Measuring, Assessing and Recording: Pulse, Body Temperature, Respirations and Oxygen Saturation

Abstract

Abstract As part of the measuring physical observations simulated examination, students will be asked to measure, assess and record pulse, body temperature, respirations and oxygen saturation. This assessment is becoming more common in all universities as it has been identified as a mandatory simulated assessment within the NMC Essential Skills Clusters (NMC 2007). Although this chapter will focus upon each observation in turn, it is imperative that when undertaking physical observations the findings are not assessed in isolation. Like a jigsaw, each result, alongside the patient’s appearance, pallor, demeanour and responsiveness, link together to form an overall picture of the patient’s condition. The skill of undertaking these observations may sometimes be reviewed as being routine, but the skill has important clinical significance. Students have to demonstrate their underpinning knowledge and to make sense of the relevance of the observations—this can be complex and challenging. Some student nurses will have previous experience, prior to commencing their nurse education training, of taking patients’ physical observations, but the ability to demonstrate an understanding of the underpinning knowledge differentiates between the role of a health care support worker and a student nurse. Revision of key material will enable the student to understand, undertake and assess the relevance of measuring pulse, body temperature, respirations and oxygen saturation. The importance of the professional nurse’s ability to accurately assess, record and evaluate pulse rate, body temperature, respirations and oxygen saturation cannot be underestimated. Concern has been raised that NHS staff are failing to recognize patient deterioration in a timely manner. In a study by the National Patient Safety Agency (NPSA 2007) factors for this lack of recognition included failure to take physical observations, not acknowledging the significance of the observations and finally not reporting on issues that were of concern, or acting upon these findings. Guidelines on recognizing and managing patient deterioration have been issued by NICE (2007) alongside competencies for recognition and management of a deteriorating patient, which all staff working in acute settings should achieve (DOH 2009). Throughout these the importance of assessing, recording, evaluating and appropriately reacting to the results of physical observations cannot be denied.