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Vital Signs PDF
Vital Signs PDF
Vital Signs PDF
BestPractice
Evidence Based Practice Information Sheets for Health Professionals
Vital Signs
Acknowledgement Levels of Evidence
This Best Practice Information Sheet has
This Practice Information
been based on a systematic review of Sheet Covers The Following All studies were categorised according to the
strength of the evidence based on the
research relating to vital signs. If you wish Concepts following classification system.
to view the primary references on which
this information sheet is based, they are Level I
available in the systematic review report Evidence obtained from a systematic review
of all relevant randomised controlled trials.
published by the Joanna Briggs Institute. 1. Vital Signs: General
Level II
Introduction Issues Evidence obtained from at least one properly
designed randomised controlled trial.
Patient observations are an important part
of nursing care in that they allow the 2. Vital Signs: Respiratory Level III.1
patients progress to be monitored and also Evidence obtained from well designed
ensure prompt detection of adverse events Rates controlled trials without randomisation.
or delayed recovery. Patient observations, Level III.2
or vital signs, traditionally consist of blood Evidence obtained from well designed cohort
pressure, temperature, pulse rate and 3. Vital Signs: Pulse Rate or case control analytic studies preferably
from more than one center or research
respiratory rate. A systematic review was group.
recently conducted addressing issues such
as the purpose of vital signs, the optimal 4. Vital Signs: Blood Level III.3
frequency with which they should be Evidence obtained from multiple time series
Pressure with or without the intervention. Dramatic
conducted, what observations constitute results in uncontrolled experiments.
vital signs and to identify issues related to
the individual measures of temperature, 5. Vital Signs: Temperature Level IV
pulse rate, respiratory rate and blood Opinion of respected authorities, based on
clinical experience, descriptive studies, or
pressure. reports of expert committees.
This Best Practice Information Sheet inconsistent and at times inter-changeable. What Constitutes Vital Signs
summarises current best evidence on the The term vital signs suggests measurement Traditionally, the term vital signs is used
topic. In this information sheet, the term of vital or critical physiologic functions, in reference to the measurement of
observations refers to patient observations where as the term observations implies temperature, respiratory rate, pulse rate
in general, while vital signs is used in broader range of measures. While there and blood pressure. However, within the
reference specifically to temperature, is no clear definition in the literature, the literature there are suggestions that these
pulse, respiration and blood pressure. panel of experts which guided the system-
parameters could be supplemented with
atic review process argued that observa-
other useful measures such as nutritional
Vital Signs: General Issues tions is the more appropriate term, in that
it more accurately reflects current clinical status, smoking status, spirometr y,
practice. This implies that patient obser- orthostatic vital signs and pulse oximetry.
Vital Signs versus Observations
The measurement of temperature, pulse, vations need not be limited to the tradi- However, only pulse oximetr y and
heart rate and blood pressure is termed tional four parameters but supplemented determining a patients smoking status have
both vital signs and observations. Neither with other measures as indicated by the been shown to actually change the practice
have been well defined and their use is patients clinical status. of clinicians.
Table One
Korotkoffs Sounds
Measurement of blood pressure by auscultation is based on the sounds produced as a result of changes
in blood flow, termed Korotkoffs sounds, and are:
1. Phase I The pressure level at which the first faint, clear tapping sounds are heard, which increase as the
cuff is deflated (reference point for systolic BP).
2. Phase II During cuff deflation when a murmur or swishing sounds are heard.
3. Phase III The period during which sounds are crisper and increase in intensity.
4. Phase IV When a distinct, abrupt, muffling of sound is heard
5. Phase V The pressure level when the last sound is heard (reference point for diastolic BP).
greater than intra-arterial pressures (see reported. Cuff width may also be important inaccurate way, and that only 3% of gen-
when measuring blood pressure in eral practitioners and 2% of nurses ob-
table one). A study in children reported
neonates and a cuff width equal to tained reliable results. Two studies evalu-
the use of either auscultation or palpation ating the impact of education programs
overestimated systolic pressure. See table approximately 50% of the arm on blood pressure measurement, found
two for current recommended practice for circumference has been recommended. they increased agreement between the dif-
the measurement of blood pressure. ferent blood pressure readings and also
Arm and Body Position significantly reduced differences in opera-
Comparisons of blood pressures measured tor technique.
Palpation versus Auscultation
A comparison between systolic blood pres- in the sitting person with their arm sup-
Limitations
ported horizontally or with the arm rest- A descriptive study of blood pressures in
sure measurements taken by auscultation
ing at their side, have found an average critically ill patients who had suffered a
and palpation found both were within 8
difference in systolic pressure of 11mmHg cardiac arrest highlighted some limitations
mmHg. While palpation has been commonly
and diastolic pressure of 12mmHg. When to these measurements. Of the 15 patients
limited to the measurement of systolic blood investigated, 5 patients had adequate
the arm was placed above or below the
pressure, one study reported that diastolic intra-arterial blood pressures, but
level of the heart, blood pressure meas-
pressures could be accurately palpated us- unreadable cuff pressures. Four patients
urements changed by as much as had cuff pressures approaching normal,
ing the brachial artery to identify the sharp
20mmHg. As a result of this, it has been but had an inadequate cardiac output. This
phase IV Korotkoffs sound, However, the
recommended that blood pressures be study suggests that indirect blood pressure
value of this technique in clinical practice, measurements do not always accurately
taken in the sitting position with arm sup-
and its accuracy when used by health care ported horizontally at approximately heart reflect haemodynamic status of critically ill
workers, has yet to be demonstrated. level. people.
Studies evaluating technique suggest an ear tug should be used during the measurement of tympanic
temperatures, as this is reported to straighten the external auditory canal. Failure to use the ear tug means
infrared thermometers are only partially directed at the tympanic membrane. The tug technique in adults
has been described as pulling the pinna (auricle of ear) in an upward and backward direction, and in
infants it is pulling the pinna in a backward direction.
Evaluations of the impact of ambient temperatures on tympanic temperatures suggest that while a hot
environment can significantly affect readings, cold appears to have little effect.
Cost analyses of the different temperature measurement methods suggest infrared measurements may be
the most cost effective despite the greater initial costs. These savings are the result of the rapid reading
capabilities of these instruments, and the labour cost savings that result.
Rectal Temperature
Many studies have compared the different methods of temperature measurement, and commonly rectal
temperatures are used as the standard comparison. However, these studies will be summarised in a separate
systematic review. The most common reported issue related to rectal temperature measurement is that of
rectal perforation, which appears to be a risk primarily for the newborn and very young. Other reported
complications include peritonitis secondary to rectal perforation, and one case of intra-spinal migration of
a rectal thermometer in a two year old, which broke during routine rectal temperature measurement. A ten
year review of hospital records identified 16 children admitted to a surgical unit with broken or retained
rectal thermometers. In response to this problem axillary temperature measurements have been recommended
in preference to the rectal measurements. With the advent of infrared tympanic thermometers, these
complications are likely to become less common.
Table Three
Temperature Measurement
The different body areas that have A wide range of instruments have been
been used for the measurement of used to measure these temperatures,
body temperature include: and include:
mouth glass mercury thermometer
axilla electronic thermometer
tympanic membrane
pulmonary artery catheter
rectum
skin surface endotracheal tube with temperature
pulmonary artery probe
nose urinary catheter with temperature
groin probe
oesophagus liquid crystal thermometer strip
trachea
disposable thermometers
urinary bladder
urine infrared (tympanic) thermometers
Other issues identified during the systematic review that impact on clinical practice include:
1. the term observations should be used in preference to vital signs, as this better reflects the diversity of what may
constitute patient monitoring;
2. the rectum should not be the first site of choice for the measurement of temperature;
3. normal vital sign parameters do not guarantee normal physiologic status;
4. education programs will likely be effective in improving health care workers blood pressure measurement technique; and
5. while many factors can have a small influence on the accuracy of vital sign measurements, there may be a cumulative
effect, and so organisations should promote a standardised method for all measurements.
Recommendations
Because of the lack of evidence relating to most of the broader issues of patient observation, these recommendations have
been generated by the expert panel, and have been rated level IV evidence (expert opinion)
The specific patient observations, their frequency and duration, should be based on clinical assessment rather than protocol
alone.
Patient observations should be performed as often as indicated by the patients clinical status.
Beginner practitioners should validate their clinical assessment with a more experienced practitioner.
Vital signs should not be used as a way to ensure frequent visits by the nurse.
When visual checks or inspection of the patient are all that is indicated by the patients clinical status, this should be an
acceptable form of patient observation.
Health care workers should be trained to perform patient observations in a standardised manner within each institution, and
be made aware of the risks and limitations associated with this activity.
Pulse oximetry should be considered a vital sign in situations where accurate assessment and monitoring is critical.
Acknowledgements
For further information contact: This publication was produced based on a
The Joanna Briggs Institute for Evidence Based Nursing and Midwifery, Margaret Graham systematic review of the research literature
Building, Royal Adelaide Hospital, North Terrace, South Australia, 5000. undertaken by The Joanna Briggs Institute
http://www.joannabriggs.edu.au, ph: (08) 8303 4880, fax: (08) 8303 4881 under the guidance of a review panel of
NHS Centre for Reviews and Dissemination, Subscriptions Department, Pearson Professional, clinical experts, and was led by Mr. David
PO Box 77, Fourth Avenue, Harlow CM19 5BQ UK. Evans Coordinator of Reviews, The Joanna
AHCPR Publications Clearing House, PO Box 8547, Silver Spring, MD 20907 USA. Briggs Institute; Mr. Brent Hodgkinson
Research Officer, The Joanna Briggs Institute;
The procedures described in Best and Ms Judith Berry Nursing Director, The
Practice must only be used by Royal Adelaide Hospital. The Joanna Briggs
Disseminated collaboratively by: people who have appropriate Institute would like to acknowledge and
expertise in the field to which the thank the review panel members whose
procedure relates. The applicability expertise was invaluable throughout this
of any information must be activity. The review panel members were:
established before relying on it. Ms Judith Berry
While care has been taken to ensure Ms Heidi Silverston
that this edition of Best Practice Mr Peter Le-Gallou
summarises available research and Ms Deb Henrys
expert consensus, any loss,
Ms Kathy Read
damage, cost, expense or liability
Ms Lee Hussie
suffered or incurred as a result of
reliance on these procedures Ms Sue Edwards
(whether arising in contract, Ms Annette Heinmann
negligence or otherwise) is, to the Ms Hazel Morrison
extent permitted by law, excluded. Mr Lyell Brougham