone has abnormal vitals. Plus I only trust manuals on patients with conditions such as A-fib.

[ADeks]

If pt presents with possible stroke symptoms ALWAYS check a blood glucose! Hypoglycemia mimicks stroke symptoms. [/quote']

This! I had a patient that we called a stroke alert on in the ER from the waiting room. Meanwhile were having trouble getting an IV and blood work (delayed lab values). Usually we run labs to our ER lab and stroke blood work gets done priority. Checking a quick CBG completely slipped my mind because we were pushing to get him into CT. Comes to find out his CBG was 50. Some OJ and D50 he was back to completely normal.

Now I'm a stickler for doing a CBG for anything neuro and when any diabetic pt feels "funny".

[DedHedRN]

Lets see, most common reasons for abnormal vitals that I have seen in LTC, could probably apply anywhere.

1. BP taken after pt upset over something

2. BP cuff upside down, to tight, wrong size.

3. BP after pt gets toe ran over by wheelchair, skin tear ect.

4. Pt just drank hot drink/cold drink

5. Pt talking so much they forget to breath

6. Pt holding breath

7. Pt late on getting BP med

8. Pt late on getting cardiac med

9. Pt refused meds completely.

10. Pt spit out meds.

I take em twice if they are abnormal and look at the pt, then ask them how they feel, and look for above reasons to see if any apply.

[Here.I.Stand, BSN, RN]

Gotcha. Actually now that I think about it, it seems like my floor had VS parameters set where the CNA would notify the RN immediately if the pt was outside of those parameters. Not that we were expected to know/interpret abnormals.

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.

[fetch, BSN, RN]

Chewing gum can cause a temp elevation too -- not a huge jump in most cases, but if someone runs hot to begin with and they're chewing gum right before temp is taken, it can bump it up that little bit into "abnormal" category. (source - plus anecdotal experience)

[nurseprnRN, BSN, RN]

Gotcha. Actually now that I think about it, it seems like my floor had VS parameters set where the CNA would notify the RN immediately if the pt was outside of those parameters. Not that we were expected to know/interpret abnormals.

I always told the CNA that I wanted to know right away if Ms. Jones' VS were more than/less than because ... . Makes it more likely that I'd find out, too, because the CNA feels more like part of the care team and less like an automaton with no judgment or feelings.