Running head: EBP ORTHOSTATIC VITAL SIGNS

Nursing 240 EBP Orthostatic Vital Signs & Quality Patient Care Sara J Staffen Ferris State University

EBP ORTHOSTATIC V ITAL SIGNS

Nursing 240 EBP Orthostatic Vital Signs & Quality Patient Care Evidence-based practice (EBP) is the conscientious and cautious use of current best researched evidence along with clinical expertise and patient values to guide health care decision making. Typically, patient safety research focuses on quantitative data to detect problems and demonstrate that a new practice will lead to improved quality of care and increased patient safety. The evidence based practice that I researched analyzed orthostatic vital signs. Nurses use orthostatic, or postural, vital signs to assess the patient's response to position changes when fluid volume loss is suspected. Orthostatic vital signs are often taken in a triage setting when a patient presents with vomiting, diarrhea or abdominal pain, fever, or bleeding with syncope or dizziness. Orthostatic vital signs are also measured routinely after surgery. Orthostatic vital signs should not be collected when there is a potential spinal cord injury or when the patient is displaying an altered level of consciousness. Additionally, orthostatic vital signs should not be performed when a patient is showing signs of hemodynamic instability, which is an abnormal or unstable blood pressure but can also suggest inadequate blood supply to organs. (ENA, 2011) Any time there is potential to cause further harm or injury to a patient, it is not best practice or quality care to execute the procedure. However, performing orthostatic vital signs when it is appropriate can be imperative to superior patient care because it provides opportunity for early detection of orthostatic hypotension (OH), hypovolemia, or a delay in healing. Orthostatic vital signs should include blood pressure and heart rate and should be assessed in three different positions: starting in supine, then straight to standing, and finally sitting with periods of rest in between. In a healthy patient blood that pools in the lower extremities while lying supine, should circulate back through the rest of the body when the blood

EBP ORTHOSTATIC V ITAL SIGNS vessels constrict. In patients that are not experiencing proper vasoconstriction, a sudden drop in blood pressure (BP) may occur upon changing positions. This sudden drop in BP is called orthostatic hypotension (OH). Orthostatic hypotension is often accompanied by other symptoms such as syncope, weakness, fatigue, blurred vision, and others. A sudden drop in BP

accompanied by a rise in heart rate can indicate fluid loss or volume depletion. The main purpose of performing orthostatic vital signs is to rule out hypovolemia caused by dehydration or loss of bodily fluids and blood. Hypovolemia, commonly known as a state of shock, is a decrease in blood volume. Performing vitals in this manner can help detect hypovolemia and is also known to bring to light neurological complications. [See description of accepted current nursing interventions performing orthostatic vital signs under the implementation heading] There are several things that need to be taken into consideration when implementing this system of conducting orthostatic vital signs. Symptoms such as dizziness and syncope, in combination with orthostatic vital signs, are more sensitive indicators of volume loss than vital sign changes alone. Therefore we should not rely solely on vital signs as an indicator of hypotension. Symptoms and vital signs should be documented as the orthostatic variables (ENR, 2012). Although the article does state that more research needs to be done on the topic, I think there is ample proof that we should follow these current recommendations for measuring and interpreting orthostatic vital signs. The key points in this system of measuring are the position change from laying supine straight to standing and measuring at one and three minute increments. Researchers have shown that Pulse change (supine to standing) at one minute had the greatest change between no blood loss and 1000 ml blood loss. (Knopp, 1999). The patient should rest in a flat, supine position for 5-10 minutes before starting vital measurements. Harkel

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and colleagues (1990) discovered that the period of rest did impact the changes in blood pressure and heart rate with more pronounced changes identified following a longer period of rest. During position change, from supine to standing, multifaceted mechanisms such as increased heart rate and vascular resistance typically compensate for the effects of gravity on the circulatory system to maintain blood flow to the brain. The research suggests that compensatory mechanisms may be impaired in patients with hypovolemia which predisposes them to weakness, dizziness, syncope, and the increased risk of falls. (ENA, 2011) EBP Implementation Guidelines Adults (age 17 years and older)* i. The individual should rest in a flat, supine position 5-10 minutes prior to the first blood pressure measurement. (ENR, 2012). ii. Blood pressure measurements should be taken at one and three minutes after standing. (ENR, 2012). iii. Position change from supine to standing has better diagnostic accuracy in volume depleted adults compared to position changes from supine to sitting and then to standing. (ENR, 2012). iv. Orthostatic vital signs alone lack the sensitivity to reliably detect volume losses less than 1,000 ml. (ENR, 2012). iv. Symptoms such as dizziness and syncope, in combination with orthostatic vital signs, are more sensitive indicators of volume loss that vital sign changes alone. Therefore, symptoms and vital signs should be documented as the orthostatic variables. (ENR, 2012) vi. When measuring orthostatic vital signs, one or more of the following findings may indicate intravascular volume loss in adult patients: a. Decrease in systolic blood pressure of 20 mmHg or more b. Decrease in diastolic blood pressure of 10 mmHg or more c. Increase in heart rate of 20 or greater beats per minute (Durukan et al., 2009). Pediatric and Adolescent (less than 17 years) There is insufficient evidence in the literature to make recommendations regarding orthostatic vital signs in the pediatric or adolescent population with fluid volume alterations. (ENR 2012)

EBP ORTHOSTATIC V ITAL SIGNS Vital Outcomes Orthostatic Vitals Signs Include:

Heart rate Blood pressure Symptom assessment

Potential Outcomes Considered Evidence of orthostatic hypotension Vital signs (blood pressure, heart rate) Sensitivity of diagnostic testing (ENA, 2011)

Healthcare is a patient based system that requires expedited critical thinking, constant reevaluation of practices and procedures and standardized implementation of evidence based best practices (EBP) into the clinical setting. Standardization is the key to implementing EBP. It is crucial that once a practice has been researched and new scientific evidence is provided that it is immediately and consistently put into practice. However, these practices are not always implemented properly or at all in patient care therefore, variations in clinical settings appear. Yet, only by putting into practice what is gleaned from research will patient care be made safer. In an EBP study conducted by (Areskough, Kammerlind, & Sund-Levander, 2012) it was found that twenty percent of participants answered that they worked in the way they always had, and 11% responded that they did use evidence from research as a basis for change. This brings to light that fact that EBP is not being implemented adequately in the clinical setting. It is also noted that there are practical and structural barriers along with time and resource shortages that can limit usage of certain EBP. These results indicate that the EBP in healthcare is not used effectively as a basis for decisions in every day practice nor innovating new practices. Consequently, this could affect the care of the patients in a negative way. Increased awareness of

EBP ORTHOSTATIC V ITAL SIGNS EBP and a monitored evidence-based approach are imperative to ongoing improvement and quality patient care. Although there tends to be a lack of, different strategies are necessary to facilitate and promote EBP. These studies were conducted to provide the best evidence-based information for emergency department nurses to implement in caring for their patients. I believe that there should be a standardization of any practice in the nursing field for diagnostic accuracy to

improve patient outcome. There is evidence from these articles that position change from supine to standing has better diagnostic accuracy in volume depleted adults compared to position changes from supine to sitting and then to standing. (ENR, 2012). Therefore, these recommendations of measuring orthostatic vital signs should be implemented as the current clinical practice. Patient safety also needs to be taken into consideration because it should always be a nurses number one priority. Therefore syncope and lightheadedness must be assessed and patients should be assisted to a standing position only when not contraindicated.

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References Areskough, J., Kammerlind, A., & Sund-Levander, M. (2012) Evidence-based practice in a multiprofessional context. International Journal of Evidence-Based Healthcare, 10 (2), 117-125. 04.22.2013, CINAHL database. Naccarato, M., Leviner, S., Proehl, J., Barnason, S., Brim, C., Crowley, M., & ... Papa, A. (2012). Emergency Nursing Resource: Orthostatic Vital Signs. JEN: Journal of Emergency Nursing, 38(5), 447-453. 04.08.2013 CINAHL database. [No Authors] Forum: ENA Emergency Nursing Resources Development Committee. (2011) Emergency nursing resource: orthostatic vital signs. Emergency Nurses Association; 2011 Dec. 12 p. April 21, 2013. Published raw data.