Recording vital signs and statistics in your nursing assessment

Published: 19th April 2011
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Through your nursing assessment accurate measurements of your patient's vital signs provide crucial information about body functions . Even if these have been carried out by another practitioner it is important to reassess pulse and respiratory rate as a minimum, as you need to judge the quality (such as rhythm and depth) as well as rate, and be alert to any changes or deterioration. No matter whether you plan to write up your notes as you go along or later, chart or make a note of vital signs as you record them, as they are very easily forgotten.

Interpreting level of consciousness and vital signs through your nursing assessment

AVPU
A rapid determination of level of consciousness can be achieved using the AVPU scale. This scale is applicable to all age groups. The practitioner assesses the patient as fitting into one of four categories:

• Alert
• Responds to Voice
• Responds to Pain
• Unconscious.

Any concerns following this initial nursing assessment should be followed up with a full Glasgow Coma Score assessment.

Track and trigger
NICE (2007b) recommends that a physiological 'track and trigger system' (in the form of a multiparameter or aggregate weighted scoring system) should be used to determine deterioration or to grade the risk of deterioration in all adult patients in acute hospital settings. A variety of different systems exist, with weighted systems such as an Early Warning Score (EWS) or a Modified Early Warning System (MEWS) being amongst the most commonly used. Such systems consider vital signs and other findings such as urine output and AVPU to determine deterioration or risk. Choice of tools and parameters vary from one setting to the next, so it is important to familiarise yourself with the tool(s) used in your care setting. Scoring systems are also being developed for use with children – Paediatric Early Warning Systems (PEWS). For more information on EWS, see Baines and Kanagasunduram (2008).

Accuracy
If you obtain an isolated abnormal value when monitoring vital signs, firstly look at the whole patient and other findings. If the value seems unexpected and the patient seems otherwise well, it may be appropriate to recheck the reading again, but don't automatically assume the reading is inaccurate. Electronic devices in particular MAY give inaccurate readings for a variety of reasons, but on the other hand patients with concerning abnormal fi ndings may not look obviously unwell. Remember also that normal readings vary with the patient's age – for example, blood pressure increases as you get older. But don't make assumptions that such abnormal readings are 'normal in the elderly'; any such abnormalities should still be reported and explored further.

Individuality
Also remember that an abnormal value for one patient may be a normal value for another. Each patient has their own baseline values, which is what makes recording baseline vital signs so important wherever this is possible.

Repeat vital sign recordings
Afterwards, take or request measurements of vital signs at regular intervals, with frequency depending on the patient's condition. A series of readings invariably provides more valuable information than a single set.

MEWSing on the problem
If the patient is acutely unwell or deteriorating, repeat initial observations and AVPU scoring at frequent intervals. Consider findings in relation to a 'track and trigger system' such as an Early Warning Scoring system (EWS) or a Modified Early Warning Scoring system (MEWS), which uses vital signs and other findings to predict risk of deterioration.

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