Abstract
Vitals signs focus on measuring blood pressure, respiratory rate, pulse, blood oxygen (sometimes), and temperature (Khan, Ostfeld, Lochner, Pierre, & Arias, 2016). These measurements offer crucial data regarding the state of a patient’s health (Kenzaka et al., 2012). They can be used to detect the presence of a serious medical issue, as a way to measure the level of an illness and how the body is coping with the pressure, and as indicators of protracted illness states (Elliott & Coventry, 2012). Orthostatic blood pressure and pulse measurements are used to assess dizziness or hypovolemia, which necessitates the measurement of BP and HR when the patient is supine and repeating the procedure when the patient is standing (Parati, Ochoa, Lombardi & Bilo, 2013). In this paper, a summary of the study on Orthostatic Vital Signs done by Naccarato et al. (2012) is offered.
Purpose
The objective of the study was to determine the required orthostatic procedure when detecting major changes in patients of all ages. According to the researchers, orthostatic vital signs are required in the evaluation of how the body reacts to changes in positions after losing volume. When the body position changes during normal conditions, blood pooling in the lower body parts moves to the upper part through blood vessel vasoconstriction. Orthostatic hypotension may, however, arise due to autonomic and hypovolemia failure, which can lead to impaired perfusion to the top body parts. Symptoms of this condition include syncope and neck ache, headache, tremulousness, palpitations, nausea, cognitive impairment, fatigue, weakness, blurred vision, dizziness, and lightheadedness. Posture change also leads to a high heart rate due to an immediate blood pressure reduction. Heart rate changes can be used to diagnose orthostatic hypotension (OH), which may indicate changes in volume. There is, however, a confusion regarding the required procedure for measuring orthostatic vital signs. The study, thus, sought to identify the required measurement procedure for orthostatic vital signs.
Delegate your assignment to our experts and they will do the rest.
Methods
Information was collected following an extensive literature review and analysis. Researchers engaged in an extensive literature search in which they identified the relevant articles. They searched six databases, which included the National Guideline Clearinghouse, Google Scholar, BioMed Central-Open Access, Cochrane Library, CINAHL, and PubMed (Medline). The researchers identified common terms found in the literature, which included orthostatic vital signs, postural vital signs, and tilt test. Keywords used during the searches included vital signs, hypotension, orthostatic hypotension, blood pressure, orthostatic, and orthostatic vital signs. In the identification of studies related to the volume status of orthostatic vital signs, the researchers used the keyword hypovolemic. Initially, the search focused on English articles ranging from January 1990 to March 2011, which was later extended to include 1940s studies. Additionally, the chosen studies were screened for relevant research findings, which led to an extra search that ranged from April 2011 to June 2015. The Clinical Guideline Committee made the clinical outcomes and recommendations levels about managing patients based on ENA recommendation practice rules.
Results
Body Position and Timing
The study found that further research is required to offer a better definition of orthostatic vital signs. The literature review showed that most studies based their definition of orthostatic vital signs on the purpose, the method of measurement, and physiological factors (stroke index, heart rate, lightheadedness or dizziness symptoms, and blood pressure). The researchers described orthostatic vital signs to be a shift in heart rate, blood pressure, or commencement of symptoms after changing the body position.
The study identified the rest period before measuring the supine to be one minute, two minutes, three minutes, or five minutes. The study also found that the rest period influenced heart rate and blood pressure changes. Significant changes occurred after a long rest period. The recommended time to measure blood pressure was after five minutes of rest and in the upper arm. During the measurement the patient should not talk, cross the legs, and support should be offered to the arm and the back to avoid influencing blood pressure interpretations.
Regarding sitting, the study identified that the sitting position had no effect on blood pressure as changes in blood pressure only occurred from the supine to the standing position.
When standing, it was possible to detect OH within two minutes of standing, even though studies demonstrated time variations that ranged from three minutes to one minute. Within an average of 20 minutes, delayed OH occurred whereas traditional OH happened within three minutes. The elderly may experience delayed OH more regularly due to diuretic and vasoactive use of medications and co-morbidities. People with mild symptoms and standard orthostatic vital signs should be examined again within 3 minutes of standing to exclude delayed orthostatic hypotension.
Fluid Volume Loss Sensitivity
The study found orthostatic vitals to be less sensitive to less than 1000 ml volume losses among adults. Pulse rate was found to be the most sensitive vital sign to detect a loss of 450 ml of blood. At one minute, a change in pulse (supine to standing) had the most significant change between lack of blood loss and loss of 1000 ml of blood. Change in pressure had no effect on blood changes.
Orthostatic Vital Signs
The main measured physiological aspects were blood pressure and heart rate. In adults, orthostatic hypotension occurred when the blood pressure decreased and the heart beat increased due to changes in the body position. Patients should rest for 5 to 10 minutes before taking the initial blood pressure measurements as any activity before orthostatic vital signs measurement can affect the outcomes.
In many adolescents, diastolic and systolic blood pressure increased instead of decreasing upon changes in position, which suggested that hypovolemic adults and adolescents experience different blood pressure reactions caused by identical position changes. Orthostatic vital signs measurements in adolescents, thus, necessitate further research due to varying measurements among this population. Children did not show significant systolic blood pressure changes.
The second common variable to be measured was the heart rate. There were notable heart rate changes in a few studies involving healthy participants. The heart rate was found to have a 9 per cent sensitivity and a 98 per cent specificity following a heartbeat increase of more than 20 beats per minute. Sensitivity increased to 17 per cent following more than 20 beats per minute even though specificity remained constant. There were no significant changes between healthy people and ill people regarding heart rate changes. There were no notable changes among children, which necessitates further research for proper comparisons with adults.
Syncope symptoms and shock index was also assessed. Syncopal patients had identical timing of blood pressure changes, baseline blood pressure, drugs, and age, whether or not they had OH. Presyncopal signs were recorded after a 3 minute break but prior to a 5 minute break. There were also significant shock index changes when participants were in semi-supine positions. Researchers suggested that it would be challenging to measure shock index in emergency situations without a readily available calculator because of the required time.
Equipment
Studies used different equipment to measure blood pressure, which ranged from manual tools in the 1980s to automated tools in the 2000s. The researchers suggested that automatic tools are unreliable during the detection of blood pressure or exclude orthostatic hypotension due to their low sensitivity.
Patient Safety
The study found that among the hypovolemic people, the compensatory mechanism was impaired, which predisposed the people to a high risk of falls, syncope, dizziness, and weakness. The reasons that would necessitate orthostatic vital signs measurement include injuries to lower body parts, pelvis, or the spine, severe altered mental state, shock, and supine hypotension.
Conclusion
The researchers concluded that studies reported different pieces of evidence regarding different variables required to obtain and interpret orthostatic vital signs. Their recommendations emphasized resting before the first blood pressure measurement, taking measurements at 1 and 3 minutes after standing, focusing on position changes from supine to standing, using other techniques besides orthostatic vital signs to detect less than 1000 ml volume losses, combining orthostatic vital signs with syncope and dizziness symptoms to measure volume losses, and using at least one criteria from the following to identify intravascular loss of volume among adults: a 20mmHg or more reduction in systolic blood pressure, a 10 mmHg or more reduction in diastolic blood pressure, or a 20 or greater increase in beats per minute heart rate.
The researchers also concluded that the reviewed studies lacked adequate evidence to allow them to make suggestions about orthostatic vital signs among children or adolescents with changes in fluid volume.
References
Elliott, M., & Coventry, A. (2012). Critical care: the eight vital signs of patient monitoring. British Journal of Nursing , 21 (10), 621-625.
Kenzaka, T., Okayama, M., Kuroki, S., Fukui, M., Yahata, S., Hayashi, H., ... & Hashimoto, M. (2012). Importance of vital signs to the early diagnosis and severity of sepsis: association between vital signs and sequential organ failure assessment score in patients with sepsis. Internal Medicine , 51 (8), 871-876.
Khan, Y., Ostfeld, A. E., Lochner, C. M., Pierre, A., & Arias, A. C. (2016). Monitoring of vital signs with flexible and wearable medical devices. Advanced Materials , 28 (22), 4373- 4395.
Naccarato, M., Leviner, S., Proehl, J., Barnason, S., Brim, C., Crowley, M., ... & Papa, A. (2012). Emergency nursing resource: orthostatic vital signs. Journal of Emergency Nursing , 38 (5), 447-453.
Parati, G., Ochoa, J. E., Lombardi, C., & Bilo, G. (2013). Assessment and management of blood- pressure variability. Nature Reviews Cardiology , 10 (3), 143.
