Standards for Assessing, Measuring and Monitoring Vital Signs in Infants, Children and Young People

Standards for Assessing, Measuring and Monitoring Vital Signs in Infants, Children and Young People CLINICAL PROFESSIONAL RESOURCE Acknowledgements The RCN would like to thank everyone who contributed to earlier editions, and to those who provided expertise and guidance to develop the standards contained in this edition, particularly: Coral Rees Rachael Bolland Advanced Paediatric Nurse Practitioner, Nurse Consultant Acute Paediatrics, Noah’s Ark Children’s Hospital for Wales St George’s University Hospitals NHS Foundation Trust Sarah Neill Senior Lecturer, Children’s Nursing, London Associate Professor in Children’s Nursing, South Bank University University of Northampton Gerri Sefton Doreen Crawford Advanced Nurse Practitioner PICU, Senior Lecturer, De Montfort University Alder Hey Children’s NHS Foundation Trust Nurse advisor for an Independent Lead for Paediatric Early Warning System Healthcare Consultancy Consultant Editor Nursing Children Peter-Marc Fortune and Young People Journal Consultant Paediatric Intensivist, Associate Clinical Head Royal Manchester Children’s Hospital This publication is due for review in May 2020. To provide feedback on its contents or on your experience of using the publication, please email [email protected] Publication This is an RCN practice guidance. Practice guidance are evidence-based consensus documents, used to guide decisions about appropriate care of an individual, family or population in a specific context. Description The monitoring and measurement of vital signs and clinical assessment are core essential skills for all health care practitioners working with infants, children and young people. This guidance applies to professionals who work in acute care settings, as well as those who work in GP surgeries, walk-in clinics, telephone advice and triage services, schools and other community settings. Publication date: May 2017 Review date: May 2020 The Nine Quality Standards This publication has met the nine quality standards of the quality framework for RCN professional publications. For more information, or to request further details on how the nine quality standards have been met in relation to this particular professional publication, please contact [email protected] Evaluation The authors would value any feedback you have about this publication. Please contact [email protected] clearly stating which publication you are commenting on. RCN Legal Disclaimer This publication contains information, advice and guidance to help members of the RCN. It is intended for use within the UK but readers are advised that practices may vary in each country and outside the UK. The information in this booklet has been compiled from professional sources, but its accuracy is not guaranteed. Whilst every effort has been made to ensure the RCN provides accurate and expert information and guidance, it is impossible to predict all the circumstances in which it may be used. Accordingly, the RCN shall not be liable to any person or entity with respect to any loss or damage caused or alleged to be caused directly or indirectly by what is contained in or left out of this website information and guidance. Published by the Royal College of Nursing, 20 Cavendish Square, London, W1G 0RN © 2017 Royal College of Nursing. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise, without prior permission of the Publishers. This publication may not be lent, resold, hired out or otherwise disposed of by ways of trade in any form of binding or cover other than that in which it is published, without the prior consent of the Publishers. 2 ROYAL COLLEGE OF NURSING Contents 1. Introduction 4 2. Education and training 7 3. Teaching children, young people and parents/carers 8 4. Assessing and measuring vital signs 9 5. Record keeping 17 6. Medical devices and equipment 18 Appendix 1: APLS normal values 19 Additional resources 20 References 21 3 STANDARDS FOR ASSESSING, MEASURING AND MONITORING VITAL SIGNS 1. Introduction The monitoring and measurement of vital signs and clinical assessment are core essential skills for The aim of observing and all health care practitioners working with infants, monitoring infants, children children and young people (Cook and Montgomery and young people fulfils 2010). This guidance applies to professionals who many functions: work in acute care settings, as well as those who work in GP surgeries, walk-in clinics, telephone 1) To provide a baseline of normal vital signs advice and triage services, schools and other for well children attending for a procedure community settings. or surgical intervention, so that their health status can be re-evaluated later Vital signs assessment takes place as part of the following the procedure. art of observation and monitoring of the infant, child or young person. The term assessment 2) To provide a baseline of the sick child’s describes the broader process involving visual physiological state at presentation to observation, palpation (touch), listening and hospitals or health care settings. NB: communication to evaluate the infant, child or This is not the child’s baseline normal young person’s condition. Assessment can physiological state but can contribute to include the characteristics, interactions, trend analysis of a child’s illness. non-verbal communication, and reaction to 3) To demonstrate a rigorous assessment of physical surroundings that infants, children physiological state is made eg, at admission or young people may display (Aylott, 2006). to hospital or when there is concern that The vital signs included in this document are there is deterioration in a child’s condition: heart/pulse rate, respiratory rate and effort, blood • to assist in making a diagnosis pressure, oxygen saturations, capillary refill time, • to contribute to consideration of level of consciousness and temperature. Weight, differential diagnoses height and pain assessment will also be discussed. • to judge how unwell a child is, or The following document describes standards, whether they are in compensated or based on current evidence, best practice and expert decompensated shock. opinion. 4) To triage workload and to identify potential children at risk of deterioration. 5) To allow planning to manage and mitigate those risks. 6) To monitor an infant or child’s growth. 4 ROYAL COLLEGE OF NURSING Paediatric Early Warning Requirements for Scores (PEWS) undertaking vital signs The use of a validated Paediatric Early Warning Nurses at the point of registration, must meet the (PEWS) score may aid individual and team Nursing and Midwifery Council’s (NMC 2010) situation awareness of the children at risk of Standards for pre-registration nursing education, deterioration, particularly for junior staff or which include the ability to: those new to caring for infants, children and young people. However, it is acknowledged • carry out comprehensive nursing that PEWS will not identify all children at risk assessments of children and young people, of deterioration, either due to the speed or the recognising the particular vulnerability mechanism of deterioration. Therefore, it is of infants and young children to rapidly essential that all clinical staff are trained to deteriorate physiologically recognise common patterns of deterioration • select valid and reliable assessment tools for with or without the use of a PEWS and not just the purpose required use the score for reassurance. • systematically collect data regarding health Other components of a safe system to and functional status of individuals, clients recognise and respond to children at risk and communities through appropriate of deterioration include: interaction, observation and measurement • succinct communication tools to • analyse and interpret data accurately and convey critical information eg, SBAR take appropriate action Situation, Background, Assessment and Recommendation (SBAR) tool • recognise when the complexity of clinical (NHS Institute for Innovation and decisions requires specialist knowledge and Improvement, 2008) expertise, and consult or refer accordingly. • a multidisciplinary approach to care In many instances vital signs will be assessed, (Confidential Enquiry into Maternal measured and monitored by health care support and Child Health (CEMACH) 2008, workers, assistant practitioners and nursing McCabe et al., 2009). students, who have received appropriate training to undertake this role. Health care support • safety huddles. workers, assistant practitioners and nursing students undertake this role under the direction Continuous assessment and supervision of a registered nurse, and must understand when they are required to escalate Sequential assessments of vital signs are used concerns. to screen children for signs of serious illness or deterioration, measuring success of treatment Parents and guardians can provide useful context and provide a trend of how a child’s illness regarding how a child is in comparison to their is progressing. More frequent and rigorous normal state. Staff undertaking observation and monitoring of some children will be required monitoring of infants, children and young people for those with acknowledged risk factors for must be cognisant of this and acknowledge and deterioration, where there is concern of serious record any concerns raised. illness/deterioration and those undergoing high

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