Year 2 MBChB

Clinical Skills Session

Vital signs

Authors:

The Clinical Skills Lecturer Team

Reviewed & ratified by:

Jamie Fanning

Theme Lead for Clinical Examination and Procedural Skills

Learning objectives

To be able to assess the pulse and blood pressure To be able to measure and understand the temperature To be able to measure and understand your partner’s respiratory rate and SPO2

To be able to assess a patient using ACVPU scale To understand the normal parameters of vital signs.

Background/ theory

Vital signs are the evidence of the current physical functioning of the body. Each vital sign has a range of values that is considered normal for the adult population, when at rest.

Vital sign ‘Normal’ adult range

Respiratory Rate (RR) 12-20 breaths per minute (RCP, 2017)

Oxygen Saturation (SpO2) 94-99% (British Lung Foundation, 2019)

Pulse Rate (HR) 60-100 beats per minute (NHS 2019)

Blood Pressure (BP) 90/60 – 140/90 mmHg (NICE 2019)

Conscious Level (ACVPU) Alert (RCP, 2017)

Temperature (T) 36.5oC (fluctuates throughout the day)

Vital signs provide information to support patient assessment and ongoing management. An alteration in vital signs may indicate an acute or chronic medical problem. The further the measurement is from the normal value provides an indication of the severity of the individual’s condition. The order of taking the vital signs in a non-emergency situation is not important.

When measuring vital signs in a non-emergency situation, the room should be quiet and the patient as comfortable as possible. Ideally the patient would be seated, feet on the floor and rested before taking any measurements to avoid altered readings due to activity. Other factors may alter the measurements e.g. pain or anxiety.

Commonly recorded vital signs include

Respiratory Rate Pulse rate Blood Pressure Temperature Peripheral Oxygen Saturation Level (SpO2)

Level of consciousness or new confusion (ACVPU) Urine output Capillary blood glucose level

Prior to taking any vital sign measurements ensure that you address patient safety considerations:

Respiratory rate (RR)

Respiratory rate, or the number of breaths per minute (bpm), is a clinical sign that represents ventilation (the movement of gases in and out of the lungs). A change in respiratory rate is often the first sign of deterioration in health as the body attempts to maintain oxygen and acidity levels (Doherty and Lister, 2015). It is an essential vital sign and fundamental element of patient assessment. Generally changes in respiratory rate occur automatically in response to physical demand but it is possible to consciously increase or decrease respiratory rate for short periods. Changes by as little as 3-5 breaths per minute may indicate a change in condition (Field 2005). Respiratory rate provides a base line for future comparisons and helps determine the patient’s acuity.

Royal College of Physicians (RCP), NEWS2 sets normal RR range for adults as 12-20 bpm

Eupnoea – Normal, good, unlaboured breathing

Bradypnoea – Slow respiratory rate < 12 bpm (RCP 2017)

Tachypnoea – Fast respiratory rate > 20 bpm (RCP 2017)

Some causes of Tachypnoea Some causes of Bradypnoea

Anxiety Emotional distress Pain

Medication/Drugs Raised intracranial pressure Exhaustion

Pyrexia Exercise Pulmonary disorder Neuromuscular disorder Anaemia Cardiovascular disorder Medication/Drugs

Obesity Sleep apnoea

It may be useful to assess RR at the same time as pulse rate or oxygen saturation, an awareness by the patient that you are observing their breathing may introduce inaccuracy by adding conscious influence to the rate.

Respiratory rate may to be referred to as:-

RR – respiratory rate, bpm – breaths per minute, resps.

Take care when interpreting/using bpm as an abbreviation as this is commonly used for beats per minute (pulse) and breaths per minute (respiratory rate)

To measure respiratory rate –

Use a watch with a second hand, count breaths (chest rise and fall = 1 breath) for a full minute. This length of time is needed as changes can occur in pattern and rate and gives you the resulting breaths per minute (bpm).

Record the RR on the observations chart/Early Warning Score/Patient record and report to the local person responsible for patient’s care.

Oxygen Saturation ( SpO 2)

Oximetry is used routinely in secondary care and increasingly in primary care.

Haemoglobin (Hgb) molecules can bind up to 4 oxygen (O2) atoms.

The term oxygen saturation refers to the amount of oxygen bound to Hgb in relation to the maximal amount (100%) of oxygen that can bind Hgb. At 100% O2 capacity, the heam groups of Hgb molecules are fully saturated with O2, and at 75% O2 capacity, three of the four haem groups are occupied.

Oxygen saturation levels are measured with an oximeter using principles of spectrophotograpy; the relative absorption of red (absorbed by deoxygenated blood) and infrared (absorbed by oxygenated blood) light. An oximeter records measurements of relative light multiple times per second and gives a reading every 0.5-1 second based on the average of the previous 3 seconds.

A healthy adult normal blood oxygen saturation level is around 94-99% at sea level (British Lung Foundation 2019).

NB. Most oximeters are unable to distinguish between different types of Hgb. High levels of carbon monoxide will cause high levels of carboxyhaemoglobin which would be interpreted by most oximeters as oxyhaemoglobin – do not rely on oximeters if there is a suspicion of carbon monoxide poisoning as results may appear normal in a dangerously hypoxaemic patient (low levels of oxygen in the blood).

Current guidelines (Royal College of Emergency Medicine 2018/19) recommend that people with resting stable oxygen saturations of 92% or less should be referred for blood gas assessment as part of an assessment of the need for oxygen therapy.

Oxygen saturations may be referred to as: - Oxygen sats, O2 sats, saturations, pulse – ox, SaO2

There are numerous models and manufacturers of oximeters, however, the same basic principles should be followed when measuring oxygen saturations:

If the probe is to be placed on a finger, the hand should be resting (to reduce movement artefact) and warm (well perfused).

Emitters and detectors must oppose one another – light should not reach the detector except through the tissue.

Follow manufacturer’s instructions. Frequency of monitoring will depend upon the patient’s clinical status and the purpose of the

monitoring.

An oximeter probe may also be referred to as: - Sats probe, pulse oximeter or pulse ox.

To measure SpO2 –

Ensure that oximeter probe is clean and appropriate for the patient. Switch it on and check that it is in good working order (you could test it on yourself).

Note levels of any inspired supplemental oxygen therapy (this would affect interpretation of the result). Assess for sources that may produce inaccurate readings – environmental interference (excessive

vibration & high levels of ambient light, including infrared); cold extremities; surface dyes - nail polish (may cause false readings and should be removed), skin dyes e.g. henna; use of intravascular dyes (blue/green cause inaccurately low readings); false nails; cardiac arrhythmias.

Apply the probe to fingertip (or alternate location using an appropriate probe), wait for several seconds and the measurement appears on screen.

If there is a pulse rate displayed, check that what is displayed is within 5 beats of the patient’s pulse. Wait until the measurement is stable before noting the result.

Images showing preparation of an oximeter for use, application and results displayed.

Source: CSTLC

Record the SpO2 on the observations chart/early warning score/patient record, noting any supplemental oxygen and report to the local person responsible for patient’s care.

Pulse

The pulse rate is a measurement of the heart rate (HR), the pulse being the resulting flow of blood through the artery.

Most adults have a resting heart rate between 60 and 100 beats per minute. To assess a resting heart rate, the patient should be at rest for at least 5 minutes. (NHS 2019)

Tachycardia – resting heart rate > 100 beats per minute

Bradycardia – resting heart rate < 60 beats per minute

Heart rate varies depending on health status and activity.

Some causes of Tachycardia Some causes of Bradycardia

Anxiety Emotional distress Pain Pyrexia Exercise Pulmonary disorder Hypoxia Anaemia Cardiovascular disorder Medication/Drugs Shock Electrolyte imbalance Hyperthyroidism

Medication/Drugs Raised intracranial pressure Cardiac damage/abnormality Hypothyroidism Electrolyte imbalance Hypoxia Athlete Vagal nerve stimulation

Assessing pulses can form part of many patient examinations. When pulses are taken for the purpose of vital signs, the relevant features of the pulse to note are the rate and rhythm. Other features are relevant to system examination, such as character and state of the vessel wall. In responsive patients, any pulse point can be utilised – the most common, due to accessibility and ease, is the radial pulse.

When assessing pulse in an unresponsive patient assess a central pulse (usually carotid) as unresponsive patients may have a palpable central pulse but impalpable peripheral pulse.

Arterial pulses are detected by palpating the relevant vessel. If you have difficulty, you may need to vary the degree of pressure in order to pick up the relevant pulsation.

Rate – The number of beats per minute

Rhythm – The pattern of the beats.

When you initially feel the pulse, you need to assess whether the rhythm is regular (the beats are evenly spaced) or irregular (varying interval between beats).

If the rhythm is regular, using a watch with a second hand, count the number of beats occurring during 30 seconds. Then double the number to provide the pulse rate – beats per minute.

If the rhythm is irregular or slow, count the beats for a full minute to ensure accuracy.

If you are unable to feel a radial pulse and the patient is well, try the opposite radial artery. If you are still unable to locate a radial pulse and the patient is well, try the brachial artery. You can assess the brachial artery in the first instance if this is your preference.

A carotid pulse assessment is not commonly made when routinely measuring vital signs, although it is not incorrect to do so. Carotid pulses are usually assessed for vital signs during medical emergency situations, when you must always call for help using the local procedure for summoning emergency medical assistance. During medical emergencies, vital signs are assessed in a specific order following an A to E approach which you will learn about in later years.

The brachial artery, in the antecubital fossa, lies medial to the tendon of the biceps muscle. This is the position where a stethoscope is placed to hear the pulse of the vessel when taking a blood pressure reading.

The radial pulse is palpated by applying gentle pressure to the artery against the distal shaft of the radius, using the tips of the middle and index fingers – it provides information about rate and rhythm.

Source: CSTLC

Source: CSTLC

Record the pulse rate on the observations chart/early warning score chart/patient record and report to the local person responsible for patient’s care.

Pulse rates may be referred to as:

Pulse, heart rate, beats per minute (bpm)

NB – Care when interpreting/using bpm as this abbreviation is commonly used for beats per minute (pulse) and breaths per minute (respiratory rate)

To measure a pulse rate for vital signs (non-emergency) –

Ensure the patient is at rest for 5 minutes Have access to be able to observe 30 seconds or 1 minute Palpate the appropriate pulse of choice and assess rhythm Count the beats in the appropriate length of time Calculate the beats per minute rate. Record the result

Blood Pressure

Blood pressure (BP) is a measure of the pressure that circulating blood exerts against arterial walls. Systolic pressure is the maximal pressure that occurs during ventricular contraction (systole). During ventricular filling (diastole), arterial pressure is maintained at a lower level by the elasticity and compliance of the vessel wall. The lowest value (diastolic pressure) occurs immediately before the next cycle. The following re-created chart details categories of blood pressure as detailed by the British Cardiovascular Society. These categories are detailed by NHS and Blood Pressure UK (2019) in patient literature

Never assess both carotids simultaneously as this could result in syncope (patient collapse).

To assess carotid pulse, place the tips of your fingers between the larynx and the anterior border of the sternocleidomastoid muscle.

Palpate gently and do not rub the carotid artery, this is to avoid a vagal reflex, which could result in syncope.

Source: CSTLC

Blood pressure measurement is a component of assessing an individual’s cardiovascular status and where treatment is necessary, assists the prescription of intervention e.g. well person clinic, drug therapy to manage hypertension or fluid management in trauma. A blood pressure should be assessed on both arms when first assessed on a patient; this is to ensure that the pressure in each arm is within or equal to 10 mmHg difference which is acceptable. A difference of > 10mmHg requires further investigation as it could be evidence of an abnormality such as co-arctation, stenosis or dissection. If a patient has a history of collapse or dizziness, blood pressure should be recorded with the patient lying and standing to assess for postural hypotension.

Some causes of Hypertension Some causes of Hypotension

Obstructive sleep apnoea Emotional distress Hormone disorder Raised intracranial pressure Cardiovascular disorder – atheroma,

obstruction Renal disease Medication/Drugs Pain

Medication/Drugs Cardiac damage/abnormality Hormone disorder Fluid loss, e.g. dehydration, sepsis, trauma Autonomic dysreflexia Vagal nerve stimulation

BP is usually measured using a sphygmomanometer. In certain situations, such as the intensive care unit, it is measured invasively using an indwelling intra-arterial catheter connected to a pressure sensor.

Images of examples of a manual and an electronic sphygmomanometer

A normal adult systolic pressure range is considered to be 90 - 120 mmHg

A normal adult diastolic pressure range is considered to be 60 - 80 mmHg

Hypertension (high blood pressure) is considered to be a systolic pressure >140 mmHg and/or a diastolic pressure >90 mmHg (>140/90 mmHg)

Hypotension (low blood pressure) is considered to be a systolic blood pressure <90 mmHg and/or diastolic pressure <60 mmHg (<90/60 mmHg)

A sphygmomanometer (commonly abbreviated to ‘sphyg’) consists of an extendable cuff that contains an inflatable bag. There are manual and electronic sphygs available. The cuff is wrapped around an extremity, usually the arm, directly over the artery to be compressed. The bladder in the cuff should cover at least 80% of the circumference of the arm but not more than 100%. Blood pressure cuffs usually have markings to assist your assessment of the appropriate size to use for the patient. It is important to use the correct size – if the cuff is too short or too narrow the reading may be falsely high, if too long or too wide, falsely low. A sphyg should have a range of cuff sizes available with it.

The artery is occluded by inflating the bag, by means of a squeeze bulb or electronic inflation unit, to a pressure in excess of the arterial systolic pressure. The pressure in the bag is measured by means of manometer or pressure sensor. Pressure is released from the bag with a needle valve in the squeeze bulb or by electronic means. Automated spyghs may not measure accurately if there is an irregular pulse. If the patient has an irregular pulse measure the blood pressure manually using auscultation over the brachial artery (NICE guideline, 2019, CG136)

If a stethoscope is placed over the brachial artery in the antecubital fossa in a normal person (without arterial disease), no sound should be audible, blood flow is laminar (smooth, non-turbulent). Similarly, if the cuff of a sphygmomanometer is placed around a patient's upper arm and inflated to a pressure above the patient's systolic blood pressure, there will be no sound audible. This is because the pressure in the cuff is sufficiently high enough to completely occlude the blood flow. If the pressure is dropped to a level equal to that of the patient's systolic blood pressure, the first Korotkoff sound will be heard. As the pressure in the cuff is the same as the pressure produced by the heart, some blood will be able to pass through the upper arm when the pressure in the artery rises during systole. This blood flows in spurts as the pressure in the artery rises above the pressure in the cuff and then drops back down beyond the cuffed region, resulting in turbulence that produces an audible sound. As the pressure in the cuff is allowed to fall further, thumping sounds continue to be heard as long as the pressure in the cuff is between the systolic and diastolic pressures, as the arterial pressure keeps on rising above and dropping back below the pressure in the cuff.

Eventually, as the pressure in the cuff drops further, the sounds change in quality, then become muted, and finally disappear altogether. This occurs because, as the pressure in the cuff drops below the diastolic blood

Source: CSTLC Source: CSTLC

pressure, the cuff no longer provides any restriction to blood flow allowing the blood flow to become smooth again with no turbulence and thus produce no further audible sound. There are 5 Korotkoff sounds (Phases I-Phase V), Korotkoff sounds 1 and 5 are relevant to manual blood pressure measurement:

Sound 1/Phase I - The first appearance of faint, repetitive, clear tapping sounds which gradually increase in intensity for at least two consecutive beats is the systolic blood pressure.

Sound 5/Phase V - The point at which all sounds finally disappear completely is the diastolic pressure.

Blood pressure readings are traditionally recorded with the systolic value preceding the diastolic value, usually separated by a slash e.g. 126/82 mmHg

In people with symptoms of postural hypotension (falls, postural dizziness), initially measure the blood pressure with the patient seated or lying. Stand the patient for at least 1 minute and repeat the measurement. If the systolic pressure falls by 20mmHg or more when they are standing, further review of the patient is needed. (NICE guideline, 2004, amended 2011, CG127).

Potential sources of error – Poor sphyg maintenance, incorrect cuff size, incompatibility between cuff and sphyg, tube/pump/cuff leak, irregular pulse, environmental interference (movement/noise), incorrect arm/cuff/sphyg position and poor technique.

To measure the blood pressure using a manual sphygmomanometer (British and Irish Hypertension Society, 2019)

The patient should be seated in a chair with a backrest and feet on the floor for at least 5 minutes, relaxed and not speaking.

The arm should be supported at the level of the heart, resting on a cushion, pillow or arm rest. If the patient is in a bed, the arm should be at the level of the heart. Ensure no tight clothing constricts the arm.

Place the cuff neatly on the arm, 2 cm above the antecubital fossa, aligning the ‘artery’ mark (middle of the bladder) to the brachial artery. Once you have the correctly sized cuff, wrap it around the arm and secure it with the Velcro or tuck in the tail of the cuff to secure if non-Velcro.

Source: CSTLC

Use the cuff size recommended by the manufacturer of the sphygmomanometer. Manufacturers vary, cuffs may not be interchangeable between different manufacturer’s sphygs.

Estimate the systolic blood pressure – estimating systolic pressure aids prevention of unnecessary over inflation of the cuff which may cause patient discomfort and supports accurate measurement in patients that may have an auscultatory gap. An auscultatory gap is a period of diminished or absent Korotkoff sounds during the manual measurement of blood pressure. The improper interpretation of this gap may lead to blood pressure monitoring errors: namely, an underestimation of systolic blood pressure. Palpate the brachial/radial artery.

1. Inflate the cuff until pulsation disappears – continue to feel for the pulse whilst you increase the pressure in the cuff an additional 30mmHg. Whilst feeling for the pulse, deflate the bladder slowly and note the pressure reading when the pulse returns – this is the estimate.

2. Deflate the cuff.

Re-inflate the cuff to 30mmHg above the estimated systolic level to occlude the pulse Place your clean stethoscope diaphragm over the brachial artery in the antecubital fossa and deflate

the cuff at a rate of 2-3mm/second until you hear regular tapping sounds (Korotkoff sounds). Measure systolic (first sound) and diastolic (disappearance) to the nearest 2mmHg Record the blood pressure on the observations chart/early warning score chart/patient record and

report to the local person responsible for patient’s care.

To measure the blood pressure using an automated sphygmomanometer (British and Irish hypertension Society, 2019)

The patient should be seated in a chair with a backrest and feet on the floor for at least 5 minutes, relaxed and not speaking.

The arm should be supported at the level of the heart, resting on a cushion, pillow or arm rest. If the patient is in a bed, the arm should be at the level of the heart. Ensure no tight clothing constricts the arm.

Place the cuff neatly on the arm, 2 cm above the antecubital fossa, aligning the ‘artery’ mark (middle of the bladder) to the brachial artery. The bladder in the cuff should cover at least 80% of the circumference of the arm but not more than 100%.

Use the cuff size recommended by the manufacturer of the sphygmomanometer. Some blood pressure monitors have a choice of manual or automated blood pressure selection where

you choose the appropriate setting. Some monitors will automatically inflate and re-inflate to the next setting if required. Warn the patient that this may happen to avoid alarm.

Repeat 3 times and record measurement as displayed. Initially test blood pressure in both arms and use the arm with the highest reading for subsequent measurements.

Temperature

The expected normal temperature of adult patients is 36.5oC (Paterson and Dover, 2018) – variances will be seen in clinical practice .Texts vary when describing a normal range. When a temperature measurement is within the normal range the patient is termed apyrexial or normothermic. Many National Institute for Health and Clinical Excellence (NICE) clinical guidelines include the accurate measurement of temperature.

Body temperature represents the balance between heat production and heat loss. All metabolising body cells manufacture heat in varying amounts, therefore, body temperature is not evenly distributed across the body (Childs, 2011). Variations in what is considered normal will be affected by the equipment measuring the temperature and the site at which the temperature is recorded.

Core body temperature is found in the blood supplying organs such as the brain and those in the abdominal and thoracic cavities. Core temperature may be affected by intrinsic factors and, to a lesser degree, extrinsic (environmental) factors. Peripheral temperature is recorded in tissues such as the skin, where environmental factors and a lack of insulating connective tissue influence temperature.

True core temperature readings can only be measured by invasive means, such as placing a temperature probe into the oesophagus, pulmonary artery or urinary bladder (Childs, 2011). It is not practical, nor indeed necessary, to use such sites and methods in all cases; they tend to be reserved for patients who are critically ill. Alternative sites such as the rectum, oral cavity, axilla, temporal artery (forehead) and external auditory canal are accessible and are believed to provide the best estimation of the core temperature (Pusnik and Miklavec, 2009). The temperature measured between these sites can vary greatly, so the same site ought to be used consistently and recorded on the chart with the reading (Davie and Amoore, 2010)

Normothermic, Apyrexial (normal temperature) – 36.5 oC

Hypothermia (low temperature) – core temperature of <35oC. (NHS 2017)

Sub- categories of hypothermia: - Mild 32-35oC, Moderate 28-32oC, Severe <28oC

Pyrexia (high temperature) – generally considered a temperature > 37.8oC

Some causes of Pyrexia Some causes of Hypothermia

Infection Exercise Bio rhythm Medication/Drugs Exposure to heat/sun Metabolic disorder

Medication/Drugs Exposure to cold environment Metabolic disorder

Oral (Sub-lingual)

The oral cavity temperature is considered to be reliable when the thermometer is placed posteriorly into the sublingual pocket. This landmark is close to the sublingual artery, so this site tracks changes in core body temperature. Factors affecting accuracy include recent ingestion of food or fluid, having a respiratory rate >18 per minute and smoking (Dougherty and Lister, 2011).

Electronic or disposable chemical thermometers may be used. Chemical thermometers should be avoided if the patient is hypothermic (<35°C) because their range of operation is 35.5°C-40.4°C (Fulbrook, 1997). Low-reading thermometers may be of some use.

Ensure an electronic thermometer is set to record oral temperature.

The thermometer should be cleaned before and after use as per manufacturer’s instructions. Many electronic thermometers will have single use disposable covers for the temperature probe, apply a cover and place thermometer in the sublingual pocket of the mouth until the device indicates that it is done- this normally takes approx. 15 seconds. Please then dispose of cover in a clinical waste bin.

Mercury-in-glass thermometers can no longer be bought because of European Council rules (Medicines and Healthcare products Regulatory Agency, 2011), due to the risks of injury from broken glass and poisoning due to mercury. Glass and mercury thermometers should not be used.

Axillary

Ensure an electronic thermometer is set to measure axilla temperature.

The thermometer should be cleaned before and after use as per manufacturer’s instructions. Many electronic thermometers will have single use disposable covers for the temperature probe, apply a cover and place the probe in the axilla (armpit) in the central position, adducting the arm close to the chest wall. Hold the probe in place until the result is displayed. When completed, remove and dispose of the probe cover. Literature suggests that this is an unreliable site for estimating core body temperature because there are no main blood vessels around this area. Fulbrook (1997) produced convincing evidence indicating that chemical thermometers are clinically unreliable for measuring axillary temperature. Giantin et al (2008) suggested that electronic digital thermometers can be used at this site as a reliable alternative in older people.

Tympanic (Aural)

The tympanic thermometer senses reflected infrared emissions from the tympanic membrane through a probe placed in the external auditory canal. This method is quick (<1 minute), minimally invasive, easy to perform and commonly seen used clinically. It has been reported to estimate rapid fluctuations in core temperature accurately because the tympanic membrane is close to the hypothalamus. Ear wax is known to reduce the accuracy of readings, so it is recommended that the ear is inspected before measurement.

Skin temperatureAn example of a skin temperature measuring device is the Feverscan™ used particularly with children.To use this device, hold the FeverScan™ firmly in place for 15 seconds across the patient’s forehead, with the black surface flat against the middle of a DRY forehead.Read the FeverScan™ whilst it is on the forehead using the lower (Celsius) scale, temperature is indicated by the central yellow line. It may be inaccurate in flushed patients, in this circumstance it is advisable to use an alternate method.After use the FeverScan™ is cleaned with a soft clean cloth and stored in its case.

Temporal Thermometers scan the skin overlying the temporal artery and are increasingly being used. However, there are conflicting studies regarding their accuracy when compared to more traditional methods such as oral and rectal measurement.

Rectal temperatureRectal thermometry has been demonstrated to be more accurate than oral measurements. It is not commonly done in practice as it has many patient dignity considerations and is not practical.An electronic thermometer may be used with disposable probe covers, if used, ensure that the thermometer is set to measure a rectal temperature. Thermometers with more than one probe often have a red coloured probe to distinguish it from oral, which is blue. The thermometer needs to be inserted at least 4cm into the rectum in adults and held in position securely to prevent movement. The presence of faeces prevents the thermometer from touching the wall of the bowel and may generate inaccurate readings.

Body temperature should be measured and recorded regularly with precision, consistency and diligence. Temperature measurements serve as a useful indicator of change in patients’ clinical condition.

To take the temperature reading; place a disposable sheath onto the thermometer’s probe, pull the patients’ ear gently upwards and backwards to straighten the auditory canal. The aural thermometer is then gently inserted into the ear. (Pressing too deep may be painful)The temperature reading appears in the thermometer’s LED window. It is preceded by an audible “beep” indicating that the temperature has been measured.The reading may be inaccurate if a poor technique is employed. This method can also be painful if the patient has an ear infection and may result in an elevated temperature reading. Take another reading using a different method in order to determine if the raised temperature is localised or not.

Temporal artery

To measure a temperature:

Choose an appropriate method to measure temperature considering factors that affect accuracy of measurement

Choose appropriate equipment to measure temperature and ensure thermometer is clean, functioning with probe covers applied where necessary.

Take temperature as per instructions for specific thermometer and site of measurement Dispose of probe covers and clean thermometer Record the temperature on the observations chart/early warning score chart/patient record and report

to the local person responsible for patient’s care.

Level of Consciousness

An altered level of consciousness presents in a variety of forms including confusion, lethargy, disorientation, delirium, impaired cognition or coma. Patients with acute illness may develop an acutely altered mental state, this is an important sign of acute clinical deterioration requiring urgent clinical assessment. A baseline assessment is useful in establishing whether alterations are an acute deterioration for the patient or is in keeping with that which is considered normal for the patient.

Some factors that can affect level of consciousness:

Infection, electrolyte imbalance, raised intracranial pressure, hypoxia, hypoglycaemia, brain injury/lesion, drugs/medication.

There are 2 scales commonly accepted for use in the assessment and reporting of conscious level – ACVPU and Glasgow Coma Score (GCS).

ACVPU is a quick assessment tool that is used for basic assessment in clinical practice. ACVPU is an acronym

1. A – Alert, a fully awake patient. Such patients will have spontaneous opening of the eyes, will respond to voice and will have motor function.

2. C – A patient may be alert but confused, disorientated or have an altered mental state. Royal College of Physicians (2017) recommend that if it is unclear whether a patient’s confusion is new, or their normal state, the confusion should be assumed to be new until confirmed to be otherwise.

3. V – Responds to voice. The patient makes some kind of response when you talk to them, which could be in any one of the three component measures of eyes, voice or motor. The response could be as little as a grunt, moan or slight movement of a limb.

4. P – Responds to painful stimulus. Moves or groans to painful stimulus. Squeezing the trapezius muscle is an excellent way of applying a central stimulus. Hold the trapezius muscle (not just the skin) between your thumb and two fingers, squeeze 2.5-5.0 cm and twist.

5. U – Unresponsive, also commonly referred to as unconscious. No response at all is elicited to a painful stimulus.

ACVPU is the assessment tool used in NEWS2.

Glasgow Coma Score or G.C.S. The patient is assessed for eye opening, verbal response and motor response. This provides a clinical index of the overall acute impairment of brain function. Pupil response to light can be added (GCS-P score) which assesses for brainstem dysfunction. You may see clinicians using GCS as an assessment tool, particularly in critical care, emergency care and neurological speciality areas. More information about GCS can be found at : https://www.glasgowcomascale.org

To assess level of consciousness: Perform an assessment of the patient – following the pathway below will assist your assessment

Record the assessment of conscious level on the observations chart/early warning score chart/patient

record and report to the local person responsible for patient’s care.

This study guide should be read in conjunction with NEWS study guide

Sources and useful resources -

Dougherty L, Lister S (2015) The Royal Marsden Manual of Clinical Nursing Procedures. Chichester: Wiley-Blackwell.

Field D (2005) Respiratory care In: Sheppard M, Wright M (eds) Principles and Practice of High Dependency Nursing. Edinburgh: Baillière Tindall.

Royal College of Physicians (2017) National Early Warning Score (NEWS) 2.

https://www.nursingtimes.net/clinical-archive/respiratory/respiratory-rate-3-how-to-take-an-accurate-measurement/7025005.article

https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2

https://improvement.nhs.uk/documents/3603/Patient_Safety_Alert_-_Placement_of_oximetry_probes_FINAL.pdf

Berne & Levy Physiology, seventh edition (2018) – Chapter 24, Oxygen & Carbon Dioxide Transport; Oxygen Saturation, Content and Delivery. https://www-clinicalkey-com.liverpool.idm.oclc.org/student/content/book/3-s2.0-B9780323393942000249#hl0000488

https://www.blf.org.uk/support-for-you/breathing-tests/pulse-oximetry-test

https://www.nhs.uk/common-health-questions/accidents-first-aid-and-treatments/how-do-i-check-my-pulse/

https://www.nice.org.uk/guidance/cg127/chapter/1-Guidance#measuring-blood-pressure

http://www.bloodpressureuk.org/BloodPressureandyou/Thebasics/Bloodpressurechart

https://bihsoc.org/wp-content/uploads/2017/11/BP-Measurement-Poster-Manual-2017.pdf

https://bihsoc.org/wp-content/uploads/2017/11/BP-Measurement-Poster-Automated-2017.pdf

https://www.nice.org.uk/guidance/qs49/chapter/quality-statement-3-patient-temperature

https://www.glasgowcomascale.org/

Childs C (2011) Maintaining body temperature. In: Brooker C, Nicol M (eds) Alexander’s Nursing Practice. Oxford: Elesvier.

Davie A, Amoore J (2010) Best practice in the measurement of body temperature. Nursing Standard; 24: 42, 42-49.

Pusnik I, Miklavec A (2009) Dilemmas in measurement of human body temperature. Instrument Science Technology; 37: 516-530.

Dougherty L, Lister S (2011) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Oxford: Blackwell Publishing.

Fulbrook P (1997) Core body temperature measurement: a comparison of axilla, tympanic membrane and pulmonary artery blood temperature. Intensive and Critical Care Nursing; 13: 266-272.

Giantin V et al (2008) Reliability of body temperature measurements in hospitalised older patients. Journal of Clinical Nursing; 17: 1518-1525.

https://www.nice.org.uk/guidance/ng136

Patterson, R., and Dover, A, R. (2018) ‘The deteriorating patient’, in Innes, A, J., Dover, A, R., and Fairhurst, K. (eds.) Macleod’s: Clinical Examination (14th edn). Edinburgh: Elsevier, pp. 339-347