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O
ne of the traditional roles of nurses involves
surveillance.This might include watching patients
for changes in their condition, recognising early
Abstract
Nurses have traditionally relied on five vital signs to assess their
clinical deterioration and protection from harm patients: temperature, pulse, blood pressure, respiratory rate and
or errors (Rogers et al, 2008). For over 100 years, nurses oxygen saturation. However, as patients hospitalised today are sicker
have performed this surveillance using the same vital signs: than in the past, these vital signs may not be adequate to identify
temperature, pulse, blood pressure, respiratory rate and in recent those who are clinically deteriorating. This paper describes clinical
years, oxygen saturation (Ahrens, 2008). Prompt detection and issues to consider when measuring vital signs as well as proposing
reporting of changes in these vital signs are essential as delays additional assessments of pain, level of consciousness and urine
in initiating appropriate treatment can detrimentally affect the output, as part of routine patient assessment.
patient’s outcome (Chalfin et al, 2007).
Patients admitted to acute hospitals today are sicker than in Key words: Vital signs n Patient monitoring n Assessment
n Quality n Safety
the past, as they have more complex health problems and are
far more likely to become seriously ill during their admission
(Ryan et al, 2004). In addition, patients who were once too In the clinical environment, body temperature may be affected
sick to be operated on are now undergoing complex surgical by factors such as underlying pathophysiology (e.g. sepsis), skin
procedures. This, coupled with the increasing demand for exposure (e.g. in the operating theatre) or age. Other factors
beds, means that ward nurses are often caring for patients who may not affect the body’s core temperature but can contribute
previously would have been cared for in a high-dependency to inaccurate measurements, such as the consumption of hot or
or intensive care unit (Butler-Williams and Cantrill, 2005). cold fluids prior to oral temperature measurement.
Furthermore, system factors such as skill mix, nurse:patient Clinically, there are three types of body temperature: the
ratios and bed shortages significantly impact on the quality of patient’s core body temperature; how the patient says they feel;
nursing care delivered in these environments. and the surface body temperature or how the patient feels to
This challenging situation is further complicated by touch. Importantly, these three are not always the same and may
increasing patient survival rates, which have resulted in an differ according to the underlying disease process. The nurse
increasingly complex and older patient population (James must be able to interpret conflicting assessment findings such
et al, 2010). Patients aged 65 and older, for example, have as these in light of the patient’s underlying pathophysiology.
twice the risk of younger adults of developing peri-operative When measuring body temperature, a number of factors
complications. They are also more likely to be admitted as must be considered. Not only must the measuring device
emergencies and undergo emergency surgery (Romano et be correctly calibrated, but the nurse must also be aware of
al, 2003). Diminished reserves in cognitive, renal and hepatic the difference in the core temperature between anatomical
function also contribute to older patients being a group at sites. For example, a study found significant differences in the
high risk of adverse events (Thornlow, 2009). As such, the five accuracy and consistency of several commonly used devices
traditional vital signs may not be adequate to detect clinical for measuring temperature – tympanic, oral disposable, oral
changes in patients who have more complex care needs than electric and temporal artery (Frommelt et al, 2008). This
nurses have encountered in the past. highlights the importance of regular calibration, correct
Before an acute change in a patient’s physiology can be use, accurate documentation (site of measurement and
recognised, the vital signs must be accurately assessed (Smith temperature reading) and consistency (using the same site)
et al, 2006). The aim of this paper, therefore, is to provide an as ways of accurately identifying trends in the patient’s core
overview of the essential knowledge required to accurately temperature. No single thermometer or measurement site is
assess these signs. This paper summarises the five traditional recommended as best practice, but in order to ensure accuracy
vital signs and recommends additional ones that should be part
of an acute care nurses’ repertoire of patient assessment. The Malcolm Elliott is Lecturer, Faculty of Health Science and Community
signs are listed in Table 1. Studies, Holmesglen Institute, Victoria, Australia and Alysia Coventry
is Lecturer, School of Nursing, Midwifery & Paramedicine, Australian
Catholic University, Victoria, Australia
Temperature
The body’s temperature represents the balance between heat Accepted for publication: March 2012
produced and heat lost, otherwise known as thermoregulation.
measurement that is outside normal range, it is easy for the factors such as patient movement (e.g. tremor, shivering),
nurse to perform another reading using the machine and keep hypovolaemia, hypothermia, arrhythmias, vasoconstriction or
doing so, until a value within normal range is obtained.This has heart failure. The SpO2 reading may also be misleading if
been described as observer bias or prejudice, where the nurse the patient is anaemic, because an oximeter does not measure
simply ‘adjusts’ the BP recording to what he or she thinks it the patient’s haemoglobin level, and an anaemic patient may
should be or wants it to be (Beevers et al, 2001). have a normal SpO2 despite having a lowered potential to
This practice indicates a lack of critical thinking and may carry oxygen (Tollefson, 2010). For this reason, nurses should
also be defined as professional misconduct.Vital signs recorded not rely on SpO2 as the sole indicator of the patient’s tissue
by a nurse must be a true reflection of the patient’s condition. oxygenation. Other assessments, such as respiratory rate and BP
In the situation where an automated monitor gives varying BP measurements, should also be performed.
readings, the BP should be assessed using a sphygmomanometer.
In a systematic review, the use of auscultation to ensure accurate Pain
BP measurement is recommended (Lockwood et al, 2004). Although it may be expected that patients in acute hospitals
will have pain (such as post-operatively), it is not acceptable
Respiratory rate that they suffer from it. Patients should be assessed frequently
Respiratory rate is an important baseline observation and for the presence of pain and it should be treated promptly and
its accurate measurement is a fundamental part of patient effectively. For some time, pain has been described as the sixth
assessment (Jevon, 2010). Respiratory rate measurement serves vital sign and this reflects its importance in nursing assessment
a number of purposes, such as being an early marker of and patient care (Cordell, 1996).
acidosis (Cooper et al, 2006). It is also one of the most sensitive Pain is also a nurse-sensitive patient outcome, meaning that
indicators of critical illness (Smith et al, 2008). An increase its successful management is directly related to the quality of
from the patient’s normal rate of even three to five breaths per nursing care provided (Given and Sherwood, 2005). Nurses
minute is an early and important sign of respiratory distress and must, therefore, make pain assessment a routine part of their
potential hypoxaemia (Field, 2006). care, rather than waiting for patients to express their pain.
Despite this, research has found that the respiratory rate is Research has also found that appropriate pain management
often not recorded in clinical settings or is simply guessed (Van results in decreased lengths of hospital stay and improved
Leuvan and Mitchell, 2008). This is disturbing given that an functional outcomes (Klassen et al, 2009).
abnormal respiratory rate is the best predictor of an impending Research, however, suggests that patients experience pain
adverse event such as cardiac arrest (Cretikos et al, 2007). The too frequently in hospital and this could be because nurses do
reason for this haphazard assessment is unclear. Perhaps it is not assess or manage it as well as they should (Manias et al,
because nurses assume that oxygen saturation provides a greater 2002). This is partly explained by the frequent interruptions
reflection of the patient’s respiratory function or because which occur during nursing care, causing delays between
there is no automated machine for measuring respiratory rate pain assessment and analgesic administration (Manias et al,
(Hogan, 2006). 2002). These interruptions may occur owing to system factors
In the acutely ill patient, respiratory rate should be counted beyond the control of the nurse such as clinical workloads
for a full minute, rather than 30 seconds and then doubled or nurse:patient ratios, though knowledge gaps may also
(Morton and Rempher, 2009). In measuring the respiratory contribute.
rate, the pattern should also be assessed and classified as Assessment of pain is vital, as it provides the only way
eupnoea, tachypnoea, bradypnoea or hypopnoea (Moore, to ensure that management methods are appropriate and
2004). Labeling it as such encourages the nurse to do more effective (Mac Lellan, 2006). Assessment is also important
than simply count a number, and to consider why the in establishing the cause of the pain and evaluating the
respiratory rate may be fast or slow. Nurses should also assess effectiveness of analgesics (Australian and New Zealand College
respiratory effort (depth of inspiration and use of accessory of Anaesthetists, 2005). However, just because a nurse does not
muscles) and equality of thoracic expansion. work in an acute surgical ward, he or she is not excused from
having sound pain assessment skills. Numerous mnemonics
Oxygen saturation (SpO2) (e.g. PQRST (Position, Quality, Region, Symptoms/Severity,
A pulse oximeter is an extremely valuable clinical tool and Triggers/Treatment); Castledine and Close, 2009) are available
easy to use. Research suggests that pulse oximetry is useful to help nurses remember how to assess pain. Importantly, the
for detecting a change in condition that may otherwise patient’s self-reported pain should be considered the most
have been missed, resulting in changed patient management reliable indicator. Furthermore, as with any assessment, it is
and a reduction in the number of investigations undertaken important that the findings are documented, even if the patient
(Lockwood et al, 2004). To avoid error with its use, the nurse is pain free.
must understand the factors that affect its accuracy, but studies
have shown this knowledge is often lacking (Giuliano and Level of consciousness
Liu, 2006). Specifically, the nurse must understand respiratory As many factors can alter a patient’s level of consciousness,
physiology, how to assess peripheral circulation and the nurses should assess it routinely along with other vital signs
oxyhaemoglobin dissociation curve. (Palmer and Knight, 2006). Cognitive deficits are often subtle
To work effectively, a pulse oximeter requires an adequate in their presentation and can easily be overlooked by nurses
peripheral blood flow. This flow may be impaired by who are focused on more obvious physical problems, such as