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MODULE 2: CLINICAL MONITORING ESSENTIALS
Section 5: Vital Signs & Physical Assessment
If lab values are the high-resolution photographs of a patient’s internal state, then vital signs are the live video feed. They provide a continuous, real-time stream of data about the body’s most basic functions. For a pharmacist, vital signs are not just numbers in a chart; they are the immediate feedback loop on the effects—both therapeutic and adverse—of the medications you verify.
Blood Pressure (BP): The Force of Life
Normal Range: Typically < 120/80 mmHg
Blood pressure is the force exerted by circulating blood on vessel walls. Adequate BP is essential to perfuse vital organs. In the hospital, you will manage both hypertension and, more acutely, hypotension.
Hypotension (Low BP)
Low blood pressure (e.g., SBP < 90 mmHg) is an urgent issue indicating inadequate organ perfusion. It's a common feature of shock and a frequent side effect of medications.
Your Core Interventions
- The Antihypertensive Hard Stop: Your most critical daily intervention is to check the BP trend before verifying any antihypertensive. It is your absolute responsibility to recommend holding metoprolol, lisinopril, etc., in a patient with a low or declining BP.
- THE TREND IS EVERYTHING: A single low reading might be an error. A trend of declining BPs over hours is a sign of impending crisis. Always look at the graph in the EHR.
Hypertension (High BP)
Severe hypertension in the hospital can be a sign of pain, anxiety, or a hypertensive emergency. Management requires careful consideration of the clinical context.
Your Clinical Judgment
- Treat the Cause, Not the Number: Before verifying a PRN IV antihypertensive, investigate the cause. Is the patient hypertensive because their pain is 10/10? The correct intervention may be an analgesic, not hydralazine.
- Gatekeeper for IV Use: You are the gatekeeper for appropriate use. PRN IV antihypertensives (labetalol, hydralazine) are for emergencies. For routine inpatient hypertension, recommend optimizing the patient’s scheduled oral regimen.
Deep Dive: Mean Arterial Pressure (MAP)
In the ICU, MAP is the most important perfusion indicator. A MAP < 65 mmHg is a sign of shock. Vasopressor infusions are titrated to this goal. You must be fluent in this language.
[ MAP approx frac{SBP + 2(DBP)}{3} ]
Heart Rate (HR): The Body’s Pace Car
Normal Range: 60 – 100 bpm
Heart rate is a direct reflection of the heart’s effort. Many medications you manage have a direct effect on it, requiring your constant vigilance.
Bradycardia (< 60 bpm)
A slow heart rate is often a sign of medication effect. Symptomatic bradycardia (e.g., HR < 50 with dizziness) is a serious issue.
The Rate-Slowing Drug Check
Before verifying any medication that lowers heart rate, you must check the HR trend. This is a critical safety check for: beta-blockers, diltiazem, verapamil, digoxin, and amiodarone. Holding these for a low HR is a vital intervention.
Tachycardia (> 100 bpm)
A fast heart rate is a non-specific sign that something is wrong—pain, fever, dehydration, or a primary arrhythmia. Tachycardia is a symptom, not a disease.
Investigate the Cause
- Is the patient’s fever being treated? Is pain controlled?
- Identify culprit drugs: high-dose albuterol, stimulants.
- For atrial fibrillation with RVR, you will recommend and dose IV rate control agents (diltiazem, metoprolol).
Respiratory Rate (RR) & Oxygen Saturation (O₂ Sat)
The Twin Metrics of Breathing
RR is the number of breaths per minute, a sensitive indicator of distress. O₂ Sat estimates the oxygenation of the blood. Together, they provide a picture of how effectively the patient is breathing.
Normal Ranges: RR ~12-20 breaths/min; O₂ Sat > 92%
Masterclass: Guardian of the Respiratory Drive
Opioid-induced respiratory depression is a leading cause of preventable death in hospitals. Your role in monitoring these vitals is paramount.
| Vital Sign | The Red Flag | Your Intervention |
|---|---|---|
| Respiratory Rate (RR) | A downward trend, or any RR < 12 (bradypnea), especially if the patient is also sedated. | This is a critical finding. You must recommend holding the next opioid dose, ensure naloxone is available, and communicate your concern to the nurse and provider. |
| Oxygen Saturation (O₂ Sat) | A drop in O₂ saturation (hypoxia) is a LATE sign of respiratory depression. The RR will almost always drop first. | Do not wait for the O₂ sat to drop. By then, the patient is already in significant trouble. Focus your monitoring on RR and sedation level. |
Temperature, Pain, & Neurological Assessments
The Subjective and Neurological Dashboard
These assessments provide crucial context for your pharmacotherapy decisions, moving beyond simple numbers to the patient’s experience and neurological status.
Temperature
A fever (>100.4°F or 38°C) is a cardinal sign of infection. A new fever is your call to action to review the chart for signs of infection, ensure blood cultures are drawn, and recommend timely empiric antibiotics.
Pain Scales (0-10)
Pain scores are your primary tool for assessing analgesic efficacy. If a patient is consistently rating pain as 8/10 and using PRN opioids frequently, it is a clear sign their scheduled, long-acting pain regimen is inadequate. This should prompt your recommendation to increase their basal pain control.
Masterclass: Delirium Assessment (CAM-ICU)
Delirium (acute confusion) is rampant in the ICU and associated with poor outcomes. The CAM-ICU is a bedside screening tool. A positive CAM-ICU is a major clinical finding that should trigger your immediate intervention.
- Your First Action: Hunt for Deliriogenic Drugs. Your primary job is to find and eliminate offending medications. Benzodiazepines are the #1 enemy. Other culprits include anticholinergics (diphenhydramine), and sometimes opioids.
- Your Recommendation: Recommend Safer Alternatives. Advocate to stop the benzodiazepine and switch to a “delirium-friendly” sedative like dexmedetomidine (Precedex) or to use low-dose antipsychotics (haloperidol, quetiapine) for agitation.
