CLINICAL
The global elements of vital signs’
assessment: a guide for clinical practice
Malcolm Elliott
ABSTRACT
The assessment of vital signs is critical for safe, high-quality care. Vital signs’
data provide valuable insight into the patient’s condition, including how they
are responding to medical treatment and, importantly, whether the patient
is deteriorating. Although abnormal vital signs have been associated with
poor clinical outcomes, research has consistently found that vital signs’
assessment is often neglected in clinical practice. Factors contributing to
this include nurses’ knowledge, clinical judgement, culture, tradition and
workloads. To emphasise the importance of vital signs’ assessment, global
elements of vital signs’ assessment are proposed. The elements reflect
key principles underpinning vital signs’ assessment and are informed by
evidence-based literature.
Key words: Vital signs ■ Assessment ■ Global elements
V
ital signs’ assessment is a key component of safe,
high-quality care and a fundamental nursing priority.
Trends in vital sign data provide early warning of
impending sepsis and respiratory failure, and can
independently predict mortality (Churpek et al, 2014; Nielsen
et al, 2015). Furthermore, vital signs’ data is important for
medical emergency teams and early warning scores to function
effectively, but only if there is adherence to vital sign monitoring
protocols (Hands et al, 2013).
Despite their clinical importance, research has consistently
found that vital signs’ assessment is often inaccurate, incomplete
or falsified (Ludikhuize et al, 2012; Philip et al, 2013; Cooper et
al, 2014).The reasons for this are not clear, but nurses’ knowledge,
skills and clinical judgement, culture, tradition and ritual, along
with laziness and workload have been identified as contributing
factors (Hogan, 2006; Yeung et al, 2012; Philip et al, 2013;
Burchill et al, 2015; Cardona-Morrell et al, 2016). It has therefore
been recommended that nurses need ongoing education to
improve their attitudes towards vital sign monitoring (Mok
et al, 2015).
To help emphasise the importance of vital signs’ assessment,
Global Elements of Vital Signs’ Assessment are proposed. The
Elements reflect key principles underpinning vital signs’
Malcolm Elliott, Senior Lecturer, Monash Nursing and
Midwifery, Monash University, Melbourne, Australia,
grandmal70@hotmail.com
Accepted for publication: August 2021
956 
assessment and are grounded in national and international
guidelines and the current literature. The Elements aim to
address the enduring neglect of vital signs’ assessment and are
a guideline for clinical practice. The Table of Elements (Figure
1) can be printed for students and clinicians to use as a visual
prompt.The Elements can also be used for audit, benchmarking
and teaching.
Respiratory rate
Changes in respiratory function are increasingly recognised
as the most sensitive indicator of clinical deterioration (Cahill
et al, 2011). Respiratory rate is an early and extremely good
indicator of conditions such as hypoxia, hypercapnia and
acidosis (Rolfe, 2019). Respiratory rate is also often the first
vital sign to be affected if there is a change in the patient’s
cardiac or neurological state (Liddle, 2013).The global elements
of respiratory rate assessment are (Figure 1: dark blue cells):
1. Sensitive marker (Sm): Respiratory rate is the most
Sensitive marker of acute illness (Cahill et al, 2011). A
respiratory rate of 21–24 breaths per minute is an early
clinical sign of deterioration (Wheatley, 2018). A decrease
in respiratory rate is also indicative of deterioration (Rolfe,
2019)
2. First sign (Fs): Respiratory rate is often the First sign
affected if there is an acute change in the patient’s condition
(Kelly, 2018). Alteration in the respiratory rate can occur
up to 24 hours before other signs of clinical deterioration
(Malgaard et al, 2016)
3. Powerful predictor (Pp): Respiratory rate is a Powerful
predictor of disease severity and of a poor outcome (Kellett,
2017; Bunkenborg et al, 2019 ).
4. Illness marker (Im): A high or increasing respiratory
rate is an Illness marker and a warning that the patient
may deteriorate suddenly (Resuscitation Council UK
(RCUK), 2021)
5. Minor changes (Mc): Minor changes in respiratory rate
(3–5 breaths/minute) can be an early sign of deterioration
(Dougherty et al, 2015; Kelly, 2018)
6. Never falsify (Nf): Respiratory rate should Never be
falsified or not assessed simply because ‘the patient looks
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fine’ or the oxygen saturations are normal
7. Assess independently (Ai): Respiratory rate should be
Assessed independently of oxygen saturation (SpO2), as
respiratory rate measurements correlate poorly with SpO2
measurements (Kellett and Sebat, 2017)
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8. Count manually (Cm): The respiratory rate must be
Counted manually rather than guessed or estimated (ACT
Government Health, 2011)
9. One minute (Om): The ideal length of time to measure
respiratory rate is One minute, without the patient’s
awareness that they are being assessed (Hill et al, 2018)
10. Other characteristics (Oc): When assessing the
respiratory rate, Other characteristics such as respiratory
depth, use of accessory muscles, pattern and signs of distress
should also be assessed (Rolfe, 2019).
Oxygen saturation
A pulse oximeter measures peripheral arterial oxygen saturation
(SpO2), reflecting the percentage of haemoglobin that is
bound with oxygen (Williams, 2018). SpO2 readings should be
interpreted within clinical context—and appropriate clinical
judgement rather than complete reliance on oximetry readings
should provide the basis for effective patient management (Pretto
et al, 2014).The global elements of oxygen saturation assessment
are (Figure 1: light blue cells):
1. Clinical context (Cc): Interpret SpO2 readings within
Clinical context (Pretto et al, 2014)
2. Not ventilation (Nv): SpO2 does Not reflect the adequacy
of ventilation (Pretto et al, 2014)
3. Pulsatile flow (Pf): A pulse oximeter requires adequate
Pulsatile blood flow to be accurate. Without a pulse
signal, any SpO2 readings are meaningless (World Health
Organization (WHO), 2011)
4. Probe site (Ps): The Probe site may affect the reliability
of SpO2 readings (Fernandez et al, 2007). Depending on
the patient’s clinical condition, some probe sites are more
reliable than others (Chan et al, 2013)
5. Random checks (Rc): Although Random SpO2 checks
have clinical benefit, they cannot be used to accurately
estimate PaO2, particularly because the response time of
oximeter probes varies (Pretto et al, 2014; Jubran, 2015)
6. Allow time (At): Allow time for the oximeter to detect
the pulse and calculate the oxygen saturation (WHO, 2011).
The response time of oximeter probes varies (Jubran, 2015)
7. Impaired delivery (Id): SpO2 does not necessarily reflect
tissue oxygen delivery (Pretto et al, 2014). SpO2 readings
may actually be normal, despite Impaired O2 delivery.
Oxygen delivery to the tissues cannot be solely determined
by using a pulse oximeter because an oximeter does not
evaluate the haemoglobin concentration or cardiac output
(Casey, 2011)
8. Waveform (Wf): If the Waveform displayed on the
oximeter is attenuated or inconsistent, the SpO2 reading
is unreliable (Chan et al, 2013)
9. Unreliable readings (Ur): Many factors may cause
Unreliable or misleading SpO2 readings such as poor
perfusion, venous pulsations, excessive movement, fingernail
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polish, and severe anaemia (Chan et al, 2013)
10. No surrogate (Ns): SpO2 is Not a surrogate marker
or replacement for respiratory rate assessment (Rolfe,
2019). It is possible, for example, for the SpO2 to be
normal but for the respiratory rate to be increased due
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CLINICAL
to hypercapnia (Parkes, 2011)
11. Not attach (Na): Do Not attach the probe to an area
that is oedematous, has compromised skin integrity, to
fingers or toes that are hypothermic, or where the patient
has peripheral vascular disease (ACT Government Health,
2011)
12. Re-evaluate (Ev): After manually palpating the patient’s
pulse, compare it with the pulse rate calculated by the
pulse oximeter. If a difference exists, re-Evaluate the probe
placement (ACT Government Health, 2011)
13. Remain normal (Rn): During early stages of deterioration,
the SpO2 may Remain in the normal range due to an
increase in respiratory rate to compensate for inadequate
O2 delivery (Kellett and Sebat, 2017; Dix, 2018).
Pulse
Although heart rate is calculated by a pulse oximeter, manual
pulse assessment provides an opportunity to touch the patient
and thus assess numerous characteristics related to cardiac output.
These include heart rate, rhythm, amplitude or strength, equality
and regularity (Elliott and Coventry, 2012).The global elements
of pulse assessment are (Figure 1: orange cells):
1. Alteration (Al): Alteration in the pulse rate along with
respiratory rate is often the first sign of deterioration
(Tollefson and Hillman, 2019)
2. Assess manually (Am): Pulse rate should be Assessed
manually; reliance on automated machines should be
avoided where possible (ACT Government Health, 2011)
3. Thirty sixty (Ts): If the pulse is regular, count for Thirty
seconds and multiply by two; if the pulse is irregular, count
for sixty seconds (ACT Government Health, 2011)
4. Ignore monitor (Im): Ignore any monitor’s heart rate
reading until you have assessed the pulse manually; doing
so will help validate your findings. Manual palpation also
allows for assessment of pulse amplitude and volume—
information that monitors are not designed to evaluate
(Dougherty et al, 2015)
5. Characteristics (Ch): When palpating the pulse, assess all
Characteristics such as rate, rhythm, quality and regularity
(RCUK, 2021)
6. Normal range (Nr): Know the Normal range for an adult
patient and ideally the patient’s normal range (Liddle, 2013).
Using established normal ranges can help quantify abnormal
findings (Chester and Rudolph, 2011).
Blood pressure
Blood pressure is one of the most inaccurately measured vital
signs, despite being an indicator of oxygen delivery (Pickering
et al, 2005). Automated blood pressure monitors, for example,
might be used to save time, but their use increases the risk
of measurement error (Elliott and Coventry, 2012). Even if
blood pressure is measured manually, there is still the risk of an
inaccurate reading due to human error (Coogan et al, 2015).
The global elements of blood pressure assessment are (Figure 1:
red cells):
1. Use cautiously (Uc): Use automated blood pressure
monitors cautiously. Manual auscultatory blood pressure
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CLINICAL

Malcolm Elliott
Key Element
Increase
Frequency
Level of

If
Blood Respiratory O²
Pulse conscious- Temperature Symbol
Pressure rate saturation
ness
CE-7 Family

Use Temperature
cautiously differs

Uc Td
BP-1 T-1

Carefully Alteration Routinely Favourable

verify assess conditions

Cv Al Ra Fc
BP-2 P-2 LOC-1 T-2

Second Assess Validated Repeat

reading manually scale

Sr Am Vs Re
BP-3 P-2 LOC-2 T-3

Normal Thirty sixty Sensitive No Predictor Individual

marker surrogate variation

No Ts Sm Ns Pr Iv
BP-4 P-3 RR-1 OSat-10 LOC-3 T-4

Late sign Ignore First sign Minor Count Clinical Probe Impaired Not attach Subtle Three tem-
monitor changes manually context site delivery changes peratures

Ls Im Fs Mc Cm Cc Ps Id Na Sc Tt
BP-5 P-4 RR-2 RR-5 RR-8 OSat-1 OSat-4 OSat-7 OSat-11 LOC-4 T-5

Never Character- Powerful Never falsify One minute Not Random Wave Re- Perform Accuracy
assume istics predictor ventilation checks form evaluate frequently

Na Ch Pp Nf Om Nv Rc Wf Ev Pf Ac
BP-6 P-5 RR-3 RR-6 RR-9 OSat-2 OSat-5 OSat-8 OSat-12 LOC-5 T-6

Contra Normal Illness Assess inde­ Other char- Pulsatile Allow Unreliable Remain Delayed Hypo­thermia
indications range marker pendently acteristics flow time readings normal sign

Ci Nr Im Ai Oc Pf At Ur Rn Ds Ho
BP-7 P-6 RR-4 RR-7 RR-10 OSat-3 OSat-6 OSat-9 OSat-13 LOC-6 T-7

Critical Elements (CE)

Compare Anticipate Patient’s Previous Don’t No Increase Eight

baseline readings copy blanks Frequency hourly

Co An Pb Pr Dc Nb If Eh
CE-1 CE-2 CE-3 CE-4 CE-5 CE-6 CE-7 CE-8

Trends Clinical Calling No Full set Document Analyse

judgement criteria delegation interpret collect­
ively
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Tr Cj Cc Nd Fs Di Ac
CE-9 CE-10 CE-11 CE-12 CE-13 CE-14 CE-15

Figure 1. The Global Elements of Vital Signs’ Assessment

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assessment is the gold standard (Liu et al, 2015; Shahbabu
et al, 2016). If there is doubt about a blood pressure reading
obtained from an automated monitor, it should be verified
by auscultatory assessment (Dougherty et al, 2015)
2. Carefully verify (Cv): Automated blood pressure
machines provide less reliable readings than those taken
manually (Mirdamadi and Etebari, 2017). Once systolic
blood pressure falls below 100 mmHg, detection by
automated monitors is unreliable. All low blood pressure
readings should be Carefully verified (Kellett and Sebat,
2017)
3. Second reading (Sr): If the automated blood pressure
reading is outside the patient’s usual range, a manual Second
reading should be obtained (ACT Government Health,
2011)
4. Normal (No): Even in shock the blood pressure may
be Normal because compensatory mechanisms increase
peripheral resistance in response to reduced cardiac output
(RCUK, 2021)
5. Late sign (Ls): A change in a blood pressure reading
is a Late sign of clinical deterioration as compensatory
mechanisms fail (Tollefson and Hillman, 2019)
6. Never assume (Na): An abnormal blood pressure should
Not be assumed to be the patient’s normal; it should be
assessed in relation to previous readings, the patient’s clinical
condition and other assessments (Dougherty et al, 2015)
7. Contraindications (Ci): Assess the patient for
Contraindications to cuff placement, eg arteriovenous
(AV) fistula, lymphoedema, intravenous (IV) therapy (ACT
Government Health, 2011). If these are present, the other
limb should be used.
Temperature
Core body temperature is a valuable vital sign in the seriously ill
patient (Smith et al, 2005). Nurses should use their judgement
about whether the recorded temperature is within an acceptable
range for the patient’s condition and if more frequent temperature
measurement is needed (Grainger, 2013).The global elements
of temperature assessment are (Figure 1: green cells):
1. Temperature differs (Td): Normal body Temperature
differs between anatomical sites (Elliott and Coventry,
2012). Awareness of this is important when interpreting
readings
2. Favourable conditions (Fc): Check for Favourable
conditions of the site to perform accurate temperature
monitoring, eg for the oral site, no recent consumption of
hot or cold beverages (ACT Government Health, 2011)
3. Repeat (Re): If the temperature reading is abnormally
high or low, Repeat the reading with another thermometer
(ACT Government Health, 2011)
4. Individual variability (Iv): As body temperature varies
with age, gender and site of measurement, it should be
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assessed in relation to Individual variability, ie a baseline
value (Sund-Levander and Grodzinsky, 2013)
5. Three temperatures (Tt): Clinically, there are Three
temperatures: core body temperature, how the patient
says they feel, and how the patient feels to touch. These
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CLINICAL
are not always the same and awareness of these might
make interpretation of conflicting assessment findings easier
(Elliott and Coventry, 2012)
6. Accuracy (Ac): Numerous factors affect the Accuracy
of temperature measurements such as the device and
technique (Jevon, 2020)
7. Hypothermia (Ho): Research has found only modest
increases in mortality associated with temperatures above
38°C; a low temperature though was found to be much
more ominous (Bleyer et al, 2011; Kellett and Kim,
2012; Kellett, 2017). The clinical importance of a low
temperature (Hypothermia) should not be ignored.
Consciousness and cognition
Many factors, both primary and secondary, can affect a patient’s
level of consciousness or cognition. Accurate assessment of
consciousness is therefore paramount for the early diagnosis
and management of deterioration, as changes in conscious level
are associated with poor outcomes (Rylance et al, 2009; Vink
et al, 2018).The global elements of consciousness and cognition
assessment are (Figure 1: lilac cells):
1. Routinely assess (Ra): Because many factors may affect
consciousness or cognition, these should be Routinely
assessed in all patients (National Institute for Health and
Care Excellence (NICE), 2007).The established vital signs
(eg temperature, pulse, blood pressure, respiratory rate) fail
to provide insight into a patient’s cognitive function and
mental status (Chester and Rudolph, 2011)
2. Validated scale (Vs): Use a Validated scale or tool to
quantify the assessment, eg the Glasgow Coma Scale,Alert
Verbal Pain Unresponsive (RCUK, 2021). Terms such as
semiconscious or stuporous should be avoided because
they are subjective (Dougherty et al, 2015)
3. Predictor (Pr): A decrease in the Glasgow Coma Scale
score Predicts an adverse event. A drop of two or more
predicts a major adverse event (Massey et al, 2015)
4. Subtle changes (Sc): changes to consciousness or
cognition are often Subtle. Mild alteration of mental status
is therefore often not noticed, even though this might
reflect early deterioration (Kellett, 2017)
5. Perform frequently (Pf): In patients with an acute or
rapidly changing status, assessment of consciousness should
be Performed more frequently, ie every 15–60 minutes
(Tollefson and Hillman, 2019)
6. Delayed signs (Ds): Vital sign changes are a Delayed sign
of neurological deterioration (Tollefson and Hillman, 2019).
Critical elements (CE)
Underpinning all vital signs’ assessments are the following
critical elements (Figure 1: yellow cells):
1. Compare (Co): Never trust the monitor. Compare
manual assessments of the patient with the anticipated
result and the monitor
2. Anticipate (An): Anticipate the vital sign measurement
before you assess it. Doing so will help validate the data
obtained
3. Patient’s baseline (Pb): Know the Patient’s baseline
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CLINICAL
where possible, because changes from an individual
reference point may indicate important warning signs and
thus require additional evaluation (Chester and Rudolph,
2011; Liddle, 2013)
4. Previous readings (Pr): Ignore the Previous vital signs
readings (until you have assessed the signs yourself)
5. Don’t copy (Dc): Do not copy the last vital sign readings.
Although a patient’s vital signs might remain stable,
each assessment must be an objective measurement of
physiological function, ie measured not surmised (Chester
and Rudolph, 2011)
6. No blanks (Nb): Leave No blanks on the chart. Assess
and document all vital signs (McGhee et al, 2016). The
ability of a chart to identify deterioration depends on the
reliability and completeness of the observations (Clinical
Excellence Commission, 2021)
7. Increase frequency (If): Increase frequency of vital sign
assessments if abnormal vital signs are observed (NICE,
2007). If the patient is acutely ill, for example, vital signs
may need to be assessed every 15 minutes (Alexis, 2010)
8. Eight hourly (Eh): In the absence of a documented
monitoring plan, patients should have a completed set of vital
signs assessed at least 3 times per day at Eight-hourly intervals
(Clinical Excellence Commission, 2021). Eight-hourly
measurement results in earlier detection of physiological
abnormalities and clinical deterioration (Ludikhuize et al,
2014; Kellett and Sebat, 2017)
9. Trends (Tr): Vital signs are constantly changing, so they
are better expressed and interpreted by their Trends rather
than just their precise value at any point in time (Kellett,
2017). Vital sign trends significantly improve the accuracy
of detecting clinical deterioration compared to the current
vital sign values alone (Churpek et al, 2016)
10. Clinical judgement (Cj): Clinical judgement, rather than
complete reliance on vital signs’ readings, should be the
basis for effective patient management (Pretto et al, 2014)
11. Calling criteria (Cc): Know the Calling criteria for
emergency medical assistance (DeVita et al, 2010).
12. No delegation (Nd): Vital signs’ assessment should Not
be delegated to less qualified or experienced nursing staff.
The recognition of and response to acute physiological
deterioration requires appropriately qualified, skilled and
experienced staff (Australian Commission on Safety and
Quality in Health Care (ACSQHC,) 2017). Recognising
patients whose condition is acutely deteriorating is essential
for safe and high-quality care (ACSQHC, 2017)
13. Full set (Fs): A Full set of vital signs should be assessed
prior to and on transfer of care from one ward to another,
from emergency departments, high dependency or intensive
care units to general wards, and from one facility to another
(ACT Government Health, 2018). When vital signs’
assessment is incomplete, physiological instability is often
missed (Clifton et al, 2015)
14. Document interpret (Di): Accurate Documentation
and interpretation of accurately measured vital signs helps
improve patient outcomes (Rolfe, 2019)
15. Analyse collectively (Ac): Vital signs should not be
960
assessed in isolation but Analysed collectively in conjunction
with other signs and the patient’s ongoing health condition
(Tollefson and Hillman, 2019).
Summary
Vital signs serve as a universal communication tool for patient
status and severity of illness and are a critical component of
early warning scores and medical emergency teams (Chester
and Rudolph, 2011). When acting on abnormal vital signs,
any clinical intervention needs to be implemented in a timely
manner to prevent, where possible, any further deterioration
in the patient’s condition (Grainger, 2013). For this to happen,
nurses must understand the clinical importance of vital signs’
monitoring, but research suggests that this is not always the case
(Cardona-Morrell et al, 2016; Burchill et al, 2015).
The proposed Global Elements guide can be used as
a benchmarking tool when auditing vital sign assessment
patterns or when performing a root cause analysis to determine
specific areas of neglect of vital signs’ assessment. For example,
one coroner’s case involved a 46-year-old woman who was
admitted to a ward following an endoscopic procedure to
correct complications of previous surgeries (Patient Safety
Surveillance Unit, 2014). During the second postoperative
night, her heart rate, blood pressure and respiratory rate were
elevated and oxygen saturation low. No concern was expressed
about these signs. She remained unwell with persistently
elevated heart rate, temperature and respiratory rate, and
hypoxia requiring supplemental oxygen. Routine observations
continued 4- to 6-hourly. Although these vital signs constantly
met the emergency medical call criteria, no call was made and
the frequency of observations was not increased. The patient
continued to deteriorate requiring further surgery and later
died from surgical complications (Patient Safety Surveillance
Unit, 2014).
Using the Global Elements as a guide, numerous deficits
can be seen in this patient’s vital sign assessments. The clinical
importance of the patient’s elevated respiratory rate is reflected
in the respiratory rate Elements sensitive marker (Sm), First sign
(Fs), powerful predictor (Pp), illness marker (Im) and minor
changes (Mc). These Elements highlight the critical nature of
the patient’s initial respiratory rate elevation and emphasise
that action should have been taken at that point. An increased
frequency of respiratory rate assessment should have been evident
on her vital signs’ chart. Similarly, the low oxygen saturation
in the clinical context (Cc) of an elevated respiratory rate and
heart rate should have triggered urgent clinical action. The
alteration (Al) in heart rate also reflected the initial deterioration
in her condition and a deviation from normal range (Nr). An
increased frequency of pulse rate assessment should also have
been evident on the vital signs’ chart (If) in response to the
heart rate elevation.
Finally, the abnormal vital signs should have triggered staff
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to increase the frequency (If) of vital sign assessments, and
familiarity with the emergency calling criteria (Cc) should
also have promoted action. The staff continued to assess vital
signs 4- to 6-hourly, suggesting they did not understand the
importance of vital signs’ assessments nor recognise the patient’s
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deterioration.The application of the Global Elements highlights
the care deficits in this case.
The current limited research on vital signs’ assessment means
that clinicians have little guidance for establishing a policy for
evidence-based practice (McGhee et al, 2016). It is hoped that
the global elements proposed here are one small advance towards
enhancing nurses’ understanding of the critical importance of
vital signs’ assessments. BJN
Declaration of interest: none
Acknowledgement: the author thanks Megan Pote, Mick Elliott
(WhatMickSaw) and John Bergman for creative feedback and inspiration
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KEY POINTS
■ Vital signs’ assessment is a key component of safe, high-quality care
■ Abnormal vital signs are associated with poor clinical outcomes
■ Research shows that vital signs’ assessment is often neglected in
clinical practice
■ To help emphasise the importance of vital signs’ assessment, Global
Elements of vital signs’ assessment are proposed
■ The proposed framework of Global Elements reflects the key principles
underpinning vital signs’ assessment
Systems. Resuscitation. 2010;81(4):375–382. https://doi.org/10.1016/j.
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Fundamental Aspects of
Caring for the Acutely ill Adult
Edited by Pauline Pratt
This simple, concise book covers:
n Why physiological factors change n Pain management
and how actions by the ward nurse n Renal care
can improve patient outcomes n Central line management
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n Shock n Patient assessment
Using diagrams and flow charts as well as highlighted learning points, it offers readers an
opportunity to put theory into practice and directly improve outcome in the critically ill adult.
ISBN-13: 978-1-85642-270-3; 234 x 156 mm; paperback; 224 pages; publication 2006; £19.99
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962
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