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Publication
This is an RCN practice guidance. Practice guidance are evidence-based consensus documents, used to guide decisions about
appropriate care of an individual, family or population in a specific context.
Description
The monitoring and measurement of vital signs and clinical assessment are core essential skills for all health care practitioners
working with infants, children and young people. This guidance applies to professionals who work in acute care settings, as well as
those who work in GP surgeries, walk-in clinics, telephone advice and triage services, schools and other community settings.
Publication date: May 2017 Review date: May 2020
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Published by the Royal College of Nursing, 20 Cavendish Square, London, W1G 0RN
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ROYAL COLLEGE OF NURSING
Contents
1. Introduction 4
5. Record keeping 17
Additional resources 20
References 21
3
STANDARDS FOR ASSESSING, MEASURING AND MONITORING VITAL SIGNS
1. Introduction
4
ROYAL COLLEGE OF NURSING
5
STANDARDS FOR ASSESSING, MEASURING AND MONITORING VITAL SIGNS
6
ROYAL COLLEGE OF NURSING
7
STANDARDS FOR ASSESSING, MEASURING AND MONITORING VITAL SIGNS
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ROYAL COLLEGE OF NURSING
9
STANDARDS FOR ASSESSING, MEASURING AND MONITORING VITAL SIGNS
• The child, young person and/or parent/carer • A temperature should be measured and
should consent to vital sign assessment and recorded on all children who present to
measurement. Where a child or young person health care practitioners with an acute
under 16 is unaccompanied, local policies presentation of illness with the device
should be followed. applicable for age.
• Where appropriate, the child, young • There should be clear guidance for health
person and parent/carer should be given care professionals on the accurate use of
the opportunity to assist the practitioner the equipment available for measuring the
in performing vital sign assessment and temperature in infants, children and young
measurement (RCPCH, 2016). people (Foley, 2015).
• The infant, child or young person should be • Oral and rectal routes should not be routinely
positioned correctly and comfortably prior to used to measure body temperature in
the assessment. children aged from 0-5 years (NICE, 2013).
• Actions to restrain or hold the infant or • Where the use of rectal thermometers is
child still should comply with best practice clinically indicated in intensive care or high
guidance (RCN, 2010). dependency settings, clear guidance for
health care professionals should be available.
• Capillary refill time can be a useful addition
to vital sign assessment and measurement as • In infants under the age of four weeks,
it assesses peripheral perfusion and cardiac temperature should be measured with an
output. electronic thermometer in the axilla (NICE,
2013).
• Electronic leads and electrodes should
be placed in an appropriate position and • For infants and children aged from four
changed regularly in order to minimise the weeks to five years an electronic/chemical
risk of damage to the infant, child or young dot thermometer in the axilla or an infrared
person’s skin. tympanic thermometer should be used
(NICE, 2013).
• Whilst assessing the child and young
person’s vital signs, their skin should be • For children five years and upwards an
observed for signs of a petechial rash and electronic/chemical dot thermometer in the
NICE guidance followed (NICE, 2010, axilla or mouth or an infrared tympanic
NICE, 2016). thermometer should be used (Foley, 2015).
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ROYAL COLLEGE OF NURSING
• The pulse of an older child is taken at the • The frequency of respiratory assessment
radial site at the wrist. Palpate the artery and measurement should be increased if the
using the first and second fingertips, child’s condition deteriorates during opiate
pressing firmly on the site until a pulse is infusions, or in respect of any other drug
felt (Nevin et al., 2010). which may cause hyperventilation or apnoea.
For example: prostaglandin infusion.
• Heart/pulse rates should be counted for one
minute noting the rate, depth and rhythm. Blood pressure measurement
• The pulse rate should be consistent with the • It can be difficult to obtain a manual BP in
apex beat. infants and young children because they
are unwilling to co-operate or remain still
• Electronic data should be cross-checked by
for sufficient period of time (Cook and
auscultation or palpation of the pulse.
Montgomery, 2010, Nevin et al., 2010).
Therefore, an electronic machine that
Respirations
measures blood pressure by oscillometry
• Normal respiratory pattern is an easy, should be used (Cook and Montgomery, 2010).
relaxed, subconscious philological activity
• Movement can affect the accuracy of an
which takes place at a rate dependent on the
electronic blood pressure machine.
age and activity of the child.
• The electronic blood pressure machine must be
• Where oxygen saturation monitoring is
in good working order and be used according
indicated, respiratory assessment and
to the manufacturer’s instructions (Cook and
measurement should be made and recorded
Montgomery, 2010, Green and Huby, 2010).
simultaneously in order to give a complete
respiratory assessment. • Sucking, crying and eating can influence
blood pressure measurements and these
• Children whose normal oxygen saturations
should be noted on the observation chart/
fall outside the normal acceptable limits
nursing notes.
should be documented, for example, a child
with a cyanotic heart lesion. • The arm should be used for measuring blood
pressure, but if this is not possible in infants,
• The pattern, effort and rate of breathing
the lower leg can be used ensuring alignment
should be observed and recorded.
with the artery. If regular BP measurements
• Skin colour, pallor, mottling, cyanosis and any are being undertaken, the same limb should
traumatic petechiae around the eyelids, face be used to identify any changes.
and neck should be observed and documented.
• The correct size cuff is essential for gaining
• Infants and children less than six to seven an accurate reading. If the cuff is too small,
years of age are predominantly abdominal a false high blood pressure will be given and
breathers therefore, abdominal movements vice versa (Cook and Montgomery, 2010).
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STANDARDS FOR ASSESSING, MEASURING AND MONITORING VITAL SIGNS
• The cuff should be sufficient size to ensure Blood pressure measurement with a
overlap to cover 100% of the circumference manual blood pressure machine
of the arm and 2/3 of the length of the upper (British Hypertension Society, 2016b)
arm or leg. The bladder must cover 80% of
the arm’s circumference (but not more than • Where possible the child or young person
100%) and should be positioned over the should be seated for at least five minutes,
artery from which the blood pressure will be relaxed and not moving or speaking.
taken (British Hypertension Society, 2016a).
• Where appropriate involve the health play
• Single patient only cuffs or cuffs that can be specialist where one is available and employ
cleaned between patients must be used and distraction techniques.
the healthcare professional should document
the size of the cuff used. • The child/young person’s arm must be well
supported at the level of the heart.
• The blood pressure reading should be
checked against an appropriate BP centile • Ensure that there is no tight clothing
chart to ensure that it is within normal constricting the arm.
parameters (ALSG, 2016). • Place the cuff with the centre of the bladder
• If a blood pressure reading is consistently over the brachial artery. The bladder should
high on an electronic blood pressure machine encircle at least 80% of the arm.
it should be re-taken using a manual blood • Estimate the systolic beforehand.
pressure machine.
• Palpate the brachial artery.
Blood pressure measurement with an
electronic blood pressure machine • Inflate the cuff until pulsation disappears.
(British Hypertension Society, 2016a) • Deflate cuff.
• Where possible the child or young person • Estimate systolic pressure.
should be seated for at least five minutes,
relaxed and not moving or speaking. • Inflate to 30mgHg above the estimated
systolic level needed to occlude the pulse.
• Where appropriate involve the health play
specialist where one is available and employ • Place the stethoscope diaphragm over the
distraction techniques. brachial artery and deflate at a rate
of 2-3mm/sec until regular tapping sounds
• The child/young person’s arm must be well are heard.
supported at the level of the heart.
• Measure systolic (first sound) and
• Ensure that there is no tight clothing diastolic (disappearance of sound) to the
constricting the arm. nearest 2mmHg.
• Place the cuff with the centre of the bladder • Record the readings.
over the brachial artery. The bladder should
encircle at least 80% of the arm. Blood Transfusion (Norfolk, 2014)
• Activate the electronic blood pressure Children and young people should be under
machine. regular visual observation. For each unit
• Record the readings. transfused, minimum monitoring should include:
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ROYAL COLLEGE OF NURSING
• fifteen minutes after the start of the • a post-operative assessment should include
transfusion assess, measure and record heart the level of consciousness and level of pain
rate, blood pressure and temperature. If
there is a deviation from the child’s normal • a post-operative care plan should clearly
parameters respiration rate must also be state the frequency and duration for
assessed, measured and recorded assessing and measuring vital signs. The
frequency should vary in accordance with
• if there are any signs or symptoms of a the child’s condition or if any of the values
possible reaction assess, measure and record fluctuate (Hockenberry and Wilson, 2014,
heart rate, blood pressure and temperature Aylott, 2006)
and respiratory rate and stop the infusion.
Appropriate action must be taken according • following a simple procedure – heart rate,
to local guidelines respiratory rate and blood pressure should
be recorded every 30 minutes for two hours,
• post-transfusion assess, measure and record then hourly for two to four hours until the
heart rate, blood pressure and temperature child is fully awake, eating and drinking.
not more than 60 minutes after the It can be good practice to include pulse
transfusion is completed oximetry and an assessment of capillary
refill time. A temperature should be recorded
• inpatients must be observed over the once and at intervals of one, two or four
next 24 hours and children who have been hours according to the infant, child or young
discharged given appropriate safety netting person’s general condition. A further set
advice. The safety net should provide the of vital signs should be recorded prior
parent or carer with verbal and or/written to discharge
information on late symptoms and how and
when to access further advice (Roland et al., • in the case of day surgery where children
2014). may be discharged more quickly a full set
of observations should be undertaken on
Post-operative care discharge. This should include: temperature,
pulse, respiratory rate, blood pressure and
All vital signs can be affected by surgery oxygen saturations
and anaesthesia and research suggests that
monitoring of vital signs has traditionally been • after the immediate recovery period
routine and regulated (Zeitz and McCutcheon, following adeno/tonsillectomy, pulse,
2006). Frequency of observations should respiratory rate, blood pressure and oxygen
therefore reflect the child’s level of sickness or saturations should be recorded every 30
instability. Although there is no specific evidence minutes for four hours, or more frequently
base from which to determine best practice in if there is any evidence of bleeding.
recording vital signs post-operatively (Aylott,
2006), the following guidance will enhance • following complex procedures – in
practice in this area: addition to monitoring blood pressure and
temperature, continuous cardio-respiratory
• in the recovery unit – heart rate, ECG, monitoring and pulse oximetry should be
respiratory rate, oxygen saturation, non- in place for a minimum of four hours, in the
invasive blood pressure and skin temperature following circumstances: theatre time greater
should be recorded (Trigg and Mohammed, than six hours, significant fluid loss, under
2010) continually until they can maintain one year of age, physiological instability pre-
their own airway, have stable cardiovascular operatively, physiological instability during
and respiratory systems and are awake the recovery period. If the child is stable
and able to communicate (Association of after continuous monitoring for four hours,
Paediatric Anaesthetists of Great Britain routine four hourly observations can then
and Ireland (AAGBI), 2013) be undertaken.
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STANDARDS FOR ASSESSING, MEASURING AND MONITORING VITAL SIGNS
Pain assessment
It is recommended that these patients include
specific reference to the above signs and • Acknowledging pain makes pain visible
frequency of initial observations documented and should be incorporated into routine
in the post-operative instructions. Maintaining observations as the fifth vital sign (RCN,
an accurate fluid balance record is also 2009). Pain can indicate a child who is sick.
recommended. Additionally the effect of uncontrolled pain
can have detrimental effects on the child who
Capillary refill time (CRT) is already cardio-vascularly compromised
(Twycross et al., 2013).
Capillary refill time (CRT) is the rate at which
blood returns to the capillary bed after it has • To assess pain, effective communication
been compressed digitally. Measuring capillary should occur between the child, (whenever
refill time is recommended when assessing feasible) their family/carers and health care
the circulation in sick infants and children professionals (APAGBI, 2012).
(ALSG, 2016), although its usefulness has been
questioned (Crook and Taylor, 2013) and thus • Standardised assessment tools should
should not be used in isolation. Crook and Taylor be used in their final validated form. The
(2013) found that measurements of CRT taken at tool should be appropriate for the child’s
the sternum and fingertip were not comparable. age and developmental level (RCN, 2009,
Fingertip CRT was on average 0.42 seconds APAGBI, 2012).
quicker than sternum CRT.
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ROYAL COLLEGE OF NURSING
15
STANDARDS FOR ASSESSING, MEASURING AND MONITORING VITAL SIGNS
• A second person should position the child child’s clinical notes. A child who is unable
with their feet together, heels touching the to sit or stand should be weighed in light
back plate, legs straight and in alignment clothing on a hoist scale.
with their body, buttocks against the
backboard and their scapula, wherever • Preparation for weighing a child or young
possible, against the backboard. They should person: The weighing scales must be on
hold the ankles to ensure the position is a flat, hard surface and must be checked,
maintained whilst moving the footboard flat cleaned and calibrated prior to use. The child
against the soles of the feet with the child’s must be prepared for the procedure and the
toes pointing upwards. health play specialist may be involved to
provide distraction therapy (RCN, 2017).
• Read the measurement and record the
length in centimetres to the last completed • Weighing procedure: A child aged 0-2 years
millimetre (WHO, 2008). should be weighed on baby scales. Children
over two years of age should either sit or
Measuring height stand on scales. A child with complex needs
may need to be weighed in a hoist. The child
• The child/young person should remove any or young person should stand centrally on
shoes, socks and hair ornaments. the scales with their feet slightly apart. The
reading must be taken when the child is
• The child/young person must be positioned still and documented accordingly. If a child
with their: feet together and flat on the refuses to stand still, they may be weighed
ground, heels touching the back plate, legs in the arms of a parent, carer or health care
straight, buttocks against the backboard/ professional (RCN, 2017).
wall, scapula, where possible against the
backboard/wall and arms loosely at their • Actions to take if there are concerns
side. Their head should be placed with the regarding a weight measurement: where
corner of the eyes horizontal to the middle of there are concerns, the child or young person
the ear. and the parent/carer should be consulted
regarding any history of changes in appetite
• The headboard should be placed carefully and/or feeding patterns. Previous weight
on the child/young person’s head. Read measurements should be obtained for
the measurement and record the height in comparative purposes (RCN, 2017). A
centimetres to the last completed millimetre further assessment should be undertaken
(WHO, 2008). using a malnutrition screening tool and a
referral made to the dietetics department
Measuring weight where indicated.
• The Standards for the Weighing of Infants, • If a child is noted to be failing to grow
Children and Young People in the Acute or is morbidly obese, consideration
Health Care Setting (RCN, 2017) should should be given as to whether there are
be adhered to. any safeguarding concerns and
appropriate actions taken (Department
• Clothing: The Child Growth Foundation
for Education, 2015).
(2012) recommends that children aged
0-2 years of age should be weighed naked.
Children aged over two years of age should
wear minimal clothing and nappies, shoes
and slippers and the contents of pockets
must be removed. If a child’s clothing
cannot be removed or if a child is weighed
with additional equipment eg, splint, cast,
dressing, this must be documented in the
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ROYAL COLLEGE OF NURSING
5. Record keeping
2. Use of a Paediatric Early Warning score 2. The method or devices used for assessing
(PEWS) is recommended to aid individual and measuring vital signs should be clearly
and team situational awareness of the documented.
child with increased risk for deterioration
(Hammond et al., 2013). 3. The sites used for measuring vital signs
should be recorded in the relevant health
3. There must be clarity around which care record.
observations must be recorded at which
frequency to calculate the PEWS score. 4. Where continuous monitoring is in use,
Escalation actions at a given PEWS score recordings should be made hourly, as a
should be clearly outlined. minimum.
4. Nurses, health care assistants and nursing 5. Information gained from the broader
students who undertake monitoring and assessment of the infant, child or young
assessments of vital signs should receive person should be recorded, eg, behaviour,
annual training to reinforce good record irritability, playing, etc.
keeping skills and this should be part of
6. Observations and comments made by the
the organisation’s compulsory training
child, young, person, parents/carers should
programme.
be clearly recorded.
5. The charts (paper or electronic) used for vital
7. As part of evaluation of a ward or
sign recording and monitoring are suitable department’s safety culture there should
for use in monitoring infants, children and be evidence of compliance with the
young people and in a format that enhances
monitoring and observation policy (Wood
the assessment and monitoring of trends in
et al., 2015), and reporting of significant
physiological state.
deterioration events. These include
6. In the emergency department, observation respiratory assessments, cardiac arrests,
charts should be incorporated into the peri-arrest, emergency transfer to the high
emergency department notes (paper or dependency or paediatric intensive care unit
electronic), to encourage nurses to measure or unexpected death.
and document the observations of all
children and young people presenting with
an acute illness in which a decreased level of
consciousness may be a feature.
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STANDARDS FOR ASSESSING, MEASURING AND MONITORING VITAL SIGNS
2
• Medical device errors and failures must
be reported in accordance with Medicines
and Healthcare Regulatory Authority
(MHRA) guidance.
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Appendix 1
3 years 14 14 90–140
4 years 16 16 80–135
6 years 21 20 80–130
7 years 23 22
9 years 28 28
10 years 31 32
11 years 35 35
14 years 50 50 60–110
Adult 70 70
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STANDARDS FOR ASSESSING, MEASURING AND MONITORING VITAL SIGNS
Additional resources
National Institute for Health and Clinical Most NICE guidelines also have information
Excellence (2009). Diarrhoea and vomiting for the public available to download from the
caused by gastroenteritis. Diagnosis, assessment guideline website.
and management in children younger than five
years. Developed by National Collaborating Extensive resources are also available for health
Centre for Women’s and Children’s Health. care professionals on each guideline website
London, National Institute for Health and under ‘Tools and resources’.
Clinical Excellence. www.nice.org.uk/ UK Sepsis Trust
guidance/cg84 0845 606 6255
National Institute for Health and Clinical www.sepsistrust.org
Excellence (2010). Bacterial meningitis and Meningitis Research Foundation
meningococcal septicaemia. Management 0808 800 3344
of bacterial meningitis and meningococcal www.meningitis.org
septicaemia in children and young people
younger than 16 years in primary and secondary Meningitis Now
care. NICE clinical guideline 102. Issued: June 0808 801 0388
2010 last updates: February 2015. London, NICE. www.meningitisnow.org
www.nice.org.uk/guidance/cg102
Macmillan Cancer Support (for people
National Institute for Health and Clinical at risk of neutropenic sepsis)
Excellence (2012). SQ19 Quality standard 0808 808 0000
for bacterial meningitis and meningococcal www.macmillan.org.uk
septicaemia in children and young people
London, NHS National Institute for Health More than a cold – Bronchiolitis
and Clinical Excellence. www.nice.org.uk/ awareness campaign
guidance/qs19 www.morethanacold.co.uk
National Institute for Health and Clinical You can also go to NHS Choices for
Excellence (2013). Feverish illness in children: more information on childhood illness
assessment and initial management in children at www.nhs.uk
younger than 5 years. NICE Clinical Guideline.
Paediatric Care Online
London, National Institute for Health and
www.rcpch.ac.uk/improving-child-health/
Clinical Excellence. www.nice.org.uk/
quality-improvement-and-clinical-audit/
guidance/cg160
paediatric-care-online/paediatric-care
National Institute for Health and Clinical
Health apps for mobile phones
Excellence (2014). Fever in under 5s. Quality
There are a wide range of health apps now on
standard. Published: 24 July 2014. London,
the market, many of which are free. If you are
National Institute for Health and Clinical
considering using a health app please be aware
Excellence. www.nice.org.uk/guidance/qs64
of the difficulties of checking the accuracy and
National Institute for Health and Clinical reliability of the content and whether or not it
Excellence (2016). Sepsis: recognition, diagnosis is up to date. As a health care practitioner, you
and early management. NICE guideline are responsible for any information you give
Published: 13 July 2016. London, National to others or use to guide your practice. It is
Institute for Health and Clinical Excellence. therefore your responsibility to assess any source
www.nice.org.uk/guidance/ng51 of information you use.
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ROYAL COLLEGE OF NURSING
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The RCN represents nurses and nursing, promotes
excellence in practice and shapes health policies
RCN Online
www.rcn.org.uk
RCN Direct
www.rcn.org.uk/direct
0345 772 6100
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