Help with Critical Vitals Ranges in EMR

Esme12, ASN, BSN, RN · Nov 17, 2011

adults:

normal temperature: oral (96.8f - 99.5f), rectal (97.3f - 100.2f), tympanic (97.2f - 100.0f)
normal pulse: 60 - 100
normal respirations: 12 - 20
normal blood pressure: 100 - 139/60 - 89
reference: expert 10-minute physical examinations, 1997, mosby's

newborn:

axillary temperature: 97.7f - 99.5f
pulse: 120 - 160
respirations: 30 - 60
blood pressure: 73/55 systolic

one-year old:

axillary temperature: 97.0f - 99.0f
pulse: 90 - 130
respirations: 20 - 40
blood pressure: 90/56 systolic

toddler:

axillary temperature: 97.5f - 98.6f
pulse: 80 - 120
respirations: 20 - 30
blood pressure: 92/55 systolic

pre-schooler:

axillary temperature: 97.5f - 98.6f
pulse: 70 - 110
respirations: 16 - 22
blood pressure: 95/57 systolic

school age child:

oral temperature: 97.5f - 98.6f
pulse: 60 - 100
respirations: 16 - 20
blood pressure: 107/64 systolic

adolescent:

oral temperature: 97.5f - 98.6f
pulse: 55 - 90
respirations: 12 - 20
blood pressure: 121/70 systolic

reference: saunders comprehensive review for the nclex-rn examination, 3rd edition, by linda anne silvestri

these are the "normal values" extreme's on any of these can be considered critical.

Esme12, ASN, BSN, RN · Nov 17, 2011

https://sites.google.com/a/iconopsych.com/psychlopedia-com/Home/vital-signs---critical-values

Critical Vital Signs & Symptoms

Patients exhibiting any of the critical indicators listed below to receive a face-to-face evaluation by a physician, with documentation in the medical record. Clients exhibiting critical signs and/or mental status changes require medical evaluation for possible infection, medication affects, or chronic disease.

Blood Pressure

Systolic 160

Diastolic 110

Temperature

> 103°

Pulse

> 140 must do EKG

Respirations

> 30

O2 Saturation

Acute Significant Bleeding

Any acute on set of significant bleeding

Significant Mental Status Changes

Significant changes in mental status can sometimes be a symptom of a developing or deteriorating medical condition.

Seizure Activity

New onset or prolonged seizure activity

Weight Change

> or

TiffyRN, BSN, PhD · Nov 17, 2011

I don't have any official information. My feeling is that it's not the responsibility of the EMR to alert to those critical ranges. Those should be established somewhere in a unit policy.

It's kind of like how the lab insists on calling a nurse for every "critical" value which they have in some general book, not specific to neonates (where I work). The nurses get to screen all those "critical" values, then only call the doctor for values out of the range set for our unit (or for that particular infant). Thankfully, they haven't established a requirement that the MD be notified for every critical value.

Once more, I think critical values should be established for each unit. The reason you can't find any defined values is not because someone is skirting responsibility, it's because it's not a black and white science, what's critical on one patient may not be on another. What's normal on one patient may be deadly on another.

I actually find it amusing sometimes what our EMR decides to flag in red.

Now if you could get the medical staff to agree to the ranges, then fine, put those in your EMR, but I almost guarantee you they will not come to a consensus.

BluegrassRN · Nov 17, 2011

I agree; I feel the only time the EMR should flag something is when there is a med with specific parameters, or the physician has written an order for notification/labs under certain conditions.

For example, if the pt's lasix says "Hold if SBP

If there is an order that says "Blood cultures for temp greater than 38.6" a prompt to order blood cultures (or an automatic order) should pop up to notify me.

For some odd reason, we have parameters set on our mobile charting devices, but not our computer charting devices, and not on our emar, only on our vital signs recording page. So, if a drug has parameters on it, I don't know unless I hover over it. Guess how many times I've missed that one?

And, annoyingly enough, we have tight parameters on things like BP. It always pops up a "The bp is outside of normal range". Our parameters are set at 140/90. I often go an entire shift without a pt with a normal blood pressure, so entering VS is a lot more clicking than it should require.

LaughingRN · Nov 17, 2011

hello,
thanks for taking the time to read this.
i work at a psychiatric hospital as an informaticist and am reviewing vitals ranges for our emr. anything that is entered out of range will flag red. i've been told policy states any vitals displayed in red require a call to the doc. i'm not so sure i totally buy into this, but that's what i've been told and what i'll work from.
currently, the following ranges have been set:
hr: 1 and 500.
rr: 1 and 100.
sbp: 1 and 501.
dbp: 1 and 501.
blood glucose: 51 and 350.
we have a fair amount of errors at our facility. i'm getting resistance for wanting to tighten these ranges, but i can't find any literature to define critical vitals values/ranges. i'm getting the sense these ranges are set, in part, to allow some to skirt responsibility. i get they shouldn't be tightened too much, but these ranges are just too broad.

i was waiting for someone else to point out the fact that if critical vitals are only flagged when out of these ranges, i'm pretty sure it would be a bit too late...

AngelofLTC · Nov 17, 2011

Ya think? lol.