Patients admitted to acute hospitals today are sicker than in 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 sick to be operated on are now undergoing complex surgical procedures. This, coupled with the increasing demand for beds, means that ward nurses are often caring for patients who previously would have been cared for in a high-dependency or intensive care unit (Butler-Williams and Cantrill, 2005).
Furthermore, system factors such as skill mix, nurse:patient ratios and bed shortages significantly impact on the quality of nursing care delivered in these environments. This challenging situation is further complicated by increasing patient survival rates, which have resulted in an increasingly complex and older patient population (James et al, 2010). Patients aged 65 and older, for example, have twice the risk of younger adults of developing peri-operative complications. They are also more likely to be admitted as emergencies and undergo emergency surgery (Romano et al, 2003).
Diminished reserves in cognitive, renal and hepatic function also contribute to older patients being a group at high risk of adverse events (Thornlow, 2009). As such, the five traditional vital signs may not be adequate to detect clinical changes in patients who have more complex care needs than nurses have encountered in the past. Before an acute change in a patient’s physiology can be recognised, the vital signs must be accurately assessed (Smith et al, 2006). The aim of this paper, therefore, is to provide an overview of the essential knowledge required to accurately
assess these signs. This paper summarises the five traditional vital signs and recommends additional ones that should be part of an acute care nurses’ repertoire of patient assessment. The signs are listed in Table 1. Temperature The body’s temperature represents the balance between heat produced and heat lost, otherwise known as thermoregulation. British Journal of Nursing, 2012, Vol 21, No 10 Abstract Nurses have traditionally relied on five vital signs to assess their patients: temperature, pulse, blood pressure, respiratory rate and oxygen saturation.
However, as patients hospitalised today are sicker than in the past, these vital signs may not be adequate to identify those who are clinically deteriorating. This paper describes clinical issues to consider when measuring vital signs as well as proposing additional assessments of pain, level of consciousness and urine output, as part of routine patient assessment. Key words: Vital signs n Patient monitoring n Assessment n Quality n Safety In the clinical environment, body temperature may be affected by factors such as underlying pathophysiology (e.
g. sepsis), skin exposure (e. g. in the operating theatre) or age. Other factors may not affect the body’s core temperature but can contribute to inaccurate measurements, such as the consumption of hot or cold fluids prior to oral temperature measurement. Clinically, there are three types of body temperature: the patient’s core body temperature; how the patient says they feel; and the surface body temperature or how the patient feels to touch. Importantly, these three are not always the same and may differ according to the underlying disease process.
The nurse must be able to interpret conflicting assessment findings such as these in light of the patient’s underlying pathophysiology. When measuring body temperature, a number of factors must be considered. Not only must the measuring device be correctly calibrated, but the nurse must also be aware of the difference in the core temperature between anatomical sites. For example, a study found significant differences in the accuracy and consistency of several commonly used devices for measuring temperature – tympanic, oral disposable, oral electric and temporal artery (Frommelt et al, 2008). This
highlights the importance of regular calibration, correct use, accurate documentation (site of measurement and temperature reading) and consistency (using the same site) as ways of accurately identifying trends in the patient’s core temperature. No single thermometer or measurement site is recommended as best practice, but in order to ensure accuracy Malcolm Elliott is Lecturer, Faculty of Health Science and Community Studies, Holmesglen Institute, Victoria, Australia and Alysia Coventry is Lecturer, School of Nursing, Midwifery & Paramedicine, Australian Catholic University, Victoria, Australia Accepted for publication: March 2012