Lessons · Nursing · a change in vitals: what first
A set of vitals has changed: what comes first
Go and look at the patient, confirm the measurement by repeating it yourself with the right equipment and technique, then report it with SBAR and document what you found and what you did.
Hone is a place to practise a career, one idea a day. This is one of its lessons, written out in full and free to read without an account.
What it is for
A machine reading taken through a sleeve with the wrong cuff size is a number, not a change; a patient who looks different from an hour ago is a change whatever the machine says. Going to the bedside first answers both questions at once, and it takes twenty seconds.
How to think about it
Go and look. Repeat the reading yourself, manually if the equipment is in doubt, with a cuff that fits and the arm supported. Compare with the last few sets, not only the one before. Then call, with the figures and their times, and write down the reading, the recheck and the call.
Worked example
1. Go to the patient and lookHow they look is information no machine has.
2. Repeat the measurement yourself, right cuff, arm supportedA confirmed figure is what a call can be made on.
3. Compare with the previous sets and their timesA trend across three sets says more than one figure.
4. Report with SBAR, with the figures and their timesSituation, background, assessment, recommendation.
5. Document the reading, the recheck, the call and the timeWhat was found, what was done, when.
Your turn
Write who you go to before trusting any reading.
1. Go to the and look
Solve one, graded on the server
The trap
Charting the first reading and moving on because the shift is busy. An unconfirmed figure in the record is what the next person acts on, and a cuff that was the wrong size is invisible on the page.