NR 224 Week 4 Vital Signs Write-Up Example

Vital Signs Write-Up: A Blood Pressure of 162/94 Taken on the Edge of the Bed With a Cuff Too Small, and the Repeat That Read 136/82

Student Name

College of Nursing, Chamberlain University

NR 224: Fundamentals: Skills

Instructor Name

Month Day, Year

Vital Signs Write-Up: A Blood Pressure of 162/94 Taken on the Edge of the Bed With a Cuff Too Small, and the Repeat That Read 136/82

The Grid, With Conditions Beside Each Value

The patient is Mr. T., 58, admitted for cellulitis of his left lower leg, on his second day of intravenous antibiotics; details are composite. He weighs 118 kilograms. The vital signs below were taken at 0815, just after he returned from the bathroom. Each value carries the conditions under which it was taken, because a value without its conditions cannot be judged.

Table 1

First Set of Vital Signs at 0815

Note. Values as first recorded, before any were repeated.

Equipment Before Physiology

The value that drew my attention was the blood pressure. His readings over the previous day had been in the 130s over 80s, and 162/94 was a jump. Before thinking about what might be happening in his body, I asked what the equipment and the method might have done to the number.

Three conditions could each have raised it. The cuff was a standard adult size on an arm I then measured at 38 centimeters around, which calls for a large adult cuff; a cuff that is too small for the arm tends to overestimate blood pressure. He was perched at the bedside with his back unsupported and his feet not touching the floor, and he had just walked from the bathroom. And he was talking during the measurement. The American Heart Association scientific statement on measuring blood pressure recommends a correctly sized cuff, quiet rest before measuring, a supported back, both feet on the floor, an arm resting level with the heart, silence during the reading, and averaging more than one reading (Muntner et al., 2019). My first reading met none of those conditions.

The oral temperature had a similar problem on a smaller scale: he had drunk ice water five minutes earlier, which can lower an oral reading. A temperature of 37.1 C in a man with an infection might be falsely reassuring.

The Repeat, Described

I repeated the blood pressure at 0825 after correcting each condition. I measured his arm and took a large adult cuff from the supply room. He sat in the bedside chair with his back against it and both feet flat on the floor, his right arm resting on a pillow on the over-bed table so the cuff was at the level of his heart. I asked him not to talk, and he rested for five minutes. I then took two readings one minute apart: 138/84 and 136/82, an average of 137/83, close to his readings from the previous day.

I rechecked the oral temperature at 0835, 30 minutes after his last drink: 37.8 C. The second temperature is more important than the second blood pressure. The first blood pressure was falsely high and the repeat was reassuring; the first temperature was falsely low, and the repeat showed a low-grade fever in a man being treated for an infection.

The Other Values, Briefly

The pulse of 96 was counted for 30 seconds and doubled, which is acceptable for a regular rhythm but misses irregularities that a full minute would catch; his rhythm was regular, so the method was sound. At 0825, after five minutes of rest, it was 84, which fits with the first reading having been raised by the walk back from the bathroom. The respiratory rate of 20 was counted while he thought I was still taking his pulse, because people who know their breathing is being counted tend to change it. The saturation of 96% on room air had a clean waveform on the monitor, which is the check that the number reflects a good signal rather than a cold finger or a loose probe.

None of these three needed a repeat for accuracy, but the pulse was repeated anyway as part of the second set, and its fall from 96 to 84 supports the reading of the first blood pressure as a product of exertion rather than of a change in his condition.

One Value, Worked Over

The lesson of the first blood pressure is that a single reading taken under poor conditions is not information about the patient. If I had charted 162/94 and reported it, the provider might have added or increased a blood pressure medicine, and Mr. T. might have become dizzy later that day on a pressure that was actually normal for him. If I had simply ignored it as a bad reading, I would have missed the chance to check it properly. Repeating it under correct conditions settled the question.

The temperature taught the opposite lesson. The first reading looked normal and could have been charted without a second thought, but the conditions made it unreliable in the reassuring direction. The repeat turned it into a finding that matters: a fever on the second day of antibiotics for cellulitis may mean the infection is not yet responding.

Somebody Has to Be Told

I charted both sets with their conditions: the first blood pressure noted as taken with a small cuff after exertion, and the repeat as the valid reading. I told the nurse assigned to Mr. T. at 0840, in two sentences: "His first pressure was 162 over 94 but that was on the edge of the bed with a small cuff; repeated properly it's 137 over 83. His temperature was 37.1 after ice water and is 37.8 on the recheck, on day two of IV antibiotics." The nurse agreed to look at his leg and raise the temperature with the provider at rounds, and asked me to recheck it at 1200. I also asked that a large adult cuff be kept in his room so the next reading starts with the right equipment.

References

Muntner, P., Shimbo, D., Carey, R. M., Charleston, J. B., Gaillard, T., Misra, S., Myers, M. G., Ogedegbe, G., Schwartz, J. E., Townsend, R. R., Urbina, E. M., Viera, A. J., White, W. B., & Wright, J. T. (2019). Measurement of blood pressure in humans: A scientific statement from the American Heart Association. Hypertension, 73(5), e35-e66. https://doi.org/10.1161/HYP.0000000000000087