I don't know about you, but every time I see a patient and their family for the first time and take their vitals as part of the nursing assessment, either after each vital or at the end of the vital checks, I'm asked something to the effect of “is that good?”
As you, my friendly readers, bloom as hospice nurses, you will learn that the vital sign portion of the assessment is just a smidge of the entire assessment as to whether someone is approaching the end of life, going through reversible or terminal restlessness, or just having a difficult day. Let me share how I educate families that get hyper-focused on vitals.
The education process starts the first time I'm with the patient and family (whether they are my patient or that of another nurse) and then is reinforced whenever the patient or family starts getting hypervigilant about vital signs. The framework of what I share is as follows:
We will get vital signs every time I or another nurse visits your loved one. Then I pause and ask them if they have ever been to a museum or an art gallery, somewhere with portraits and pictures where you stand about 6 to 10 feet back… most people have, and if not, then hope for a painting in the room or house you are in. I share, “Vital signs are like the artist's signature on a painting.” You don't see them 6 to 10 feet away. You must get up close to see them.” Their size in relation to the painting is relative to their importance. It's not that the artist doesn't matter, but the focus is on the painting or picture, not the artist. The same goes for vital signs. Trends may matter over time, but day-to-day until the end of life, the numbers are meaningless. If I see a vital sign of concern due to a trend or moment of crisis, I will alert the doctor and let you know so we can talk about options, but for now, don't fret about the numbers.
For those of you who are new hospice nurses, know there's always fine print. Let me go over those vitals that may have meaning based on what you've been seeing with the patient:
Low-grade to higher fevers are expected if the patient is dehydrated and at the end of life. A terminal fever cannot often be broken. Do try acetaminophen if the patient can swallow; I don't recommend rectal suppositories as the goal is patient comfort. Also, try cool, slightly damp washcloths over the patient's head, a somewhat cooler room with one or more fans, and make sure the patient is not too wet or cold.
Pulse can be higher than usual if the patient has pain, fever, low oxygenation, or low blood pressure. If you have a patient who has been in the 120s or higher for any length of time, be careful, as the patient may be in the last few days or so of life. If you see a patient who had a baseline of tachycardia for several days and suddenly has a heart rate within normal limits, think out of the box that the patient may be heading towards zero unless there are purpose-driven medication changes that have taken place (i.e., the patient was started on a beta-blocker or another medication that would impact the patient's heart rate).
Blood pressure, for me, is generally a guideline of medications to stop, such as a patient trending downwards and then calling the PCP or medical director to review medications to continue. Now, there are times when I see bradycardia with hypotension, and that can easily be a sign of a downward spiral. But daily, the biggest question I get is on the diastolic numbers, where the patient or family might question a 130/40 as being too low on the bottom number. There, I share what I learned on a cardiology unit: Unless you have a traumatic event or the bottom number is approaching or above 100, there's no concern.
