Critical Care: the Eight Vital Signs of Patient Monitoring

CRITICAL CARE Critical care: the eight vital signs of patient monitoring Malcolm Elliott and Alysia Coventry ne of the traditional roles of nurses involves surveillance. This might include watching patients Abstract for changes in their condition, recognising early 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 Oor 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 the past, as they have more complex health problems and are n Quality n Safety 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 Temperature Catholic University, Victoria, Australia The body’s temperature represents the balance between heat Accepted for publication: March 2012 produced and heat lost, otherwise known as thermoregulation. British Journal of Nursing, 2012, Vol 21, No 10 621 30 seconds or less is potentially problematic as an irregular pulse Table 1. Eight vital signs may not be detected during this interval. Using a short time Influencing period, such as this, has also been shown to increase calculation Vital sign Physiology factors Assessment issues errors four to six fold (Minor and Minor, 2006). A patient with Temperature Controlled by Age Core temperature differs atrial fibrillation, for example, may appear to have a regular the hypothalamus Infection between anatomical sites pulse if it is assessed for 30 seconds or less. Assessing the pulse Medications for a full 60 seconds may, therefore, highlight abnormalities not Pulse Reflects circulating Intravascular Should be counted for at detected during a shorter assessment interval. However, the volume and volume least 30 seconds. contradictory findings of studies reporting on the relationship strength of Contractility Regularity, strength and between the length of pulse assessment and accuracy, suggest contractility Oxygen equality should also be that the count period is only of limited significance (Joanna demand assessed Briggs Institute, 1999). Blood Regulated by Intravascular Automated monitors are Nurses should not rely on a pulse oximeter to determine a pressure vasomotor centre volume less reliable than a patient’s pulse rate. Rather, they should use their knowledge in the medulla Vascular tone sphygmomanometer Contractility and physical assessment skills to accurately assess the pulse. Respiratory Controlled by the Hypercapnia Indications for measuring: For example, if the pulse is irregular or the patient is cold or rate respiratory centres Hypoxaemia to establish a baseline; hypovolaemic, a pulse oximeter may provide an inaccurate in the medulla Acidosis critical illness, a change in reading. Reliance on technology for taking observations may and pons oxygenation, to evaluate be detrimental to patient care, as other obvious clues to the response to treatment patient’s condition can be easily missed (Wheatley, 2006). In SpO2 Reflects the Cardiac output Does not reflect addition, using a machine (e.g. pulse oximeter) to measure peripheral Hemoglobin respiratory function a physiologic parameter may limit the amount of time the saturation of level overall nurse spends with the patient, both talking to them and haemoglobin by Fraction of touching them, missing the opportunity to identify further O2 inspired O2 valuable clinical data. Pain Detected by Patient’s Often under-assessed and peripheral nerve perception treated in hospital fibers; interpreted Blood pressure by thalamus and Blood pressure (BP) refers to the pressure exerted by blood cerebral cortex against the arterial wall. It is influenced by cardiac output, Level of Controlled by Cerebral Influenced by intra-cranial peripheral vascular resistance, blood volume and viscosity and consciousness reticular activating perfusion and extra-cranial factors vessel wall elasticity (Fetzer, 2006). BP is an important vital system in the sign to measure as it provides a reflection of blood flow when brain stem the heart is contracting (systole) and relaxing (diastole). It is Urine output Produced by Renal Does not directly reflect also one of many indicators of cellular oxygen delivery. kidneys perfusion renal function Changes or trends in BP may reflect underlying Cardiac Output pathophysiology or the body’s attempts to maintain homeostasis. A drop in BP, for example, has been found to be a common and safe practice, the nurse must be aware of these factors. sign in patients prior to cardiac arrest (Rich, 1999). A change in BP alone, though, does not indicate that the patient will Pulse have a cardiac arrest, but should trigger the nurse to perform Pulse is defined as the palpable rhythmic expansion of an a more detailed assessment. The importance of measuring artery produced by the increased volume of blood pushed into BP accurately cannot be over-emphasised; and yet, it is one the vessel by the contraction and relaxation of the heart (Piper, of the most inaccurately measured vital signs (Pickering et 2008). The pulse is affected by many factors including age, al, 2005). If a BP reading consistently underestimates the existing medical

Load more