Learn — Vital signs & physical assessment

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Assessment scales — GCS, Braden, Norton, FLACC

Assessment scales turn a nurse's impression into a number that any other nurse would arrive at from the same patient, so that a change over hours or shifts can be seen rather than argued about. They matter at the bedside because the scales that matter most in nursing, consciousness, pressure risk and pain, all drive an action at a defined threshold, and the trend in the score is usually a better warning than the absolute value.

  • The Glasgow Coma Scale scores eye opening out of 4 (spontaneous, to speech, to pain, none), the best verbal response out of 5 (oriented, confused, inappropriate words, incomprehensible sounds, none) and the best motor response out of 6 (obeys commands, localises pain, normal flexion or withdrawal, abnormal flexion, extension, none), giving a total from 3 to 15.
  • A GCS of 8 or less is severe injury or coma and is the classical threshold for securing the airway, 9 to 12 is moderate and 13 to 15 is mild; the motor score carries the most prognostic weight, and an intubated patient's verbal score is recorded as 1 with the letter T rather than guessed.
  • The Braden Scale has six subscales, sensory perception, moisture, activity, mobility, nutrition, and friction and shear; five are scored 1 to 4 and friction and shear is scored 1 to 3, giving a total of 6 to 23 in which a LOWER score means higher risk, with 15 to 18 mild, 13 to 14 moderate, 10 to 12 high and 9 or less very high risk.
  • The Norton Scale has five subscales, physical condition, mental condition, activity, mobility and incontinence, each scored 1 to 4 for a total of 5 to 20, and a score of 14 or below is taken as at risk; like Braden, it runs downwards with increasing risk.
  • FLACC scores Face, Legs, Activity, Cry and Consolability from 0 to 2 each for a total of 0 to 10, and is used for children of about 2 months to 7 years and for any patient who cannot self-report; 1 to 3 is mild, 4 to 6 moderate and 7 to 10 severe pain.
  • Match the pain tool to the patient: a numerical rating of 0 to 10 or a visual analogue scale for an adult, Wong-Baker FACES from about 3 years, FLACC or a neonatal tool such as NIPS or CRIES for the pre-verbal, and PAINAD for a patient with advanced dementia; whichever is chosen, the same tool is used at every reassessment.
  • Fall risk is scored on the Morse Fall Scale, which rates history of falling, a secondary diagnosis, the use of an ambulatory aid, an intravenous line or heparin lock, gait and mental status to a maximum of 125, with many hospitals setting high risk at 45 and above.
  • AVPU (Alert, responds to Voice, responds to Pain, Unresponsive) is the rapid alternative to the GCS in a first assessment, and responding only to pain corresponds roughly to a GCS of 8.
  • A scale is only as good as its consistency: score it at the stated intervals, at the same points in the day, by the same method, and record the subscale scores and not only the total, because the total can stay the same while a component deteriorates.
  • Every scale drives an action: a Braden of 18 or less starts a prevention plan, a FLACC of 4 or more calls for analgesia and a reassessment, a Morse score in the high band triggers the fall bundle, and a falling GCS calls for the doctor.

Health assessment

Health assessment is the systematic collection of subjective and objective data about a patient, through a history and a physical examination, which the nurse then interprets to identify problems and set priorities. It matters at the bedside because it is the baseline against which every later change is judged, and because the assessment is where deterioration is caught, provided the nurse stops and acts on an abnormal finding rather than recording it and moving on.

  • The four techniques are used in the order inspection, palpation, percussion and auscultation, with one exception: for the abdomen you inspect, then auscultate, then percuss and palpate, because pressing on the abdomen first alters the bowel sounds you are about to listen for.
  • Palpation is light to about 1 to 2 cm for tenderness and surface masses and deep to about 4 to 5 cm for organs; use the fingerpads for texture and masses, the ulnar surface of the hand for vibration and fremitus, and the back of the hand for temperature.
  • Percussion notes are resonant over normal lung, hyper-resonant over a pneumothorax or emphysema, dull over consolidation, an effusion, the liver or a full bladder, flat over muscle and bone, and tympanic over a gas-filled stomach or bowel.
  • Auscultate with the diaphragm for high-pitched sounds such as breath sounds, bowel sounds and the first and second heart sounds, and with the bell held lightly for low-pitched sounds such as a third or fourth heart sound, the murmur of mitral stenosis and vascular bruits.
  • Bowel sounds are counted in all four quadrants and are normally 5 to 30 a minute; you must listen for a full 5 minutes over a quadrant before recording them as absent.
  • Start with a general survey and the vital signs: level of consciousness, apparent distress, posture and gait, hygiene, skin colour, any odour, height and weight, and then work head to toe, comparing each side with the other.
  • Separate subjective data, what the patient tells you about symptoms, history and pain, from objective data, what you observe and measure; record the patient's own words in quotation marks for the presenting complaint.
  • Structure the history as the chief complaint in the patient's words, the history of the present illness explored with a framework such as OLDCARTS or PQRST, past medical and surgical history, drug and allergy history, family, personal and social history and a review of systems.
  • Match the depth of the assessment to the situation: a comprehensive assessment on admission, a focused assessment for a specific complaint, an ongoing assessment each shift, and an emergency assessment that follows the ABCDE primary survey and treats as it goes.
  • Document immediately and completely, report abnormal findings to someone who can act on them using SBAR, and never chart an observation you did not make.

Vital signs

Vital signs are the measurements of body temperature, pulse, respiration, blood pressure and oxygen saturation, with pain recorded alongside them, that show how the body's basic regulating systems are coping. They matter because they are the cheapest early-warning system in the hospital: the numbers change before the patient looks unwell, and the trend across a chart tells you more than any single reading.

  • Adult reference ranges are an oral temperature of 36.5 to 37.5 degrees Celsius, a pulse of 60 to 100 a minute, respirations of 12 to 20 a minute, a blood pressure below 120 over 80 as optimal, and an oxygen saturation of 95% to 100% on room air.
  • Site changes the temperature: the rectal reading is about 0.5 degrees higher than the oral and the axillary about 0.5 degrees lower, so the site is always recorded with the value; a temperature above 41.1 degrees is hyperpyrexia and below 35 degrees is hypothermia.
  • Paediatric values fall with age: a newborn has a heart rate of about 120 to 160 and a respiratory rate of 30 to 60, an infant about 100 to 160 and 30 to 53, a toddler about 90 to 140 and 22 to 37, a preschool child about 80 to 120 and 20 to 28, a school-age child about 70 to 110 and 18 to 25, and an adolescent reaches adult values.
  • The expected systolic pressure of a child over one year is roughly 70 plus twice the age in years, and the same figure is used as the lower limit below which a child is called hypotensive.
  • Take an apical pulse over a full minute in any child under two, in any irregular rhythm and before giving digoxin; an apical rate that exceeds the radial rate is a pulse deficit and signals dropped beats, as in atrial fibrillation.
  • Count respirations for a full minute without telling the patient you are doing it, immediately after taking the pulse and with your fingers still on the wrist, because a patient who knows he is being watched changes his breathing.
  • Blood pressure technique is examined: the cuff bladder should encircle about 80% of the arm with a width about 40% of the arm circumference, a cuff that is too small reads falsely high and one too large falsely low, the arm is supported at heart level, the patient is seated with the back supported and feet flat after 5 minutes of rest with no caffeine, smoking or exercise for 30 minutes, the cuff is deflated at 2 to 3 mmHg per second, and Korotkoff phase I is the systolic and phase V the diastolic.
  • Orthostatic hypotension is a fall of 20 mmHg or more in systolic pressure, or 10 mmHg or more in diastolic, within 3 minutes of standing, often with a rise in pulse of more than 20; measure lying, sitting and standing, and treat the finding as a fall risk.
  • Pulse is described by rate, rhythm, volume and equality on both sides; the sites are radial, brachial (for blood pressure and for a pulse check in an infant), carotid (for an adult pulse check in an arrest), femoral, popliteal, posterior tibial, dorsalis pedis, temporal and apical, and pulsus paradoxus, a fall of more than 10 mmHg in systolic pressure on inspiration, is seen in cardiac tamponade and severe asthma.
  • Pulse oximetry has traps: nail polish, cold or poorly perfused peripheries, movement and bright light give false or absent readings, carbon monoxide poisoning gives a falsely high one, and a normal saturation says nothing about carbon dioxide, so it never excludes ventilatory failure.
  • Vital signs are taken on admission, at the intervals the patient's condition warrants, before and after any procedure or any drug that affects them, before and during a transfusion, whenever the patient's condition changes and whenever he says he feels different; an early warning score is calculated from them and drives the escalation.

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