Diploma of Nursing Catalogue

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Empowering Knowledge | 7
Quality and safety in healthcare | Chapter 7 147
Eagar, K., Sansoni, J., Loggie, C., et al. (2013). A Literature Review on
Integrating Quality and Safety into Hospital Pricing Systems. Centre
for Health Service Development, Australian Health Service Research
Institute, University of Wollongong <http://
www.safetyandquality.gov.au/wp-content/uploads/2012/12/
Literature-Review-on-Integrating-Quality-and-Safety-into-Hospital
-Pricing-Systems1.pdf>.
Institute of Medicine. (2001). Crossing the Quality Chasm: A New
Health System for the 21st Century <http://www.nap.edu/
catalog/10027.html> Accessed 14.03.15.
Jeyaratnam, E., & Jackson-Webb, F. (2014). Infographic: Comparing
International Health Systems <https://theconversation.com/
infographic-comparing-international-health-systems-30784 >
Accessed 30.08.15.
Kay, J. F. L. (2007). Health care benchmarking. Hong Kong Medical
Diary Vol 12 no 2 February <http://www.fmshk.org/database/
articles/06mbdrflkay.pdf>. Accessed 14.08.15.
Latner, A. W. (2015). Medicare penalizes hospitals for preventable
medical errors <http://www.clinicaladvisor.com/legal-advisor/
medicare-penalizes-hospitals-for-preventable-medical-errors/
article/394354/> Accessed 12.08.15.
Leape, L. L. (1994). Error in medicine. Journal of the American Medical
Association, 273(23), 1851–1857.
Malone, B. (2004). Pursuing patient Safety. Quality and Safety
in Health Care,13 , 86–87. doi:10.1136/qshc.2003.009498.
< http://qualitysafety.bmj.com/content/13/2/86.2.full
.pdf+html>.
Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and
Allied Health, Seventh Edition . (2003). by Saunders, an imprint of
Elsevier, Inc. All rights reserved.
National Health Performance Committee. (2001). National Health
Performance Framework report: August 2001 <http://
www.aihw.gov.au/publication-detail/?id =6442467275>, released: 7
Sep 2001 author: ISSN 1-876532-64-5; Cat. no. AIHW 7112;
Accessed 14.03.15.
Reason, J. (1990). Human error. UK: Cambridge University Press.
—— (2000). Human error models and management British Medical
Journal Mar 18; 320(7237): 768–770.<http://
www.ncbi.nlm.nih.gov/pmc/articles/PMC1117770/> Accessed
12 August 2015.
References
Agency for Healthcare Research and Quality (AHRQ). (2015). Patient
safety primers, Human Factors Engineering <http://psnet.ahrq.gov/
primer.aspx?primerID=20>Accessed 23.08.15.
Australian Commission on Safety and Quality in Health Care
(ACSQHC). (2010). Australian Safety and Quality Framework for
Health Care 2010 <http://www.safetyandquality.gov.au/national-
priorities/australian-safety-and-quality-framework-for-health-care/ >
Accessed 14.03.15.
—— (2011).Implementation Toolkit for Clinical Handover Improvement
<http://www.safetyandquality.gov.au/wp-content/uploads/2012/02/
ImplementationToolkitforClinicalHandoverImprovement.pdf>.
—— (2012).National Safety and Quality Health Service Standards
<http://www.safetyandquality.gov.au/wp-content/uploads/2011/09/
NSQHS-Standards-Sept-2012.pdf> Accessed 14.03.15.
Australian Institute of Health and Welfare. (2014). Australia’s health
2014. Australia’s health series no. 14. Cat. no. AUS 178. Canberra:
AIHW. <http://www.aihw.gov.au/publication-
detail/?id=60129547205> Accessed 15.03.15.
—— (2015).<http://www.aihw.gov.au/sqhc-definitions/>.
Australian Medical Association. (2012). Clinical Indicators – 2012
<https://ama.com.au/position-statement/clinical-indicators-2012>
Accessed 15.08.15.
Buttell, P., Hendler, R., & Daley, J. (2007). The Business of
Healthcare Chapter 3. Quality in Healthcare: Concepts and Practice
<http://healthcarecollaboration.com/docs/quality_buttell.pdf>
Retrieved 23.05.15.
Curtis, K., Tzannes, A., & Rudge, T. (2011). How to talk to doctors
– a guide for effective communication. International Nursing Review,
58, 13–20.
Dingley, C., Daugherty, K., Derieg, M., et al. (2008). Chapter 3
Improving Patient Safety Through Provider Communication Strategy
Enhancements in Advances in Patient Safety: New Directions and
Alternative Approaches (Vol 3: Performance and Tools) In Henriksen,
K, Battles JB, Keyes, MA et al, Editors. Agency for Health Care
and Research <http://www.ncbi.nlm.nih.gov/books/NBK43663/>
Accessed 15.08.15.
Duckett, S. (2014). Australian Healthcare. Where do we stand
Review Questions
1. What is your understanding of quality in healthcare?
2. What does accreditation mean for a healthcare facility?
3. explain:
> Benchmarking
> Clinical indicators.
4. how is patient safety different from quality?
5. Why is the perspective of the person who was harmed important when measuring severity of harm?
6. What is the difference between active and latent errors?
7. What is meant by ‘contributing factors’?
8. Why is standardisation considered a powerful patient safety initiative?
Answer guide for the Review Questions, Critical Thinking Exercises, Decision-Making Framework Exercises and Critical
Thinking Questions in Case Studies are hosted on Evolve: http://evolve.elsevier.com/AU/Koutoukidis/Tabbner/148 UNIT 2 | The contemporary healthcare environment
McNicol, E., & Hamer, S. (2006). Leadership and management. A three
dimensional approach. United Kingdom: Nelson Thornes.
Mitchell, P. (2013). Safer care – human factors in healthcare: Course
handbook. UK: Swan & Horn.
N tional Pati t Safety Agency. ( 004). Seven Steps to Patient Safety
<http://www.nrls.npsa.nhs.uk/res urces/collections/seven-steps-to-
patient-safety/?entryid45=59787>.
Royal College of Physicians and Surgeons of Canada. (2003).
Canadian Patient Safety Dictionary <http://www.royalcollege.ca/
portal/page/portal/rc/common/documents/publications/patient_
safety_dictionary_e.pdf> Accessed 30.08.03.
The Commonwealth Fund. (2011). Why not the Best? Results from the
Nati nal Scorecard on U.S. Health System Performance 2011 <http://
www.commonwealthfund.org/~/media/files/publications/fund-
report/2011/oct/1500_wntb_natl_scorecard_2011_web_v2.pdf>.
Wakefield, J. G., & Jorm, C. (2009). Patient safety—a balanced
measurement framework.Australian Health Review, 33(3), 382–389,
<http://www.academia.edu/3344391/
Patient_safety_a_balanced_measurement_framework>.
Online Resources
Institute for Healthcare Improvement http://www.ihi.org/topics/
patientsafety/pages/default.aspx
http://www.ihi.org/resources/Pages/Changes/
DevelopaCultureofSafety.aspx
Joint Commission Center for Transforming Care
http://www.jointcommission.org
National Health Service UK Patient Safety Centre
http://www.nrls.npsa.nhs.uk/resources/patient-safety-topics/
http://patientsafety.health.org.uk
Smith, R. (2001). Editorial: one bristol, but there could have been
many. British Medical Journal, 323, 179–180.
Wakefield, J. G., McLaws, M. L., Whitby, M., et al. (2008). Patient
safety culture: factors that influence clinician involvement in patient
safety behaviours. Quality and Safety in Health Care, doi:10.1136/
qshc.2008.030700.
Recommended Reading
Australian Commission on Safety and Quality in Healthcare. (2014).
Vital Signs 2014 <http://www.safetyandquality.gov.au/wp-content/
uploads/2014/10/Vital-Signs-2014-web.pdf >.
Australian Commission on Safety and Quality in Health Care
(ACSQHC). (2012).Australian Safety and Quality Goals for Health
Care: Development and Consultation ReportAccessed 14.03.15
<http://www.s fetyandquality.gov.au/wp-content/uploads/2012/08/
Safety- nd-Quality-Goals-Development-and-consultation-
report.pdf>.
Braithwaite, J., Healy, J., & Dw n, K. (2005). The Governance
of Health Safe y and Quality, Commonwealth of Australia,
<https://www.anu.edu.au/fellows/jbraithwaite/_documents/Reports/
Governance_Health_2005.pdf>.
Brand, C. A., Ibrahim, J. E., Cameron, P. A., et al. (2008). Standards
for health care: a necessary but unknown quantity.Medical Journal
of Australia, 189(5), 257–260. <https://www.mj .com.au/
journal/2008/189/5/
standards-health-care-necessary-unknown-quantity>.
Joseph, A., & Malone, E. (2012). The Environment: An Often
Unconsidered Patient Safety Tool <http://webmm.ahrq.gov/
perspective.aspx?perspectiveID=130>.
Leape, L. (2011). Key Lessons in Patient Safety <https://
www.youtube.com/watch?v=oSoklPmHCkg>.
Marquis, B. L., & Huston, C. J. (2015). Leadership roles and
management functions in nursing. Theory and application.
USA: Wolters Kluwer Lippincott, Williams and Wilkins Health.
148 UNIT 2 | The contemporary healthcare environment
Joint Commission Center for Transforming Care
http://www.jointcommission.org
National Health Service UK Patient Safety Centre
http://www.nrls.npsa.nhs.uk/resources/patient-safety-topics/
http://patientsafety.health.org.uk handbook. UK: Swan & Horn.
National Patient Safety Agency. (2004). Seven Steps to Patient Safety
<http://www.nrls.npsa.nhs.uk/resources/collections/seven-steps-t
o patient-safety/?entryid45=59787>.
Royal College of Physicians and Surgeons of Canada. (2003).
Canadian Pat ent Safety Dictionary <http://www.royalcollege.ca/
portal/page/portal/rc/common/documents/publications/patient_
safety_dictionary_e.pdf> Accessed 30.08.03.
The Commonwealth Fund. (2011). Why not the Best? Results from the
National Scorecard on U.S. Health System Performance 2011 <http://
www.commonwealthfund.org/~/media/files/publications/
fund-report/2011/
oct/1500_wn b_natl_scorecard_2011_web_v2.pdf>.
Wakefield, J. G., & Jorm, C. (2009). Patient safety—a balanced
me surement framework. Australian Health Review, 33(3), 382–389,
<http://www.academia.edu/3344391/
Patient_safety_a_balanced_measurement_framework>.
Online Resources
Institute for Healthcare Improvement http://www.ihi.org/topics/
patientsafety/pages/default.aspx
http://www.ihi.org/resources/Pages/Changes/
DevelopaCultureofSafety.aspx
Online Resources
Institute for Healthcare Improvement http://www.ihi.org/t pics/
patients fety/pages/default.aspx
http://www.ihi.org/resources/Pages/Changes/
DevelopaCultureofSafety.aspx
Joint Commission Center for Transforming Care
http://www.jointcommission.org
National Health Service UK Pati nt Safety Centr
http://www.nrls.npsa.nhs.uk/resources/patient-safety-topics/
http://patientsafety.health.org.uk
Recommended Reading
Australian Commission on Safety d Quality in Healthcare. (2014).
Vital Signs 2014 <http://www.saf tyandquality.gov. u/wp-content/
uploads/2014/10/Vital-Signs-2014-web.pdf>.
Australian Commission on Safety and Quality in Health Care
(ACSQHC). (2012).Australian Saf ty and Quality Goals for Health
Care: Development and Consultation Report Accessed 14.03.15
<http://www.safetyandquality.gov.au/wp-content/uploads/2012/08/
Safety-and-Quality-Goals-Development-and-consultation-
report.pdf>.
Braithwaite, J., Healy, J., & Dwan, K. (2005). The Governance
of Health Safety and Quality, Commonwealth of Australia,
<https://www.anu.edu.au/fellows/jbraithwaite/_documents/Reports/
Governance_Health_2005.pdf>.
References and
Recommended Reading
encourage further
reading within each
chapter topic
Online resources
provide useful web
links r lat d to the
chapter content
Clinical Skills
are in a referenced,
step-by-step format
emphasising the
nursing process and
include rationales
for each step
Review Questions
are specific to
the assist students
with comprehension
and review of the
chapter content
Progress Note Examples
show how a student
might document care
of an individual while
on placement
Critical Thinking Exercises
stimulate the student
to think critically and
problem solve
Decision-making
Framework Exercises
are specific to
the chapter content
and the EN scope
of practice
Summary
highlights key
points in the
chapter content
Vital signassessment | Chapter20 407
Review and carry out the standard steps for all clinical skills/interventions
CLINICAL SKILL 20.1 Assessing body temperature
NMBA Decision-making Framework considerations:
1. am I educated?
2. am I authorised?
3. am I competent?
If you answer ‘no’ to any of these, do not perform that
activity. Seek guidance and support from your teacher/a
nurse team leader/clinical facilitator/educator.
Equipment:
appropriate thermometer
Disposable probe cover or sleeve
pen (blue/black) and observation chart
Skill activity Rationale
Before assessing body temperature
assess the individual for temperature alterations and
anything that may interfere with the accuracy of
temperature measurement
Wait 15–20 minutes if the individual has smoked or
ingested hot or cold foods or fluids
physical signs and symptoms of temperature alterations
may be present such as the individual being flushed or
shivering
If using an oral thermometer, intake of some foods can
cause inaccurate readings
If using a tympanic thermometer, hearing aids can
increase temperature readings
Determine appropriate temperature site and temperature
device for the individual
Different individuals will have different requirements due
to their health conditions
Assessing body temperature with a tympanic membrane electronic thermometer
assist the individual in assuming a comfortable position,
with head turned away from the nurse
ensures comfort and exposes auditory canal for accurate
temperature measurement. ensures individual safety
and comfort
Observe for ear wax (cerumen) in individual’s ear canal Lens cover of speculum must not be impeded by earwax
(will not obtain an accurate measurement). Switch to
other ear or select an alternative measurement site
remove thermometer from charging base and slide
disposable speculum cover over otoscope-like tip until
it locks into place, being careful not to touch lens cover
Base provides battery power. Soft plastic probe cover
prevents transmission of microorganisms
If holding handheld unit with right hand, obtain
temperature from individual’s right ear; left-handed
persons should obtain temperature from individual’s left
ear
the less acute the angle of approach the better the
probe will seal inside the auditory canal
Insert speculum into ear canal, following manufacturer’s
instructions for tympanic probe positioning. pull pinna
backwards, up and out for an adult, move thermometer
in a figure-eight pattern, fit probe snugly in canal and
do not move, point towards the nose
Correct positioning of probe will ensure accurate
readings as there will be maximum exposure of the
tympanic membrane
as soon as probe is in place, depress scan button. Leave
thermometer probe in place until an audible signal is
given and individual’s temperature appears on the
digital display
Depression of scan button causes infrared energy to be
detected. Otoscope tip must stay in situ until signal
occurs to ensure accurate measurement
Carefully remove speculum from auditory meatus. push
ejection button on unit to discard plastic probe cover
into an appropriate receptacle
reduces transmission of microorganisms
return handheld unit to charging base protects sensor tip from damage and keeps unit charged
ready for next use
Continued
430 UNIT6 | Healthassessment
Vital si ns r flec changes in b dy function and therefore
provide the nurse with important information about the
clinical health status of an individual. Various sites and
methods can be used to assess vital signs, and the nurse
selects the site and method that is safest for the individual
and that will provide the most accurate measurement pos-
sible. It is important to note that changes in one vital sign
can trigger changes in other vital signs.
Vital signs are generally assessed when an individual
is admitted to a healthcare agency, to establish baseline
data, when there is a change or possibility of change in
the individual’s condition and as part of routine care. Data
obtained from measurements of vital signs are then used
to plan and implement appropriate nursing interventions,
as well as to evaluate an individual’s response to nursing
interventions or prescribed medical therapy. It is important
for the nurse to have knowledge of the normal ranges of
vital signs and of the factors that regulate and influence
vital signs, as this helps them interpret the measurements
that deviate from normal. It is also imperative that the
nurse has the underpinning clinical knowledge and judg-
ment to recognise and respond to a deteriorating indi-
vidual and act accordingly to maintain the clinical health
status (ACSQHC 2012).
Summary
DECISION-MAKING FRAMEWORK EXERCISE 20.1
You have just been employed as a graduate Enrolled Nurse at a healthcare facility. You are completing a vital sign
assessmentononeofyourallocated individuals,andyoudiscoverherbloodpressure is98/55andheart rate is95 bpm;
all other vital signs are in normal limits. The individual states she does feel a bit light headed and can’t remember the
last time she passed urine. After approaching the medical officer and handing over the individual and current situation,
the medical officer asks you to insert an IV cannula and orders the commencement of IV therapy.
Using the decision-making framework:
1. From the interventions ordered by the medical officer, are all interventions within your current scope of practice?
2. What actions are required in this situation?
3. How would you document the above situation in your nursing notes?
CLINICAL INTEREST BOX 20.10
Clinical deterioration
‘Individual admitted with pneumonia. Became short of
breath and had low oxygen levels. Staff did not call for
assistance ina timelyway.The individualdied’ (ACSQHC
2008). It is imperative that nursing staff identify clinical
deteriorations and act accordingly for individual safety.
Detection System (ADDS) chart, Figure 20.5). While the
ADDS chart should allow for early recognition of an indi-
vidual’s deterioration through colour coding, it is essential
that all nurses have the underpinning clinical knowledge and
clinical judgment to respond appropriately (see Clinical
Int rest Box 20.10).
Communication is extremely important in the event of
clinical deterioration, and it is always essential to follow
ISBAR handover when escalating the care of an individual.
ISBAR handover will ensure that all information is passed on
efficiently and correctly so the individual can be managed
appropriately (see Chapter 8 on Communication for more
information on ISBAR).
PROGRESS NOTE EXAMPLE 20.1
04/06/2016
1300 hrs
Nursing: CNS: pt alert and orientated to person, place and time. Nil complaints of pain. CVS: complained
of feeling dizzy when ambulating, vital signs checked—BP 101/59, HR 66, RR 15, SaO 299% on RA, Temp
36.5. BP monitored 2/24, oral fluids encouraged and ambulation supervised. BP increased to 115/70. GIT:
tolerating diet and fluids. BNO. Renal: pt voiding on sensation. FBC maintained. ADLs: showered
independently. Supervision when ambulating with nil mobility aids. Legal: medication given as per
medication chart.
Zoe Morgan (Morgan) EN
Vital signassessment | Chapter20 431
Review Questions
1. What are the factors that can affect vital signs?
2. What are the advantag s a d isadv ntages of using each body temperature site?
3. What characteristics should be included in a respiratory assessment?
4. What is an early indicator of a clinical deterioration in an individual?
5. Ms hawdon has just given birth to a healthy baby boy. after the delivery she has a postpartum haemorrhage and
loses 1200 mL of blood. Would you expect Ms hawdon’s blood pressure to increase or decrease? State the
reason for your answer.
6. Identify two sites for taking blood pressure in an adult. Describe the procedure.
7. What are the three (3) characteristics of a pulse? What characteristic(s) would be altered during atrial fibrillation
and why?
8. Mr ryan, 82 years of age, has just been admitted with shortness of breath. Describe the observation you would
conduct.
9. review the information in the observation chart below, then answer the questions that follow.
admission obs t—36.7, p—100, r—22, B/p—140/90: 1600 hrs
preoperative obs t—36.4, p—80, r—18, B/p—130/70: 0800 hrs
postoperative obs t—35.8, p—60, r—16, B/p—120/70: 1400 hrs
t—36.4, p—80, r—18, B/p—130/70: 1800 hrs
t—36.4, p—76, r—18, B/p—120/70: 2000 hrs
Day 1 post op t—36.4, p—80, r—20, B/p—130/70: 1000 hrs
t—36.4, p—80, r—20, B/p—130/70: 1800 hrs
t—36.8, p—88, r—20, B/p—130/70: 2200 hrs
Day 2 post op t—37.0, p—88, r—20, B/p—130/70: 0100 hrs
t—37.8, p—90, r—22, B/p—135/80: 1400 hrs
t—38.5, p—90, r—24, B/p—135/90: 2000 hrs
Day 3 post op t—37.4, p—88, r—22, B/p—135/70: 0700 hrs
a Suggest a reason that, on the day of her admission, Mrs Seagal’s vital signs were slightly elevated.
b Suggest a reason why Mrs Seagal’s vital signs had decreased on the preoperative assessment.
c What could you infer from the overall change in vital signs in the postoperative period?
d What further objective and subjective data would you need to collect to confirm your assumptions?
10. Chart the above observations (i Q 9) on the dult Deterioration Detection System chart (Figure 20.5). Identify if
an scal tion of care is required for this individual. If so, what type of escalation and why?
Answer guide for the Review Questions, Critical Thinking Exercises, Decision-Making Framework Exercises and Critical
Thinking Questions in Case Studies are hosted on Evolve: http://evolve.elsevier.com/AU/Koutoukidis/Tabbner/
References
Australian Commission on Safety and Quality in Health Care
(ACSQHC). (2010). National Consensus Statement: Essential
Elements for Recognising and Responding to Clinical Deterioration.
Retrieved from: <http://www.safetyandquality.gov.au/our-work/
recognising-and-responding-to-clinical-deterioration/implementing-
r-and-r-systems/implementation-guide/>.
—— (2012). Recognising and responding to clinical deterioration in acute
health care – Standard 9 fact sheet, Retrieved from: <http://
www.safetyandquality.gov.au/publications/nsqhs-standards-
fact-sheet-standard-9-recognising-and-responding-to-clinical-
deterioration-in-acute-health-care/>.
Australian Institute of Health and Welfare (AIHW). (2015).High
blood pressure. Retrieved on 25 February 2015 from: <http://
www.aihw.gov.au/high-blood-pressure/>.
Chua, W. L., Mackey, S., Ng, E. K. C., et al. (2013). Front line nurses’
experiences with deteriorating ward patients: a qualitative study.
International Nursing Review, 60(4), 501–509.
Clarke, C. (2014). Promoting the 6Cs of nursing in patient assessment.
Nursing Standard, 28(44), 52–59.
Clinical Excellence Commission (CEC). (2012). Clinical Excellence
Commission Sepsis Kills Program: Adult Blood Culture Sampling.
Retrieved from:< http://www.cec.health.nsw.gov.au/programs/sepsis/
sepsis-tools> .
430 UNIT6 | Healthassessment
Vital signs reflect changes in body function and therefore
provide the nurse with important information about the
clinical health status of an individual. Various sites and
methods can be used to assess vital signs, and the nurse
selects the site and method that is safest for the individual
and that will provide the most accurate measurement pos-
sible. It is important to note that changes in one vital sign
can trigger changes in other vital signs.
Vital si ns are generally ssessed when an individual
is admitted to a healthcare agency, to establish baseline
data, when there is a change r possibility of change in
the individu l’s condition and as part of routine care. Data
obtained from measurements of vital signs are then used
to plan and implement appropriate nursing interventions,
as well as to evaluate an individual’s response to nursing
interventions or prescribed medical ther py. It is important
for the nurse to have knowledge of the normal ranges of
vital signs and of the factors that regulate and influence
vital signs, as this helps them interpret the measurements
that deviate from normal. It is also imperative that the
nurse has the underpinning clinical knowledge and judg-
ment to recognise and espond to a de eriorating indi-
vidual and act accordingly to maintain the clinical health
status (ACSQHC 2012).
Summary
DECISION-MAKING FRAMEWORK EXERCISE 20.1
You have just been employed as a graduate Enrolled Nurse at a healthcare facility. You are completing a vital sign
assessmentonon ofyourallocated individuals,andyoudiscoverherbloodpressure is98/55andheart rate is95 bpm;
all other vital signs are in normal limits. The individual states she does feel a bit light headed and can’t remember the
last time sh passe urine. After approaching the medical offic r and handing ov r the individual and current situ tion,
the medical officer asks you to insert an IV cannula and rders the c mmencement of IV therapy.
Using the decision-making framework:
1. From the interventions ordered by the medical officer, are all interventions wit in your current scope f practice?
2. What actions are required in this situation?
3. H w would you do ument the above situation in your nursing notes?
CLINICAL INTEREST BOX 20.10
Clinical deterioration
‘Individual admitted with pneumonia. Became short of
breath and had low oxygen levels. Staff did not call for
assistance ina timelyway.The individualdied’ (ACSQHC
2008). It is imperative that nursing staff identify clinical
deteriorations and act accordingly for individual safety.
Detection System (ADDS) chart, Figure 20.5). While the
ADDS chart should allow for early recognition of an indi-
vidual’s deterioration through colour coding, it is essential
that all nurses have the underpinning clinical knowledge and
clinical judgment to respond appropriately (see Clinical
Interest Box 20.10).
Communication is extremely important in the event of
clinical deterioration, and it is always essential to follow
ISBAR handover when escalating the care of an individual.
ISBAR handover will ensure that all information is passed on
effic ently and corre tly s the individual can be managed
appropriately (see Chapter 8 on Communicatio for more
informatio on ISBAR).
PROGRESS NOTE EXAMPLE 20.1
04/06/2016
1300 hrs
Nursing: CNS: pt alert and orientated to person, place and time. Nil complaints of pain. CVS: complained
of feeling dizzy when ambulating, vital signs checked—BP 101/59, HR 66, RR 15, SaO2 99% on RA, Temp
36.5. BP monitored 2/24, oral fluids encouraged and ambulation supervised. BP increased to 115/70. GIT:
tolerating diet and fluids. BNO. Renal: pt voiding on sensation. FBC maintained. ADLs: showered
independently. Supervision when ambulating with nil mobility aids. Legal: medication given as per
medication chart.
Zoe Morgan (Morgan) EN
430 UNIT6 | Healthassessment
Vital signs reflect chang s in body function and therefore
provide the nurse with important information about the
clinical health status of an individual. Various sit s and
methods can be used to assess vital signs, and the nurs
selects the site and method that is safest for the individual
and that will provide the most accurate measurem nt pos-
ible. It is important to note t t changes in one vital sign
can trigger changes in other vital signs.
Vital signs are generally assessed when an individual
is admitt d to a healthcar agency, to establish baseline
data, when there is change or possibility of change in
the individual’s condition and as part f routine care. Dat
obtained from measurements of vital signs are then used
to plan and im lement appropriate nursing interventions,
as well a to evaluate an i dividu l’s response to u ing
interventi ns or prescribed medical therapy. It is important
for the nurse to have k owledge of the normal ra ges of
vital signs and of the factors that regulate nd influence
vital signs, as this helps them interpret the measurements
th t deviate fr m normal. It is also imp r tive that the
nurse has the under inning clinical knowledge and judg-
ment to recognise and respond t a d teriorating indi-
vidual nd act ccordingly to maintain th clinical health
status (ACSQHC 2012).
Summary
DECISION-MAKING FRAMEWORK EXERCISE 20.1
You have just b en mployed as a graduate Enrolled Nurse at a healthcare facility. You are completing a vital sign
assessmentononeofyourallocated individuals,andyoudiscoverherbloodpressure is98/55andheart rate is95 bpm;
all other vital signs are in normal limits. The individual states she does feel a bit light headed and can’t remember the
last tim she pass d urine. After approaching the medical officer and handing over the individual and current situation,
the medical officer asks you to insert an IV cannula and orders the commencement of IV therapy.
Using the decision-making framework:
1. From the interventions ordered by the medical officer, are all interventions within your current scope of practice?
2. What actions are required in this situation?
3. How would you document the above situation in your nursing notes?
CLINICAL INTEREST BOX 20.10
Clinical deterioration
‘Indivdu a mitted with pneumonia. Became short of
breath and had low oxygen levels. Staff did not call for
assistance ina timelyway.The individualdied’ (ACSQHC
2008). It is imperative that nursing staff identify clinical
deteriorations and act accordingly for individual safety.
Detection System (ADDS) chart, Figure 20.5). While the
ADDS chart should allow for early recognition of an indi-
vidual’s deterioration through colour coding, it is essential
that all nurses ave the underpinning clinical k owledge nd
clinical judgment to respond appropriately (see Cli ic l
Interest Box 20.10).
Communication is xtremely impo t nt in the eve t of
clinical deterioration, and it is always essential to follow
ISBAR handover when escalating the care of an individual.
ISBAR handover will ensure hat ll information is passed on
efficiently and correctly o the individual can be managed
appropri tely (see Chapte 8 on Communication for m re
information on ISBAR).
PROGRESS NOTE EXAMPLE 20.1
04/06/2016
1300 hrs
Nursing: CNS: pt alert and orientated to person, place and time. Nil complaints of pain. CVS: complained
of feeling dizzy when ambulating, vital signs checked—BP 101/59, HR 66, RR 15, SaO 299% on RA, Temp
36.5. BP monitored 2/24, oral fluids encouraged and ambulation supervised. BP increased to 115/70. GIT:
toleratin iet and fluids. BNO. Renal: pt voiding on sensation. FBC maintained. ADLs: showered
independently. Su rvision when ambulating with nil mobility aids. Legal: medication given as per
medication chart.
Z e Morgan (Morgan) EN
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CRITICAL THINKING EXERCISE 20.4
1. You are working in a nursing home and the Registered Nurse asks you to complete a blood pressure reading on
a new admission. The individual is morbidly obese and the cuff only just fits around the individual’s arm. How
would this affec the accuracy o the reading?
2. You are working in a community he lth centre a d y u need to complete a blo d pressure readng on a 75-year-
old female, Rita Smith. Rita wants to keep her thick woollen jumper on while you complete the blood pressure.
How would you respond to Rita’s request?
3. You are caring for Renae Polontee, a 30-year-old apprentice chef, who has accidentally cut off her right thumb.
There was considerable blo d loss prior to first aid administered at the scene. Would you expect Renae to be
hypotensive or hypertensive? Justify your answer.
4. Which arm would you assess Renae’s blood pressure on and why?