Vital Signs for Nurses: An Introduction to Clinical Observations

Observation and Continuous Monitoring

Contents:

  • Vital signs for nurses : an introduction to clinical observations
  • 4 editions of this work
  • Clinical Guidelines (Nursing) : Observation and Continuous Monitoring
  • Clinical Guidelines (Nursing)
  • Refine your editions:
  • Vital signs for nurses : an introduction to clinical observations

    • These systems have been implemented in many countries and have reduced the incidence of deaths and cardiac arrests in acute hospitals [ 5—7 ]. However, the success of RRSs is reliant on timely vital signs data and identification of deterioration [ 8 ]. Yet, recent research shows that the monitoring and recording of the five vital signs is often incomplete which poses the potential to miss deterioration [ 9 ].

    The patient casemix on general wards has changed over recent decades, with patients now older, more acutely ill, experiencing more co-morbidities and facing complex procedures [ 10—12 ].

    Vital signs for nurses : an introduction to clinical observations

    Yet, general ward patients are still monitored in much the same way as they have for over a century: Moreover, the frequency of recording varies, with limited evidence to suggest the most effective frequency for measurement [ 13 ]. Continuous monitoring technologies are a more proactive approach to the early detection of patient deterioration and have been reported as potentially enhancing early identification of deteriorating patients [ 14 ]. There is limited research, however, that assesses clinical staff perceptions regarding patient monitoring and the potential impact of continuous monitoring on practices.

    Nursing Skills: Vital Signs

    As part of a larger project aimed at improving safety through timely recognition of deterioration, this study conducted a formative evaluation to assess perceptions of the implementation of continuous monitoring devices on general wards. Formative evaluation in the early stages of technology implementation projects has been advocated as means to inform feasibility, provide opportunities for iterative assessments of intervention viability, guide the development and refinement of interventions, and characterize success factors in the quest to optimize patient safety [ 15 , 16 ].

    The aim of this study was to investigate clinical staff perceptions of current monitoring practices and the planned introduction of continuous monitoring devices on general wards. The study objectives were to. We undertook a multi-method study comprising structured surveys, in-depth interviews and log books Table 1. These activities were conducted between January and August on two wards respiratory and neurosurgery of a large teaching hospital in Sydney, Australia.

    4 editions of this work

    Conversely, in an otherwise clinically stable patient, it may not be appropriate to wake a sleeping child to assess the level of consciousness, with every set of observations e. These activities were conducted between January and August on two wards respiratory and neurosurgery of a large teaching hospital in Sydney, Australia. In the setting of significant volume depletion, a greater drop may be seen. Growth of hands and feet as an adult, fatigue, weakness, joint pain, headache, altered vision; PE: Whenever continuous monitoring of heart rate, SpO 2 or respiratory rate is in use, clinical observations must be documented hourly, at a minimum. Paroxysms of hypertension, awareness of heart pounding, headache, fatigue; PE: In general, this measurement offers no relevant information for the routine examination.

    For the knowledge survey, the nursing unit manager s , clinical nurse consultant and clinical nurse educator were not eligible. Thus, 36 respiratory ward and 38 neurosurgery ward nurses total 74 nurses were eligible to participate in the knowledge survey. Prior to commencing the research, we held briefing sessions for staff to explain the study purpose and provide a demonstration of the continuous monitoring devices.

    Vital signs data are shown on the device display and are also wirelessly transmitted to a remote viewing display e. We used a reciprocity framework, whereby clinical staff perceptions were regarded as authoritative and central to the research, and we fed back study findings to ensure reliability of the obtained data [ 18 ].

    Clinical Guidelines (Nursing) : Observation and Continuous Monitoring

    In line with the reciprocity framework, we provided all clinical staff the opportunity to participate in one or more research activities. Participation was voluntary and consent was obtained from staff prior to their participation in each research activity. A structured survey Table 2 , relating to confidence in vital signs monitoring tools and practices, was verbally administered to 33 nurses.

    The researcher provided statements and asked respondents to indicate whether they strongly agreed, agreed, were uncertain, disagreed or strongly disagreed with each statement. Structured in-depth interviews Table 3 aimed at gauging perceptions regarding benefits, concerns and enablers in respect of the introduction of continuous monitoring devices were conducted with eight nurses and two doctors.

    The interviews were digitally recorded and transcribed.

    Clinical Guidelines (Nursing)

    Description. Accurate clinical observations are the key to good patient care and fundamental to nursing practice. Vital Signs for Nurses will support anyone in. Vital Signs for Nurses: An Introduction to Clinical Observations are the key to good patient care and fundamental to nursing practice. Vital.

    A general inductive approach [ 19 ] was used to analyse the interview data, whereby two researchers independently coded the data, discussed their coding and developed a coding schema. Results were reported to ward staff for validation. How confident do you feel about identifying high-risk patients admitted to your ward who may require more frequent or ongoing monitoring of vital signs to prevent cardiac arrest and death? In your ward, what is the basis for making a decision about the frequency of monitoring vital signs?

    Do you have any concerns about implementation of a mobile device that monitors vital signs all day and night? What barriers do you anticipate for the widespread introduction of this monitor if there was a plan to make it more widely available? If the hospital were to adopt this device, do you have any suggestions on how best to help staff with the transition from paper-based vital signs monitoring to a continuous electronic approach? Continuous monitoring devices were made available on each ward for staff to trial on themselves, in order to anticipate any problems patients may experience while wearing the device.

    Twenty-three nurses trialled the devices and provided written feedback in log books placed on each ward. The log book data were entered into a spreadsheet and independently analysed for common subject matter by two researchers. A short paper-based survey was completed by 40 nurses. The survey also included five statements about interdisciplinary communication with 5-point Likert scales Table 4.

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    Open-ended responses were entered into a spreadsheet and independently analysed for common subject matter by two researchers. Nurses, particularly those from neurosurgery, were not confident about the accuracy of current equipment used to measure vital signs Table 2. All nurses agreed or strongly agreed that they were confident in escalating patient care activating a clinical review or RRS.

    All but one nurse also agreed or strongly agreed they would escalate care for a patient they were worried about, even if their vital signs appeared normal. Four main themes emerged from the interviews: Nurses confirmed that they use the vital signs threshold criteria mandated by State health department policy the Between the Flags Program [ 20 , 21 ] to identify patient deterioration. Several stated they also rely on intuition or clinical judgement based on visual assessment of patients.

    If there is uncertainty about a patient, nurses said they perform double checks of vital signs, seek second opinions from other nurses or contact doctors. I actually look at my patient and see whether or not they look like what the observations are showing and just use clinical judgement to see [if] they need to be more supervised. Both the doctors and nurses expressed concerns about the intermittent nature of the current system of vital signs monitoring.

    I've had a patient who died on me … When I saw him he was reasonably ok and I thought—great, he's stable, I'll go and see somebody else. Then he crashed and burned in the next couple of hours and you couldn't revive him. The doctors suggested that increased frequency of manual observation may not be feasible because of nursing work pressures.

    Nurses indicated that increased observations were conducted for patients when necessary, however, they disclosed it was onerous on their time and sometimes required nursing staff to be rearranged and patients reassigned. Continuous monitoring was considered to be a means of identifying trends that might otherwise be missed by intermittent monitoring. Both the doctors and nurses anticipated this could lead to earlier identification and response to patient deterioration, and potentially prevent deterioration to a stage requiring escalation to RRS intervention.

    Another perceived benefit was greater availability and accessibility to vital signs information, which nurses suggested would provide better evidence when communicating concerns for a patient to doctors and would support their decisions to escalate care.

    Us nurses, we find it so difficult trying to get the doctors to understand what's happening. So at least when you show them—look, you need to come and see this patient now, this is what's happening and that's what the device is telling us. Respiratory effort is described in the table below.

    Greatly increased respiratory effort, in-drawing, audible grunt, nasal flaring, head bobbing,tracheal tug, accessory muscle use, apneas.

    Vital signs for nurses : an introduction to clinical observations

    Can be measured using a manual sphygmomanometer and stethoscope, by the palpation of pulse technique, with a Doppler or by using an electronic BP device. Interpret pressure readings with caution when an electronic BP device is used for an active infant; a Doppler may be a better choice.

    Introduction

    Measuring a patient's temperature using a consistent route is important to ensure accurate trending. Oral and rectal routes are more reliable and are the recommended routes for evaluating temperature. Axilla temperature should only be used when there are contraindications to the recommended routes. For guidelines on the appropriate routes for intermittent temperature monitoring, please refer to the Vital Signs and Monitoring policy.

    The above temperature ranges have been arrived at from variety of sources and should be interpreted and managed in the context of the patient's age, illness, and clinical picture. The literature demonstrates that here is no single agreement of what specific temperature reading consists a fever. Click here to view the evidence table. Please remember to read the disclaimer. The Royal Children's Hospital Melbourne. Observation and Continuous Monitoring. Introduction Regular measurement and documentation of physiological observations i.

    The orange and purple zones in EMR will appear as below: Aim To provide guidance to clinical staff regarding the: Observations should be performed at least once per hour if the patient: Observation Charts ViCTOR Ensure that observations are entered onto the correct medical record by checking the patient's identification.

    O 2 Saturation and oxygen delivery Haemoglobin-oxygen saturations SpO 2 should be entered numerically in the allocated box. The device used to deliver oxygen should be noted as follows: Respiratory rate and pulse rate Respiratory rate and pulse rate must be entered on the flowsheet activity in EMR.

    Respiratory Distress Respiratory distress should be recorded as Nil, Mild, Moderate or Severe and be determined by assessing the following features see www. Children who require neurological observations include those with: Increasing, or potential for increased, intracranial pressure Neurosurgical procedures Encephalopathy e. Diabetic ketoacidosis, Diabetes Insipidus Electrolyte disorders e. Guillain - Barre syndrome Seizures —consider underlying diagnosis, or new onset. AVPU scoring may be appropriate for children with pre-existing seizure conditions.

    Pain scores Pain scores should be calculated by using a Pain Assessment tool appropriate for the age, developmental level and clinical state of the child. Suggested ages are as follows: Additional Observations Further observations may be required. Modification of the Orange or Purple zone Emergency response criteria may be made by medical staff, in accordance with the Medical Emergency Response Procedure and must be ordered by medical staff. Continuous monitoring Continuous monitoring includes either cardio-respiratory monitoring or pulse oximetry monitoring.

    Indications for continuous cardio-respiratory monitoring include: Indications for its use include the child who: Alarm settings The alarm limits should be set at the appropriate age related profile selected on the monitor, where the default settings reflect the ViCTOR escalation of care parameters. Discontinuation of continuous monitoring As the condition of the child stabilises and the risk of sudden deterioration lessens, the decision to continuously monitor the child should be reviewed.

    Evidence Table Click here to view the evidence table. Development of heart and respiratory rate percentile curves for hospitalized children. Pediatrics, 4 , ee Pediatric Nephrology, 27 1 , Standardizing use of physiological monitors and decreasing nuisance alarms. American Journal of Critical Care. Analysis of the evidence for the lower limit of systolic and mean arterial pressure in children. Pediatric Critical Care Medicine, 8 2 , Critical Care Medicine, 22 6 , Phase One and Phase Two Report. Department of Health, Victoria, Australia.