Royal Nursing College

Standards forassessing,measuring andmonitoring vitalsigns in infants,children andyoung people

RCN guidance for children’s nurses

and nurses working with children

and young people

Acknowledgements

We would like to thank everyone who gave theirexpertise and guidance to develop the standardscontained in the first edition and to Sally Ramsay,Independent Nursing Adviser,who prepared the originaldocument.

ColinWay, Nurse Consultant, Paediatric HighDependency Unit, St George's Healthcare NHS Trust

Doreen Crawford, Senior Lecturer,De MontfortUniversity, Leicester

JasonGray, Interim Nurse Consultant /PaediatricEmergency Department, Brighton & Sussex UniversityNHS Trust

Katie Bagstaff, Senior Sister, Paediatric Recovery,Cambridge University Hospitals NHS Foundation Trust

Fiona Smith,Adviser in Children andYoung People’sNursing, Royal College of Nursing

This publication contains information, advice and guidance to help members of the RCN. It is intended for use within the UK but readers areadvised that practices may vary in each country and outside the UK.

The information in this booklet has been compiled from professional sources, but its accuracy is not guaranteed.Whilst every effort has beenmade to ensure the RCN provides accurate and expert information and guidance, it is impossible to predict all the circumstances in which itmay be used.Accordingly, the RCN shall not be liable to any person or entity with respect to any loss or damage caused or alleged to be causeddirectly or indirectly by what is contained in or left out of this website information and guidance.

Published by the Royal College of Nursing, 20 Cavendish Square, London,W1G 0RN

© 2011 Royal College of Nursing.All rights reserved.No part of this publication may be reproduced, stored in a retrieval system, or transmittedin any form or by any means electronic,mechanical, photocopying, recording or otherwise,without prior permission of the Publishers. Thispublication may not be lent, resold, hired out or otherwise disposed of by ways of trade in any form of binding or cover other than that in whichit is published,without the prior consent of the Publishers.

R O Y A L C O L L E G E O F N U R S I N G

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Standards for assessing, measuringand monitoring vital signs in infants,children and young people

RCN guidance for children’s nurses and nurses workingwith children and young people

Contents

Introduction 2

How to use this document 2

1 Education and training 3

Standards 3

Practice criteria 3

2 Teaching children, young people and parents/carers 4

Standards 4

Practice criteria 4

3 Assessing andmeasuring vital signs 5

Standards 5

Practice criteria: 5

- general 5

- temperature 5

- heart/pulse rate 6

- respirations 6

- blood pressure 6

- blood transfusion 6

- post-operative care 6

- capillary refill time 7

- pain assessment 8

- level of consciousness 8

4 Medical devices and equipment 8

Standards 8

Practice criteria 8

5 Record keeping 9

Standards 9

Practice criteria 9

6 References 10

7 Further resources 13

The assessment,measurement and monitoring of vitalsigns are important basic skills for all practitionersworking with infants, children and young people. Thisguidance applies to health care professionals who workin acute settings as well as practitioners who work in GPsurgeries,walk-in clinics,NHS 24 and NHS Direct,schools and other community settings (Cook andMontgomery, 2006). The vital signs included in thisdocument are temperature, heart/pulse rate, respiratoryrate and effort, blood pressure, pain assessment andlevel of consciousness. Important information gained byassessing and measuring these vital signs can beindicators of health and ill health.However,we believethey should not be performed in isolation to the broaderobservation and assessment of the infant, child oryoung person.

Inmany instances vital signs will be assessed,measuredandmonitored by health care assistants and nursingstudents,under the direction and supervision of aregistered nurse.

Nurses, at the point of registration,must meet theNursing andMidwifery Council’s (NMC) standards forpre-registration nursing education (2010),whichincludes the ability to:

� carry out comprehensive nursing assessments ofchildren and young people, recognising the particularvulnerability of infants and young children to rapidphysiological deterioration

� select valid and reliable assessment tools for thepurpose required

� systematically collect data regarding health andfunctional status of individuals, clients andcommunities through appropriate interaction,observation andmeasurement

� analyse and interpret data accurately and takeappropriate action

� recognise when the complexity of clinical decisionsrequires specialist knowledge and expertise, andconsult or refer accordingly.

Good record keeping is essential for effective monitoringand interpretation of vital signs.The NMC’s Recordkeeping guidance for nurses and midwives (2009) statesthat:“Good record keeping is an integral part of nursing

andmidwifery practice, and is essential to the provisionof safe and effective care.”

The following document describes standards, based oncurrent evidence, best practice and expert opinion. Theterm assessment has been used to indicate a broaderprocess involving visual observation, palpation (touch),listening and communication in order to give a holisticassessment of the infant, child or young person’scondition.Assessment can include the characteristics,interactions, non-verbal communication, and reactionto physical surroundings that infants, children or youngpeople may display (Aylott, 2006).

Whilst this document views standardising assessment,measuring andmonitoring of vital signs as a key aspectof patient care they are only one important aspect ofdetecting the sick or deteriorating child.Othercomponents of early recognition are:

1. a recognised paediatric early warning tool,

2. a systemwhich allows clear communication offindings and concerns e.g. Situation,Background,Assessment and Recommendation (SBAR) tool

3. a multidisciplinary approach to care (CEMACH,2008;McCabe et al, 2009).

How to use this documentEach topic covered in this document includes thestandard itself, a set of practice criteria and informationon underpinning literature.

The standards provide criteria for practitioners inachieving high quality nursing care.They will be of helpin guiding local policies and procedures in relation tovital signmonitoring,performance improvementprogrammes and education programmes for registerednurses,nurses in training and health care assistants.

The practice criteria provide the specific information tounderpin the standards.They will help health careprofessionals in developing care plans and performingsafely and effectively when assessing,measuring,monitoring and recording vital signs.

References to relevant supporting literature and furtherreading are also included.The reference list will helppractitioners enhance their knowledge andunderstanding of vital signs.

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S T A N D A R D S F O R A S S E S S I N G , M E A S U R I N G A N D M O N I T O R I N G V I T A L S I G N S I N I N F A N T S

Introduction

Standards

All registered nurses, students, health care assistants,and assistant practitioners who observe and monitorinfants, children and young people, are trained andcompetent in the accurate assessment and recording ofthe vital signs of temperature, heart/pulse rate,respirations and blood pressure.

Practitioners who assess,measure and monitor vitalsigns in infants, children and young people arecompetent in observing their physiological status.

Practitioners are aware of normal physiologicalparameters for blood pressure, respiratory rate andheart rate for the different ages ranges.

Practitioners take appropriate action in response tochanges in vital sign assessment and measurement.

They effectively communicate/escalate concerns about achild’s deterioration using the SBAR tool. SBAR is acommunication tool that enables users to quicklyconvey concise information about a sick child betweenall health professionals to ensure prompt treatment(NHS Institute for Innovation and Improvement, 2011).

Where continuous electrocardiogram (ECG) and pulseoximetry are used, practitioners are trained in the use,limitations and risks associated with these devices.

Practitioners working in hospital or community settingswhere paediatric early warning systems are used haveundergone specific training in their use and limitations.

Registered nurses,midwives and specialist communitypublic health nurses comply with NMC standards formaintaining their knowledge and skills (NMC, 2010).

Where capillary refill time (CRT) is included in vitalsign assessment, recording and monitoring,practitioners receive clear guidance on its use and aregiven appropriate training.

All units where children are assessed should have acompetency based training and education packagewhich can be built into practitioners' yearlyperformance reviews.

Practice criteria

Registered nurses, students, assistant practitioners andhealth care assistants will have undergone theoreticaland practical training in the following:

� legal and professional issues

� anatomy and physiology

� normal parameters for vital signs in infants,children and young people

� methods of assessing and measuring vital signs ininfants, children and young people

� communicating their concerns about a sick ordeteriorating child to medical staff using theSBAR tool.


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Education and training

1

Standards

Patients, parents or carers who are required to performvital sign assessment,measurement and monitoring aretaught by a registered nurse,who is competent inperforming these skills and in accordance with theNMC’s code of professional conduct (2008).

The registered nurse responsible for educating andtraining patients, parents or carers in measuringrecording and monitoring vital signs ensures thatreasonable and foreseeable harm does not occur to aperson as a consequence of his/her instructions anddelegation (of care) (Dimond, 1990; NMC, 2008).

The practitioner documents the information given topatients, parents or carers and records their response inthe relevant health care record (Redman, 1997).

Patients, parents/carers who perform vital signassessment,measurement and monitoring aresupported by a registered nurse.

Practice criteria

� The ability and willingness of the patient,parent/carer to perform vital sign assessment,measurement and monitoring should bedetermined.

� Clear information should be given. This includespractical and written instructions on how to assessmeasure and monitor vital signs.

� Additional guidance should be given about theactions to take in response to abnormalmeasurements.

� Information on the safe use, storage andmaintenance of any medical devices should beincluded.

� Children, young people and parents/carers shouldhave time to develop and practice their skills.

� Competency packages should be used to establishthat the child/parent/carer has been appropriatelytaught and is confident in undertaking the skill.

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Teaching children, young peopleand parents/carers

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Standards

Prior to assessing,measuring and monitoring theinfant, child or young person’s vital signs, theirpsychological needs are recognised and appropriateaction is taken.

A systematic process is used when assessing,measuringand recording vital signs.

Visual observation, palpation (touch), listening andcommunication, are used when assessing andmeasuring vital signs. This includes taking note of theviews of parents/carers.

Respiratory rate, pattern and effort forms part of theassessment and measurement of vital signs for allinfants, children and young people.

Clear explanation is given to parents/carers and wherepossible, children and young people, concerning vitalsign assessment and the data collected.

There is a clear policy in relation to paediatric earlywarning systems, their use and limitations in eitherhospital or community settings.

Vitals signs of temperature, heart/pulse rate, respiratoryrate and effort, blood pressure, pain assessment andlevel of consciousness of all infants, children and youngpeople are initially assessed,measured and recorded onattending hospital and at varying frequencies from thenon.

There are policies and procedures, specific to infants,children and young people for monitoring vital signspost-operatively, during blood transfusions and duringother therapies.

Vital signs of temperature, heart/pulse rate, respiratoryrate and effort, blood pressure, pain assessment andlevel of consciousness are assessed,measured, recordedand monitored post-operatively for all infants, childrenand young people in accordance with local policies orguidelines.

Vital signs of temperature, heart/pulse rate, respirationblood pressure, pain assessment and level ofconsciousness are assessed,measured, recorded and

monitored on all infants, children and young peoplebefore, during and after receiving a blood transfusion inaccordance with national and local guidance.

In a primary health care or community setting, vitalsign assessment,measurement, recording andmonitoring is at an appropriate level to meet the needsof the infant, child or young person.

Practice criteria

General� The child, young person and/or parent/carer should

consent to vital sign assessment and measurement.Where a child or young person under 16 isunaccompanied, local policies should be followed.

� Where appropriate, the child/young person andparent/carer should assist the practitioner inperforming vital sign assessment and measurement.

� The infant, child and/or young person should bepositioned correctly and comfortably prior to theprocedure.

� Actions to restrain the infant or child should complywith best practice guidance.

� Post-operative assessment should include the levelof consciousness.

� Capillary refill time can be a useful addition to vitalsign assessment and measurement.

Temperature� “Whenever a child feels warm to the touch the

temperature should immediately be measured evenif it was normal a short time before”(Hockenberry,2003).

� If a child feels cold or if their skin appears mottledthe temperature should be measured.

� A temperature should be recorded on all childrenwho attend with an acute presentation of illnesswith the device applicable for age.


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Assessing and measuring vital signs

3

� There should be clear guidance for practitioners onthe accurate use of the equipment available formeasuring the temperature in infants, children andyoung people.

� Mercury thermometers are hazardous and shouldnot be used.

� Oral and rectal routes should not be routinely usedto measure the body temperature in children agedfrom nought to five years (NICE, 2007b).

� Where the use of rectal thermometers is clinicallyindicated in intensive care or high dependencysettings, clear guidance for practitioners should beavailable.

� In infants under the age of four weeks, temperatureshould be measured with an electronic thermometerin the axilla (NICE, 2007b).

� For infants and children aged from four weeks tofive years an electronic/chemical dot thermometerin the axilla or an infra-red tympanic thermometershould be used.

� The thermometer should be left in position forsufficient time to gain an accurate reading,according to the manufacturer’s instructions.

Heart/pulse rate� A stethoscope should be used to auscultate the apex

heart rate of children less than two years of age.

� Electronic data should be cross-checked byauscultation or palpation of the heart/pulse rate.

� Electronic leads and electrodes should be placed inan appropriate position and changed regularly inorder to minimise the risk of damage to the infant,child or young person’s skin.

� Heart/pulse rates should be counted for one minute.

� The pulse rate should be consistent with the apexbeat.

Respirations� Where oxygen saturation monitoring is indicated,

respiratory assessment and measurement should bemade and recorded simultaneously in order to give acomplete respiratory assessment.

� Children whose normal oxygen saturations falloutside the normal acceptable limits should be

documented, for example, a child with a cyanoticheart lesion.

� The pattern, effort and rate of breathing should beobserved.

� Skin colour, pallour,mottling, cyanosis and anytraumatic petechiae around the eyelids, face andneck should be observed.

� Infants and children less than six to seven years ofage are predominantly abdominal breatherstherefore, abdominal movements should be counted.

� Signs of respiratory distress e.g. nasal flaring,grunting,wheezing, stridor, dyspnoea, recession, useof accessory and intercostal muscles, chest shapeand movement should be noted by looking andlistening.

� Respirations should be counted for one minute.

� The frequency of respiratory assessment andmeasurement should be increased during opiateinfusions or in respect of any other drug which maycause hyperventilation or apnoea, for example,prostaglandin infusion.

Blood pressure

� The arm should be used for measuring bloodpressure, but when this is not possible in infants, thelower leg can be used.

� The arm should be positioned at the level of theheart and well supported.

� The correct size of cuff is essential for gaining anaccurate recording.

� The cuff should be of sufficient size to ensureoverlap to cover 100% of the circumference of thearm and 2/3 of the length of the upper arm or lowerleg. The bladder within the cuff must cover 80% ofthe arm’s circumference and should be positionedover the artery from which the blood pressure willbe taken. Incorrect cuff placement is a frequentsource of error in both electronic and manual bloodpressure measurement (Wedgbury andValler-Jones,2008;Valler-Jones andWedgbury, 2009).

� Sucking, crying and eating can influence bloodpressure measurements and these should be noted.

� Movement can effect the accuracy of automatedblood pressure monitors.

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� The first reading of automated monitors should bedisregarded.

� If a blood pressure reading is consistently high on anautomated monitor over a period of time it shouldbe re-measured using a manualsphygmomanometer.

Blood transfusion� Temperature, respiration, pulse and blood pressure

should be assessed,measured and recorded prior toinfusing the first unit of blood; 15 minutes after thestart of each unit; and on completion of thetransfusion. If an adverse reaction occurs, vitalsigns should be measured and recorded morefrequently and a medical practitioner informed(McClelland, 2007).

Post-operative careAll vital signs can be affected by surgery andanaesthesia and research suggests that monitoring ofvital signs has traditionally been routine and regulated(Zeitz and McCutcheon, 2006). Frequency ofobservations should therefore reflect the child’s level ofsickness or instability.Although there is no specificevidence base from which to determine best practice inrecording vital signs post-operatively (Aylott, 2006), thefollowing guidance will enhance practice in this area:

� in the recovery unit (PACU) – heart rate, ECG,respiratory rate, oxygen saturation, non-invasiveblood pressure and skin temperature should berecorded (Trigg and Mohammed, 2010) continuallyuntil the patient regains consciousness

� a post-operative assessment should include the levelof consciousness.

� a post-operative care plan should clearly state thefrequency and duration for assessing and measuringvital signs. The frequency should vary in accordancewith the child’s condition or if any of the valuesfluctuate (Hockenberry,Wilson,Winkelstein andKline, 2003)

� following a simple procedure – vital signs should berecorded every 30 minutes for two hours, thenhourly for two to four hours until the child is fullyawake, eating and drinking. It can be good practiceto include pulse oximetry and an assessment ofcapillary refill time.A temperature should berecorded once and at intervals of one, two or fourhours according to the infant, child or young

person’s general condition.A further set of vitalsigns should be recorded prior to discharge

� in the case of day surgery where children my bedischarged more quickly a full set of observationsshould be undertaken on discharge

� after the immediate recovery period followingadeno/tonsillectomy vital signs should be recordedevery 30 minutes for four hours, or more frequentlyif there is any evidence of bleeding

� following complex procedures – in addition tomonitoring blood pressure and temperature,continuous cardio-respiratory monitoring and pulseoximetry should be in place for a minimum of fourhours, in the following circumstances:

– theatre time greater than six hours

– significant fluid loss

– under one year of age

– physiological instability pre-operatively

– physiological instability during the recoveryperiod.

Whilst these standards for post-operative observationsprovide a generic solution a recent NPSA rapid responsereport has highlighted the failure to recognisepost-operative deterioration in patients followinglaparoscopic procedures until circulatory collapse orseptic shock develops (NPSA, 2010).Whilst carefulmonitoring of vital signs and the use of early warningsystems remain important aspects of monitoring thereare other signs and symptoms which could be earlyindicators of deterioration. These include:

� unresolved abdominal pain requiring opiate analgesia

� anorexia or reluctance to drink

� reluctance to mobilise

� abdominal tenderness and distension

� poor urine output.

It is recommended that these patients include specificreference to the above signs and frequency of initialobservations documented in the postoperativeinstructions.Maintaining an accurate fluid balancerecord is also recommended.

Capillary refill time

Measuring capillary refill time is recommended whenassessing the circulation in sick infants and children


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Standards

Medical devices have a CE marking (denoting a productthat meets the requirements of the applicable EuropeanDirective) and are suitable for use with infants, childrenand young people and are appropriate for the setting wherethey are to be used i.e.hospital, community or home.

All medical devices and equipment are regularlycleaned during on-going use by one patient andbetween different patients, in accordance with infectioncontrol policies and guidelines.

All probe sites are changed regularly in rotation toprevent tissue damage.

Alarms on medical devices are set to quickly alert staffto changes in vital signs. These settings must be basedon the individual child’s normal vital signs.

All disposable or single use equipment is identified andused as such.

All medical devices are serviced and calibrated regularlyin accordance with manufacturers’ instructions.

There are clear policies and procedures concerning thehazards associated with all medical devices and inparticular those containing mercury.

The accuracy of data from cardiac and other monitors ischecked, as a minimum, at the start of each shift.

Practice criteria

� Training in the use of medical devices shouldcomply with CNST (Clinical Negligence Scheme forTrusts) requirements.

� Training should include the correct setting and useof alarms.

� Cables should be kept tidy to prevent damage andrisk to others.

� Battery-operated equipment should be chargedwhen not in use.

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Medical devicesand equipment

4

(RCUK, 2006b; Steiner et al., 2004), although itsusefulness has been questioned (Leonard and Beattie,2004) and thus should not be used in isolation. It is therate at which blood returns to the capillary bed after ithas been compressed digitally.

Important elements of practice include the following:

� the skin of the forehead or chest (sternum) arebetter for estimating CRT

� where fingers are used, elevate the hand to the levelof the heart

� apply pressure with a forefinger, sufficient to blanchthe skin

� maintain pressure for five seconds, then release

� count in seconds how long it takes for the skin toreturn to its normal colour

� the skin generally perfuses in less than two secondsin children and less than three in neonates

� record the site used (Glasper,McEwing andRichardson, 2007).

Pain assessmentAcknowledging pain makes pain visible and should beincorporated into routine observations as the fifth vitalsign (Royal College of Nursing, 2009). In the pre- andpost-operative surgical child pain can indicate a childwho is sick.Additionally, the effect of uncontrolled paincan have detrimental effects on the child who is alreadycardiovascularly compromised (Twycross et al., 2009).

Level of consciousnessLevel of consciousness is a vital sign that is integral toassessing the acutely unwell child and should berecorded routinely (NICE, 2007a). In the neurosurgicaland neurological child this should be assessed using anappropriate GCS scoring system.However the AVPUsystem is sufficient for all other children and youngpeople.

Standards

There is an organisation-wide policy describing bestpractice in recording vital signs.

There is a clear plan of care for the assessment,measurement,monitoring and recording of vital signsthat includes actions in response to deviations fromnormal or other changes.

All vital sign assessments and measurements arerecorded contemporaneously and clearly in accordancewith NMC guidelines for record keeping (2009).

Alarm limits are clearly documented.

Actions taken in response to variations in vital signs areclearly documented in the relevant health care record.

The charts used for vital sign recording and monitoringare suitable for use in monitoring infants, children andyoung people and in a format that enhances theassessment and monitoring of any changes.

Practice criteria

� There should be a consistent approach bypractitioners to the way in which vital signs arerecorded, for example, in using dots, crosses andarrows when recording blood pressure.

� The method or devices used for assessing andmeasuring vital signs should be clearly documented.

� The sites used for measuring vital signs should berecorded in the relevant health care record.

� Where continuous monitoring is in use, recordingsshould be made hourly, as a minimum.

� Information gained from the broader assessment ofthe infant, child or young person should berecorded, for example, crying, distress, laughing,playing.

� Observations and comments made by the child,young person, parents/carers should be clearlyrecorded.


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Record keeping

5

� When not in use, all equipment should be stored in asafe place,with use by unauthorised personnelrestricted.

� Medical device errors and failures should bereported in accordance with NPSA (National PatientSafety Agency) and MHRA (Medicines andHealthcare Regulatory Authority) guidance.

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Websites

British Hypertension Society www.bhsoc.org

Better Blood Transfusion ContinuingEducation Programme www.learnbloodtransfusion.org.uk

Department of Health www.dh.gov.uk

Department of Health, Social Services andPublic Safety for Northern Ireland www.dhsspsni.gov.uk

Every Child Matters: Change for Children www.education.gov.uk

Medicines and Healthcare Regulatory Authority www.mhra.gov.uk

National Institute for Health and Clinical Excellence www.nice.org.uk

NHS Institute for innovation and improvement www.institute.nhs.uk

National Patient Safety Agency www.npsa.org.uk

NHS Litigation Authority: Clinical NegligenceScheme for Trusts www.nhsla.com

Nursing and Midwifery Council www.nmc-uk.org

Resuscitation Council (UK) www.resus.org.uk

Royal College of Nursing www.rcn.org.uk

Scottish Executive Health Department www.sehd.scot.nhs.uk

Skills for Health www.skillsforhealth.org.uk

UK Blood Transfusion and TissueTransplantation Services www.transfusionguidelines.org.uk

Welsh Assembly Government www.wales.gov.uk

Further resources

7

The RCN represents nurses and nursing,promotes excellence in practice and shapeshealth policies

December 2007, revised editionAugust 2011

RCN Onlinewww.rcn.org.uk

RCN Directwww.rcn.org.uk/direct0345 772 6100

Published by the Royal College of Nursing20 Cavendish SquareLondonW1G 0RN

020 7409 3333

Publication code 003 196

ISBN 978-1-906633-79-0

Documents

Royal Nursing College