Nurses' documentation of physiological observations in three acute care settings

Considine, Julie, Trotter, Carissa and Currey, Judy 2016, Nurses' documentation of physiological observations in three acute care settings, Journal of clinical nursing, vol. 25, no. 1-2, pp. 134-143, doi: 10.1111/jocn.13010.

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Title Nurses' documentation of physiological observations in three acute care settings
Author(s) Considine, JulieORCID iD for Considine, Julie
Trotter, Carissa
Currey, JudyORCID iD for Currey, Judy
Journal name Journal of clinical nursing
Volume number 25
Issue number 1-2
Start page 134
End page 143
Total pages 10
Publisher Wiley
Place of publication London, Eng.
Publication date 2016-01
ISSN 1365-2702
Keyword(s) nursing assessment
patient safety
rapid response team
risk management
vital signs
Summary AIMS AND OBJECTIVES: To explore nurses' documentation of physiological observations in acute care; emergency department, medical and surgical units. BACKGROUND: In Australia, physiological observations include respiratory rate, oxygen saturation, heart rate, blood pressure, temperature and level of consciousness. There is a clear relationship between abnormal physiological observations and adverse events. Nurses have highest level of responsibility for accurate measurement, interpretation and documentation of physiological observations. DESIGN: A descriptive exploratory design was used and the study data were collected using a prospective point prevalence approach between 25 July 2012-22 August 2012. METHODS: The study was conducted in the emergency department, two 30-bed medical units and one 30-bed surgical unit of a 578 bed public health service in Melbourne, Australia. All adult patients aged ≥18 years present during data collection periods were eligible for inclusion. Patients in the emergency department resuscitation area were excluded. Patient characteristics and physiological observations for the preceding 24 hours in ward patients or eight hours in emergency department patients were collected. RESULTS: One hundred and seventy-eight patients were included; 38 emergency department patients, 84 medical patients and 56 surgical patients. The median age was 72·5 years and 43·8% were males. The most frequently documented physiological observations were respiratory rate, oxygen saturation, heart rate and systolic blood pressure. The least frequently recorded physiological observations were temperature and conscious state. One or more abnormal physiological parameters was documented in 79·8% (n = 142) patients; evidence of reporting abnormalities was documented in 19·7% of patients (n = 28/142). When controlled for length of stay, physiological observations were more frequently documented in the emergency department. CONCLUSIONS: There was variability in the number of parameters documented and frequency of physiological observations documented by nurses. RELEVANCE TO CLINICAL PRACTICE: Physiological abnormalities that do not necessarily fulfil rapid response team activation criteria are common in acute care patients and provide nurses with an opportunity for early recognition of deteriorating patients.
Language eng
DOI 10.1111/jocn.13010
Field of Research 111003 Clinical Nursing: Secondary (Acute Care)
1110 Nursing
1701 Psychology
Socio Economic Objective 920210 Nursing
HERDC Research category C1 Refereed article in a scholarly journal
ERA Research output type C Journal article
Copyright notice ©2016, Wiley
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