The nursing process, holistic assessment and baseline observations

Assessment

The first stage is assessment of the patient's/client's and family's needs. Assessment involves collecting information (data) about the person and using that information to make decisions about what care, support or intervention is required. Decision-making involves organizing and interpreting the information collected. Professional judgement may also contribute towards the decision-making process. Assessment documentation and techniques vary according to the setting, e.g. outpatient, inpatient, short stay, ambulatory care, rehabilitation, day care, primary care based in the home, clinics or surgeries. Risk assessment is discussed fully in Chapter 13; however, it is an integral part of the assessment process.

As assessment is the cornerstone of establishing what a person's needs are, so the quality of assessment is pivotal to the success of the nursing process. Successful nursing intervention hinges on a complete and thorough assessment being undertaken. Even throughout the other stages of the nursing process, the nurse continues to assess the response to care and success of interventions. Thus assessment is an ongoing process. The aims of assessment are to:

Best practice in assessing, planning and implementing care can be achieved by incorporating principles from The Department of Health Essence of Care 2010: Benchmarks for Self Care into the process of assessment. The document advocates that healthcare workers seek the views of the person to inform the care plan (DH 2010b).

Assessment is a complex, time-consuming activity that requires many skills. Assessment of someone's needs should be performed jointly with the person whenever possible. Establishing people's own perspective of their problems helps to create partnership working and assists in providing person-centred care that is holistic in nature. Sometimes, this is not possible due to the nature of the person's problems, e.g. in a high-dependency setting when the patient is unconscious, or in a mental health assessment unit when a client is confused and disorientated.

The information required in any given assessment situation will be determined by the nursing context. Confidentiality must be maintained in all settings (Nursing and Midwifery Council, NMC 2008; see also Ch. 7). Information should be collected systematically to ensure that important issues are not overlooked. A combination of observation, interview and measurement is required to provide a full assessment (NANDA 2008).

Observation is a key nursing skill that informs the overall assessment process. Observing is a form of data collection made by using the senses. Visual observation can relate to all aspects of the person. Someone's general appearance and physical signs such as skin condition can be observed (see Ch. 16). Touch is also used to assess characteristics such as the temperature of a person's skin, presence or absence of pulses or signs of dehydration such as dry, inelastic skin (Barker 2009). Smell can be used to assess dimensions of a person in relation to the environment, such as chemicals in the air. In relation to the person, alcohol may be smelt on their breath or smoke on their clothes.

Interactions with other people can be observed, e.g. verbal and non-verbal communication (see Ch. 9). People's behaviour can also be observed, e.g. their reactions to a particular situation, including emotional signs such as crying. Observations should be systematic to maximize the information gathered.

To complete assessment accurately, practitioners should strive for objectivity. Personal interpretations of observations should be avoided. For instance, when describing a person's physical characteristics, it is desirable to retain objectivity and, where possible, to be specific. For example, blood pressure ‘180/95’ instead of ‘blood pressure high’, or ‘smiles frequently’ rather than ‘happy’. Essential nursing skills include objective measurement. Equipment is often used, such as a thermometer to measure temperature (p. 323) or a sphygmomanometer to measure blood pressure (p. 328). Height and weight may be measured with the use of a measuring tape and set of scales (p. 334). Quantifiable information is therefore acquired through the use of equipment as well as direct observation.

Information can be collected in a variety of ways, depending on the situation. The initial assessment of people attending an emergency department will differ greatly from the assessment undertaken by a practice nurse who is immunizing a family going abroad on holiday. The practice nurse makes an assessment of what is required for the safety of the travellers in the longer term, whereas the emergency department nurse makes an initial short-term assessment of the person in relation to their priority for treatment.

Holistic assessment

For assessment to be comprehensive, it should be undertaken in a holistic manner. Thus, the following dimensions of need should be assessed (Fawcett 2005):

While people may present to the nurse with similar medical or social problems, it is only by thorough and systematic assessment that includes the physical, psychological, sociocultural, spiritual and emotional dimensions of their lives that a truly individualized plan of care can be developed. It can, however, be difficult to separate the dimensions, as they are all interrelated and can impact on a person's health in different ways (Box 14.1).

The nurse's role is to identify and react to a person's response to their own situation. Thus, while a medical condition is acknowledged when assessing a patient or client, it only forms part of the assessment. The aim is to acquire the fullest information necessary without gathering irrelevant information.

Priorities of assessment may differ within different fields of nursing. In mental health, assessment may concentrate initially on psychological and social dimensions, since much of the care of people with mental health problems centres on human responses to illness (see p. 316). With children, it is appropriate to use a child and family-centred approach (see p. 317). The benefit of such an approach is that it addresses the needs of the family as well as the child. Learning disability assessment also has unique characteristics, which are discussed later. Nurses working in many settings will meet people with a learning disability as most live in the community and access health services in the usual ways, e.g. though primary care via their GP or practice nurse. What is important is that the principles discussed on page 315 are incorporated into the assessment process.

The nurse will undertake a decision-making process to make sense of the data collected from the assessment and formulate a plan of care. Thus the nurse's assessment of the patient/client will form the nursing history.

Sources of information

Information can be gathered for assessment purposes from:

• The patient/client – the primary source

• Other people or records – secondary sources.

Primary source

The patient or client should be the primary source of information, including children and young people as developmentally appropriate, as it is important to elicit their own perspective of their situation. To successfully interview the patient/client, the nurse needs to be a skilled communicator; questioning, actively listening and eliciting information (see Ch. 9). The nurse's questioning technique will depend on the circumstances. Open questions are often appropriate to encourage the person to respond, however there are times when it is more appropriate to use closed questions, e.g. in the case of an acutely ill breathless patient or a patient in extreme pain.

Questions for the nurse to ask during the assessment interview should be holistic. Factors that encompass an holistic perspective may relate to physical, sociocultural, spiritual, psychological and emotional factors. It is important for the nurse to be aware of factors that may influence the patient or client's situation. Therefore, consideration of these five factors may assist the nurse in formulating appropriate questions to ask the patient or client. Perhaps environmental factors influence the person with asthma and it would be appropriate to ask about the nature of their workplace. An example of how these factors can be incorporated into holistic assessment of breathing can be seen in Box 14.2.

Box 14.2   Nursing considerations as part of holistic assessment of breathing

1. Physical:

• What is the rate and pattern of breathing?

• Is breathing affected by activities or environmental factors?

2. Psychological:

• Is there a need for breathing or relaxation exercises?

• Is there a chance that emotion may affect breathing?

3. Sociocultural:

• Are there influences on the person's behaviour, e.g. smoking?

• What are the person's health beliefs (see Ch. 1) about coughing, expectorating or using inhaled medication?

4. Environmental:

• Are there factors influencing breathing, e.g. medication, position in bed, home/workplace – dampness, irritants?

5. Politicoeconomic:

• Are there constraints on resources that affect breathing, e.g. housing issues, financial issues?

Often assessment is undertaken in difficult circumstances, e.g. emergency admission to hospital is an anxiety-provoking event for patients and their relatives. Crisis intervention within community mental health nursing is another occasion when assessment is required, usually following a series of difficult events leading up to the need for intervention. The initial impression the nurse may have of the patient/client and their family can influence the ease with which the nurse is able to elicit reliable information. If the nurse gives the impression of being disinterested or hurried, it is unlikely that an accurate assessment will be made. Assessment should form the beginning of a trusting relationship between the nurse and patient/client and provides the person with the opportunity of putting their view of their current situation forward. There may be occasions when the patient/client is unable to provide information, through illness, confusion, being too young or having difficulty with communication, e.g. learning disability.

Secondary sources

These are used together with the primary source. Biographical data can be confirmed from previous health records. It is important to confirm the currency of this information in case of changes in circumstances such as someone being widowed or having moved house. Social and medical history can often be confirmed from other health records. Other practitioners can also offer information about patients/clients. For example, key workers of individuals living in residential or nursing homes can provide information if a client is hospitalized. Patient-held records or patient passports are also used, when available. Past medical history is also important to assess along with the current health situation. This can reveal information that may impact on the current situation, such as knowledge of allergic reactions to a drug or relevant information about the person's prior experience. Family members and significant others can also be rich sources of information about the patient/client and how their current situation is affecting their ability to cope with daily living.

Discharge planning

Prevention of early readmission may be avoided if discharge planning is robust enough to support the person on discharge. Inadequate planning and coordination can lead to unnecessary suffering and can also have a major impact on the resources needed to support the person. Preparing a patient/client and their family for discharge from hospital is an integral part of nursing care (DH 2010c). In many cases, discharge is the most important aspect of a hospital admission for the patient/client and their family.

As many hospital admissions are very short, planning for discharge should be incorporated into the initial assessment and pre-assessment stage. During surgical pre-assessment visits (see Ch. 24), people are given information regarding requirements for going home following surgery or other invasive procedures. If a patient lives alone and is unable to have someone stay with them following discharge after day surgery and/or an anaesthetic, an overnight hospital stay may be more appropriate. Thus social, physical, psychological, economic and environmental aspects of assessment are crucial in providing relevant information that will inform a safe discharge. With many people being discharged following hospital admission for acute problems, or longstanding chronic problems, complex management plans and packages of care may be required and therefore a coordinated approach to discharge planning is necessary. Early supported discharge teams are in place in some specialties such as orthopaedics and care of older adults. Within these services, there is explicit inclusion of discharge criteria in the care planning documentation. The nurse caring for the patient has a responsibility to ensure that a multidisciplinary approach is taken when required. Therefore, discharge planning is documented as an integral part of care delivery, emphasizing the need for the nurse to work in partnership with other professional groups and agencies (DH 2010c).

The nature of a patient's health needs or presenting problems will inform discharge planning; for hospitalized patients, nurses also need to enquire about the perspectives of carers. Most patients have a network of significant others who can provide information about them; they must also be consulted about certain aspects of care such as the transition from home to hospital, or hospital to home. Without the support of significant others, it is often not possible to achieve a successful discharge. Patient transfer also necessitates careful planning and communication of all involved. DH (2010c) emphasize the importance of involving patients/clients and carers in the process and to help these principles be applied to transfer situations, a best practice template is available (Scottish Government 2009). Box 14.3 summarizes factors that require consideration before transfer or discharge.

Box 14.3   Factors that are taken into account before a patient is transferred or discharged

• Patient and their relatives are aware of transfer/discharge

• Specific care, e.g. wound care is documented

• Appropriate patient education has been undertaken

• Mode of transport appropriate and organized

• Name of person responsible for transfer/discharge

• Social service involvement needed and organized

• Community services needed, e.g. nurse/multidisciplinary team/home care

• GP letter/immediate discharge document/transfer documentation completed

• Medication ready to go with patient

• Follow-up appointment information available

• Aids/dressings/prosthesis are available

• Access to home has been assessed.

The assessment interview

The planned assessment interview that forms the basis of the nursing history can take place in many settings. The health visitor may conduct an assessment of a child's developmental progress at home surrounded by parents and other family members. Alternatively, the assessment might be in a situation of crisis, such as a serious injury following an accident. Whatever the situation, there must be structure to the interview. The focus will be not only on the documentation being used but also on the person being interviewed. It is important to include both. The use of documentation alone will not allow the whole spectrum of issues to be captured. The first interview allows the nurse to gather baseline information about the person. Comparisons against this will be ongoing. In some settings the interview will be conducted by a doctor and a nurse such as in acute mental health admissions (Barker 2009). The advantage of this is that the client will not have to repeat similar information to different professionals. There is also the benefit of engaging in multiprofessional working, with all health professionals sharing care of the patient to provide a cohesive service (Barker 2009).

Privacy

At all times during the assessment process, privacy must be respected. This may be easier to achieve in some settings than in others, e.g. when an interview room is available. In the patient's/client's home or in a busy department where there are many other people, it may be more difficult to achieve and therefore careful consideration is needed. In the home it may mean asking other family members to leave the room, or in the department it may be necessary to speak quietly behind screens. Other barriers to effective communication need to be identified and remedied, e.g. environmental noise affecting concentration could be avoided by moving to a quieter area. Language barriers may be overcome by the use of interpreters from within the family or the health provider organization. Confidentiality should be maintained if interpreters are being used. It should be recognized that factors affecting the quality of the interaction between the nurse and the person may have an adverse effect on the quality of information provided and the care received (see Ch. 9 and Box 14.4).

Box 14.4    Reflective practice

Sharing personal information

Before starting your nursing course, you may have had to undergo occupational health screening.

Student activities

• Reflect on the situation where someone you had not previously met has asked you to reveal personal information.

• Consider how you felt about divulging personal information to a stranger.

• How did the approach of the person affect your feelings at the time?

Interpretation of information

The nurse will undertake a decision-making process to make sense of the data collected from the assessment and formulate a plan of care. Nurses need to be aware of their own beliefs, values and attitudes as well as their level of knowledge and competence. Assumptions should not be made about the condition of a patient/client. Unlike BP measurement, not all patient/client observations, can be validated. For example, it is difficult to measure the level of anxiety a patient is experiencing (see Ch. 11). As such, nurses need a degree of self-awareness to ensure that value judgements and assumptions are not made regarding the person's situation.

Staging assessment

The use of a step-wise approach to assessment is sometimes appropriate, with some aspects of the assessment process being undertaken immediately, while others are undertaken later. For example, an older adult being admitted to a care home may have a full assessment undertaken over a period of 1 week to minimize the effects of relocating on their usual routines and ability to adapt. An unconscious child admitted to an emergency department would need immediate assessment to allow priorities of care to be established.

It is sometimes inappropriate to explore every aspect of assessment at the initial interview. In some mental health and learning disability settings, client assessment may be undertaken incrementally as the therapeutic relationship is established. This is also the case in situations when a person is moving into long-term care, e.g. a nursing home. If this is the case, the nurse assessing must take responsibility for ensuring full assessment is completed. This can be useful if the patient/client needs time to adjust to their new situation before discussing sensitive issues with the nurse.

Documentation

Documentation of the nursing process, at each stage, is an important way to communicate to other members of the healthcare team how the patient/client is progressing and responding to interventions. Documentation must be comprehensive and accurately reflect the health status of the patient/client. Accuracy is achieved by recording information precisely, e.g. ‘the patient had 150 mL of tea, and toast and scrambled eggs’ rather than ‘good appetite’, as appetite varies from person to person, and also from nurse to nurse, thus making the assessment subjective. It is a professional requirement to record nursing interventions and the information collected to inform the intervention, as nursing documentation is a legal document (NMC 2010a).

Assessment documentation takes different formats according to the setting. Electronic records of care are being implemented gradually throughout the UK as information technology systems are developed to support healthcare delivery (DH 2010c; House of Commons 2007). Patient-held records are also used, especially for people with long-term conditions. Patient-held records can support self-management and self-care, thus increasing patient involvement. For example, in asthma care when a person attends the practice nurse, the GP and an outpatient department, it is useful for them to have one record that can be used by all professionals to improve continuity of care across primary and secondary care settings. Increasingly, multidisciplinary documentation is being developed with the whole team having access to the records. Confidentiality should be maintained at all times regarding documentation, irrespective of the mechanism being used (NMC 2010a).

Single shared assessment is intended to simplify the assessment process, be person-centred and clarify responsibilities between health and social care providers, mainly for older adults in the community. Making this process work, however, requires commitment from all healthcare practitioners to keep the patient/client central to planning of their care. Additionally, this may mean the erosion of traditional professional barriers and boundaries. The underpinning philosophy of shared assessment is that it is ‘needs led’ rather than ‘service led’.

Assessment tools

Assessment tools, as part of risk assessment, form part of the assessment process and those used depend on the specific needs of the patient. Assessment tools, developed by nurses (practitioners and researchers), provide a validated method of eliciting information with a view to minimizing patient/client risk. Tools devised by other professional groups are also used by nurses, e.g. the Glasgow Coma Scale and Paediatric Glasgow Coma Scale (see Ch. 16). An example of a commonly used assessment tool is the Waterlow scale, a pressure ulcer risk assessment tool (Fig. 14.2; see also Ch. 25). This tool is used to predict the level of risk of an individual developing pressure ulcers, taking their overall condition into account (Box 14.5). Early Warning Score (EWS) charts are assessment tools commonly used to monitor patient's vital signs in order to identify deterioration in condition (see Fig. 14.14). Tools should be appropriate to the client group to optimize their effectiveness. Risk assessment (see Ch. 13) should be performed at appropriate times, e.g. when there is a change in the health status of a patient/client. It is important that all staff using an assessment tool are familiar with its use.

Box 14.5    Critical thinking

Using assessment tools

• 2-year-old Jane has been admitted to a children's ward with suspected meningitis. She has a generalized rash and moving is painful

• Isa Oliver (84) has been admitted to an orthopaedic ward through the emergency department after a fall at home. She has previously been in good health and independent at home. She has a fractured hip and is scheduled for surgery today

• Imad Jumaa (68) lives in a nursing home. He has dementia and poor mobility due to arthritis. He is doubly incontinent and is unable to attend to his own hygiene needs. Imad has difficulty with communication

• Fred Maxwell is 28 years old and has a learning disability. He lives in a house with four other service users who are supported by carers. He also has physical disabilities and mobilizes with a wheelchair. Fred is underweight and his appetite is poor; he needs help with personal hygiene and feeding, and is incontinent of urine.

Student activity

Using the Waterlow scale (see Fig. 14.2), assess the level of risk the people above may have of developing pressure ulcers (see Ch. 25 for further information, including other pressure ulcer risk assessment tools).

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Planning

This stage of the nursing process involves identifying the person's problems or needs and what nursing care, intervention or support is required. The care plan should be written down and contain clear statements about how the person's goals will be achieved (see below). The patient/client should also be involved in this stage, if possible. The format of the care plan depends on the particular setting. As well as establishing the person's existing problems, any potential problems are also identified. Learning disability nurses may also concentrate on a client's strengths as well as weaknesses.

Prioritizing care

Planning also incorporates prioritizing care according to the needs of the individual and seriousness of the problems. Life-threatening situations such as airway obstruction must be considered and acted upon before wider health needs, such as the desire to stop smoking. Determining priorities is achieved through an understanding of the theory and concepts underpinning nursing. Involvement of the person in this stage of the nursing process also assists in prioritizing care according to their wishes if there are no life-threatening issues. Through communication, mutually agreed goals can be set, based on the person's perception of their situation.

Actual and potential problems

The aims of planning are to:

• Solve actual problems (or meet health needs)

• Minimize the risk of potential problems

• Reduce recurring problems

• Assist in development of coping strategies for problematical health issues

• Build on strengths.

Consequently, nurses need to be able to ‘see beyond’ the present situation and use their knowledge and expertise to avoid complications and potential problems occurring (Box 14.6). It can be seen from Rashid's situation that the impact of one problem can potentially create many other problems for him that transcend different dimensions of need (p. 311).

Box 14.6   Actual and potential problems

59-year-old Rashid was admitted to hospital with a left-sided weakness and investigations show that he has had a stroke. Rashid is left handed. One of his actual problems is that he is unable to move his left side, which might affect his mobility, skin integrity and independence.

Actual problem

• Unable to move left side.

Potential problems

• Negative impact on self-esteem

• Help required with eating and drinking

• Reduced mobility (see Ch. 18)

• Pressure ulcers (see Ch. 25)

• Deep vein thrombosis (see Ch. 24)

• Muscle weakness

• Limb contractures

• Inability to attend to personal hygiene

• Loss of independence.

Goal setting as part of care planning

Goals are set to enable measurement of the success, or otherwise, of the nursing interventions planned to meet them. Different types of nursing action are often required to meet the goals. For example, different members of the healthcare team may deliver different aspects of the care required. Which member of the team delivers the care to an individual depends on the complexity of their care and on the skills of the members. Competent healthcare assistants may perform some nursing interventions, e.g. they may be able to assist people to maintain personal hygiene. However, for some therapeutic interventions, the registered nurse (RN) would be required to monitor some parameters such as central venous pressure.

Goals can be either short or long term. They should be person centred and achievable. To assist in this, goals should be SMART and incorporate the following characteristics:

• Specific – state clearly what is to be achieved

• Measurable – be made quantifiable

• Achievable – must be able to be achieved by the patient/client

• Realistic – possible for the patient/client to achieve

• Timed – have a time limit by which the goal can be achieved and evaluation undertaken.

A goal could be ‘the patient should drink 2.5 L of fluid within the next 24 hours’. Within this goal, it would have been assessed that the patient is capable of taking fluids orally, making it achievable and realistic. It is specific because it states the amount of fluid to be taken, is measurable as fluid intake and is timed as there is a timeframe allocated to its achievement. Box 14.7 provides an example of short- and long-term goals. If goals are unrealistic and unachievable, this can lead to disappointment of both the patient/client and the nurse. As a consequence, the therapeutic relationship may be adversely affected.

Box 14.7   Short- and long-term goals

Eddie has been admitted to the ward with breathlessness. In relation to this, the following goals may be appropriate.

A short-term goal may be:

• To reduce Eddie's respiratory rate to <20 breaths/min within 2 hours

    The goal may be achieved by:

• Careful positioning in bed; sitting upright, well supported with pillows or leaning on a bed table (see Ch. 17)

• Administration of prescribed medication (see Ch. 22)

• Administration of prescribed oxygen therapy (see Ch. 17).

A long-term goal may be:

• To cope with mild breathlessness prior to discharge

    The goal may be achieved by:

• Education regarding breathing exercises prior to discharge

• Teaching Eddie to reduce activity that provokes breathlessness

• Referral to the physiotherapist.

The Roper, Logan and Tierney model for nursing

The Activities of Living model was developed in the UK by Roper, Logan and Tierney who first published the Elements of Nursing in 1980. Their work developed some of the central components of Virginia Henderson's earlier definition of nursing (see Ch. 2). There are two parts to this model: the model of living and the model for nursing (Fig. 14.3). Over the years it has been refined, indicating that nursing is a dynamic profession, constantly developing in response to external influences.

According to Roper et al (2000), five interrelated components form the core of the model of living:

The individual

According to Roper et al (2000), individuality in living acknowledges that each person has a unique way of performing the ALs according to where they are on the lifespan, the degree of dependence/independence they have and the influences of biological, psychological, sociocultural, environmental and politicoeconomic factors. Individuality in living is concerned with how an individual experiences and performs ALs according to their preferences, abilities and attitudes.

Activities of living

Roper et al (2000) suggested that 12 activities are essential for survival:

• Maintaining a safe environment (Ch. 13 + others)

• Communicating (Ch. 9)

• Breathing (Ch. 17)

• Eating and drinking (Ch. 20)

• Eliminating (Chs 20, 21)

• Personal cleansing and dressing (Ch. 16)

• Controlling body temperature (see p. 319)

• Mobilizing (Ch. 18)

• Working and playing (Ch. 8 + others)

• Expressing sexuality (Ch. 8 + others)

• Sleeping (Ch. 10)

• Dying (Ch. 12).

It is evident that the activities cannot be viewed as mutually exclusive as they are dimensions that interlink with each other (Box 14.8). For example, it is not possible to consider elimination without considering eating and drinking.

Box 14.8    Critical thinking

The relationship between factors influencing activities of living (ALs) and the interdependence of ALs

Jane is 17 years old and lives with her mother and 11-year-old sister. Jane's parents are divorced and her father is not in contact with them. Her mother has chronic arthritis and is physically dependent on Jane to support her with running the house. Jane helps her mother to get into the shower in the evenings and collects her prescriptions. She also does the shopping, cleaning, ironing and supervises her younger sister with homework and getting ready for school. Jane is at college full-time and on Friday evenings, her friends often go the student union then on to a nightclub. Jane is usually too tired to join them.

Student activities

• Think about how Jane may experience social isolation from her peers (working and playing).

• Consider the psychological impact that home circumstances may have on Jane (sleeping).

• Identify ways in which Jane could get additional support to ease her situation (maintaining a safe environment).

Lifespan

The lifespan is considered to be a continuum with changes occurring along it from birth to death. Throughout this time, every aspect of living is influenced by biological, psychological, sociocultural, environmental and politicoeconomic factors. The five stages of life identified by Roper et al (2000) are:

• Infancy

• Childhood

• Adolescence

• Adulthood

• Old age.

Throughout these periods, levels of dependence and independence vary. An infant is vulnerable and dependent on others for survival and love. Childhood and adolescence are affected by cultural issues, sociocultural norms and subcultures (see Ch. 8) and are dominated by the family. In adulthood, work and family affect lifestyle. In old age, individuals may have an illness that affects their level of independence, e.g. arthritis which can impair mobility.

Factors influencing the ALs

There are five main factors that can influence daily living (Roper et al 2000), as outlined below.

Biological factors

In the context of the model of living, biological factors relate to physical and physiological performance. While there are predetermined genetic influences affecting physical characteristics such as skin colour, hair colour, height or genetically determined diseases such as haemophilia, other factors can also affect physical characteristics and function. In wartime, if a child is deprived of food, growth may be affected, resulting in slower rates of growth and development. Thus, environmental and politicoeconomic issues may also affect physical factors. Biological factors associated with ageing may affect a person's ability to work, thereby impacting on their sociocultural status.

Psychological factors

Mental and intellectual activity begins in childhood and continues through adolescence, adulthood and into older age. The stimuli within these lifespan phases vary. In childhood, development begins through sensory stimuli that can be influenced by family issues such as having siblings who may spend time playing with the toddler. In adolescence, development can be affected by the place of the child in the family and the expectations placed upon them. Thus environmental factors may also influence psychological development. Development across the lifespan is discussed in Chapter 8.

Sociocultural factors

Ideas, values, knowledge and beliefs are embedded within cultural norms of groups within society (see Ch. 8). Thus, many variations exist among the population from which patients and clients will come. Culture is unique to groups of people and can affect the behaviour of individuals. It is important to remember that cultural beliefs may have a profound impact on lifestyle and the responses of people who need to access health services. Dietary practices can have an impact on biological factors; for example, vegetarians may have a low iron intake leading to low blood haemoglobin levels and anaemia. Religion may affect how individuals respond to treatment options, e.g. Jehovah's Witnesses may reject blood transfusion as a treatment option compatible with their beliefs. Therefore sociocultural aspects may impact on biological and psychological factors.

Environmental factors

Environmental factors include housing, the atmosphere, noise and sound. Any of these elements can influence the other factors. Atmospheric pollutants such as carbon monoxide can aggravate respiratory conditions such as asthma, thereby having an impact on biological and psychological factors. Noise pollution can cause anxiety that may impact on psychological and biological functioning, e.g. by causing insomnia and anxiety.

Politicoeconomic factors

The economy, law and the state comprise the politicoeconomic factors that impact on individuals. People are governed by fiscal measures such as the need to pay council tax. Local and national economies also affect people and consequently their behaviour. For example, people on low incomes have limited choices on which to spend their money. Asylum seekers who are given vouchers as part of their financial support may have few choices about where they can exchange them. This may lead to lack of choice and being unable to follow dietary customs, thus impacting on biological and psychological factors.

It can be seen that the main themes of the model are inextricably linked and the activities in Box 14.9 highlight this.

Box 14.9    Critical thinking

Factors influencing activities of living (ALs)

Groups such as asylum seekers, people with a learning disability and those with chronic illness may have limited control over the five factors that influence ALs.

Student activities

• Think about the impact of the five influencing factors on the three groups of people above. Draw on any experiences you have had in practice, but if you have not encountered such situations, use the information you have read.

• Think of an occasion when one of the five factors that influence ALs has affected your own well-being and how that occasion affected other aspects of your life.

Roy's adaptation model

Sister Callista Roy developed this model in the USA in the 1960s. It has been refined over the years to make it suitable for nursing in the twenty-first century (Roy & Andrews 1999). The basis of Roy's model is that individuals must adapt to a constantly changing environment. The health of the individual is a reflection of that adaptive process. It is a behaviourist model, as it is concerned with the way in which individuals behave in response to changing circumstances. Behaviourism is the study and observation of how individuals behave.

Roy's behaviourist model is based on the following two philosophical assumptions:

The model is based on the following two scientific assumptions:

Within the model, there are three types of stimuli (systems). These are:

Roy and Andrews (1999) state that there is an interrelationship between these three systems, with all of them working together to maintain a balance within the individual. For example, if a person is physically unable to drink fluids due to a swallowing problem they may become dehydrated, and thus the internal body environment may be affected. Equally, if someone is trekking across the desert with no water to drink, their social system is affecting their physiological status as they are unable to access fluid to prevent dehydration. Thus the systems are interrelated and interdependent, interacting with each other at all times.

According to Roy, if an individual adapts to these stimuli, it could be said that they are healthy. Most people cope effectively with constant changes to their internal and external environments. During a heat wave, for example, an individual may drink more fluids, slow down their level of activity and increase the ventilation of their home. An individual who is unable to make these changes, such as a toddler, may be considered to have an ineffective response to the stimulus of heat. If the individual has not adapted to the stimulus, then the role of the nurse is to assist the person to adapt to it. Thus, the focus for the nurse is to identify the stimuli to facilitate adaptation in the individual patient/client. Roy acknowledges the individuality of people and so there will be no complete state of balance applicable to everyone. Therefore, the nurse must recognize the needs of individuals.

Roy discusses the adaptation level of individuals as forming an adaptive range. Behavioural responses to stimuli can be effective, adaptive stimuli or maladaptive. The factors that cause problems of maladaptation are called stimuli and there are three types:

Adaptive modes

There are four adaptive modes within Roy's model that serve as a framework for assessment. It is believed that a person's response to stimuli can be observed in these adaptive modes:

• Physiological adaptive mode – physiological balance, i.e. homeostasis

• Self-concept adaptive mode – psychological integrity, moral, spiritual

• Role function mode – social integrity, managing social interaction

• Interdependency mode – emotional and affective (moods or emotions) behaviour.

Roy states that these four modes contribute towards the promotion of adaptive goals leading to integration and wholeness. Nursing intervention would be required if there is a need deficit.

Assessment

With Roy's model, assessment is advocated using three stages:

• Stage 1 – examine the adaptive modes; identify if coping is adequate

• Stage 2 – detailed assessment; identify focal, contextual and residual stimuli

• Stage 3 – make a nursing diagnosis based on adaptation status; plan the nursing intervention based on the nursing diagnosis.

Planning

Planning should identify SMART patient-centred goals (see p. 310) that should incorporate the following:

• Ineffective behaviour to be changed: For example, if a patient is pyrexial (see p. 321) the goal may be to ‘assist patient to regain normal temperature range by providing cool drinks, administering antipyretic medication and monitoring temperature 4-hourly’.

• Adaptive behaviours to be reinforced: For example, if a patient has stopped smoking since admission to hospital, the goal may be to ‘provide positive reinforcement and assist distraction from smoking through a range of activities such as listening to the radio, reading health education literature and providing access to smoking cessation helpline’.

Evaluation

This involves exploring whether the goals have been met, thus determining if the adaptation response has been achieved effectively or ineffectively. Reassessment occurs at this stage.

Figure 14.4 shows the nursing process as it relates to Roy's adaptation model.

Person-centred planning

Person-centred planning is a way of working in partnership with people and their families to achieve personal autonomy, which is pivotal to realizing the policy aims for people with learning disability (Scottish Executive 2004). As people with learning disability often have unmet health needs, another aim in caring for these people is to help the person have more control over their health (Scarborough & Godsell 2011). For people who have difficulty in articulating their views, an advocate may assist in eliciting their views and thoughts. An advocate may be a paid care-worker or a family member or friend.

Person-centred planning aims to assist people to choose the lifestyle they want. Acknowledgement of the person's disability is made, with acceptance of their need for support on their own terms. The focus is on capacity and capacity building, which means working towards maximizing ability.

Person-centred planning can be achieved by sharing of power between the person, family and professional. Any significant person involved with the client may be involved, e.g. paid support workers or those who act as advocates for the person such as family members. Support workers may be part of the MDT such as learning disability nurses, resource workers, physiotherapists, speech and language therapists, occupational therapists and psychologists. Learning about the person is crucial to developing an understanding of their needs. Careful listening (see Ch. 9) and consultation are essential to fully assess the individual. Person-centred planning is a process that takes time and usually starts with a planning meeting. The key features of person-centred planning are shown in Box 14.11 and some are described in more detail below.

Consulting the person throughout the planning process

If the person with learning disabilities has been involved with planning before, it is sensible to talk to them about how they would like to plan, e.g. whether they want a meeting and, if so, what kind of meeting and how they want to be involved. If they are new to planning, it is important to spend time explaining the purpose of planning and looking at different options. Box 14.12 summarizes how this process may work for an individual.

Box 14.12    Health promotion

Craig's story

Craig, who is 32 years old, lives at home assisted by his family and a group of part-time support workers. He has learning disabilities, is unable to speak and moves his hands and eyes to communicate. Craig attends a day centre three times a week. While at the day centre, Craig sleeps a lot. His family and support workers describe him as witty and lively, but staff at the day centre find him disinterested and uncommunicative.

It was decided to make a plan for the future. Craig's family asked him who he would like to be involved in the planning. Craig invited staff from the day centre. He asked for the two members of staff he felt most comfortable with. They were happy to come, as they thought that Craig might not be getting the most from his time in the day centre. The meeting was held in Craig's home and took up most of an evening.

During the planning meeting, Craig communicated to the group that he was interested in learning to play a musical instrument, finding a girlfriend and making changes that would allow him to make new friends. It was the first time that anyone had realized Craig had these ambitions and no one thought it was impossible to achieve them. Staff from the day centre then recognized that the reason Craig was different at the day centre was probably because he felt he did not know the staff well and they did not know fully how to communicate with him.

The people who attended the meeting then worked together to change things. Craig now attends a weekly music class with a support worker. One of the staff from the day centre has spent time in Craig's home to get a better understanding of his needs. The next stage of the plan is to find other activities that interest Craig and, like the music class, he will attend these with a support worker. In time, it is planned that he will reduce the time he spends at the day centre as other activities increase. Things are slowly changing for the better and Craig is now involved in every decision that is made.

Student activity

Visit the Scottish Consortium for Learning Disability website (www.scld.org.uk) and find out how one agency is trying to achieve the goals of the government strategies for people with learning disability.

The person chooses who to involve

Unlike traditional planning, it is for the person with learning disabilities to decide who they want to include in the planning process and how. This is easy to say but, with existing services, this is very different from the way meetings are typically organized. If the people around those with learning disabilities cannot find a way to help them make and communicate that decision for themselves, then they must decide in good faith who they think the person would want to involve. A good starting point is thinking about ‘people who know and care about the person’, which may well yield a different answer from ‘people who provide a service to this person’.

The person chooses the setting and timing of meetings

If a meeting takes place it should be at a time convenient to the person with learning disabilities, with the people they wish to invite and be in a place where they feel ‘at home’. The planning should be carried out in a way that is accessible to the person with learning disabilities. Graphics, tapes, videos or photos are often used.

The Tidal model

The Tidal model (Barker 2009) was initially developed from a study into mental health nursing. It is a multidimensional approach to the provision of mental healthcare. The philosophy is that people can recover from the experience of mental health problems and that nurses can assist clients to return to their daily life. Therefore, the philosophy is about helping people to cope with their problems and find solutions through their own experiences. As it is not about ‘fixing them’, this model has an empowering approach.

The Tidal model represents the unique contribution that nurses make to the care of people with mental health problems, though it also acknowledges the close relationships with other health and social care practitioners. One of its features is that a care continuum exists. The care continuum straddles the primary and secondary care settings with the premise that the needs of the person should be the focus of care rather than the setting. The assumption is that the need for nursing lies wherever the person is and not within the ‘compartments’ of primary or secondary care. Other features of the model are:

The role of the nurse is two-fold:

Barker (1996, p 236) illustrates the core basis of the Tidal model:

Barker (1996) asserts that there are three dimensions within the model:

The aim of assessment and planning within the three dimensions is to allow the person to verbalize their own experience to determine how their needs can be met. The narrative basis of the model suggests that the ‘self’ of the person-as-the-expert can be explored through careful inquiry by the nurse. Therefore, the therapeutic relationship between the nurse and person is crucial to allow construction of the person's experience through narratives. The care plan should document the needs of the person expressed in their own words rather than in professional language or in the third person. Thus the lived experience of the person can be documented.

The aim of the Tidal model, using a person-centred approach, dovetails with best practice statements regarding engagement with the person to work towards person-centred care (Barker 2009).

Further information about approaches to mental health nursing can be found in Useful websites, p. 335.

The Nottingham model

While the philosophy of this model includes the family members as partners, it is still important to include the child in the decision-making process where possible. By doing this, dignity and respect for the child are maintained. As the model uses a holistic approach, taking account of the wider influences that can affect a child's health, the family's perception of health in relation to the child should be assessed when the history is being taken during admission.

Hospital admission can be very disruptive, not only to the child but also to the wider family. The child may have alteration in normal functioning that spans the physical, psychological, social, emotional and/or environmental dimensions of life (DH 2003). To minimize the trauma associated with hospital admission, a welcoming environment is necessary to enable the process of negotiated care to be established. A routine that allows a child's normal activities to be undertaken in relation to activities of living is encouraged, particularly in respect of education and recreation. Play is an important element of the nursing care provided (see Chs 8, 9) and forms an important aspect of pain management (see Ch. 23). The family or main caregivers should be considered the experts on young children. Their knowledge of the child's behaviour and level of independence can be communicated to the nurse and the plan of care is developed jointly. Assisting the family to retain some control over their lives, while meeting the needs of their child, is desirable. This often means that the family will be involved in direct care giving. To provide this type of family-centred care, the family must have clear guidelines about what to expect from the nurse. Therefore, nurses caring for children need to be excellent communicators. Older children and young people are often the experts about their own conditions and associated care.

If hospital admissions are planned (elective), some of the fear associated with hospital admission can be allayed. Receiving written and verbal information prior to admission may help reduce anxiety for the child and their family. It may also reduce recovery times. Preadmission schemes can also reduce some of the fears and anxiety by providing an opportunity to visit the environment and meet with some of the staff (Smith et al 2002). The Nottingham model follows the steps of the nursing process from assessment, planning, implementing and evaluating care.

Negotiated care

Negotiated care refers to a two-way process between the nurse and the child and their family. The relationship between these people should be based on mutual trust and respect. With each person's contribution being equally valued, an agreed plan of care can be made. The process of negotiation begins at the assessment stage. The level of family involvement should be frequently reassessed as the situation may change, as can the needs of the family. Thus parental participation in direct care delivery may vary over time.

Building an equal partnership

An equal partnership can be developed through the nurse assisting the family to acquire the additional knowledge and skills of caring needed. Equipping the family with knowledge can empower them. Factors that can build the partnership include:

• A positive attitude of the nurse that includes the family in care delivery if desired

• Willingness of the nurse to share information, knowledge and skills

• The ability of the nurse to educate, teach and support others.

Casey's model

This also incorporates negotiated care and partnership building with the child and family. According to Casey (2007), the key elements of paediatric nursing assessment are:

• The nature of the health problem and the child and family's understanding of it

• The developmental effects the health problem has on the child

• The family's situation, its responses to the problem and the nature of the coping

• The wishes of the family and educational needs

• The usual routines of the child

• The child and family's expectations of care and treatment.

Variance

There are often reasons why a patient will not follow the expected path of recovery or response such as the presence of other health issues from any aspect of their life, i.e. physical, psychological, emotional, spiritual, sociocultural or environmental. This does not necessarily mean that the pathway is unsuitable for the patient, but rather it may highlight the unique features of any individual who requires care. If a patient varies from the expected pathway, this is documented on the care pathway, including whether the variance was avoidable or not. For example, other diseases impacting on patient progress is unavoidable whereas a delay in having a test performed is avoidable.

Body temperature

Core body temperature in health is in the range of 36.4–37.3° ± 0.2°C. It is measured in degrees (°) Celsius (C), and is relatively constant. Body temperature is an indicator of the balance between the amount of heat being generated by cellular processes and the excess that is lost. Efficient cellular metabolism requires the maintenance of body core temperature and organs that are located within the core, such as the brain, heart and liver, function best around 37°C. This is called the ‘set point’ and serious problems occur if temperature deviates much from this.

Distribution of body heat

Heat is generated by cellular metabolism; therefore areas of high metabolic activity such as the liver or exercising skeletal muscle have the highest temperatures. The locations that best reflect the body's inner or ‘core’ temperature are the heart and brain. Peripheral regions, which are nearer to the environment, are cooler as they are more exposed to the lower ambient temperature outside the body. Temperature sensors placed on the skin surface estimate peripheral or ‘shell’ body temperature. Body core temperature (BCT) can be measured using instruments that may be placed in sites such as the ear canal, oral cavity, axilla or rectum. Figure 14.5 shows body temperature at different sites.

Heat balance

Maintaining body temperature within the normal range requires a balance between heat produced by the body and its loss to the environment. Heat balance is achieved through the interplay of mechanisms that conserve heat and others that promote heat loss.

Heat conservation

When sensors in the hypothalamus detect a fall in temperature they trigger responses that promote heat conservation. These include:

• Vasoconstriction – peripheral blood vessels constrict, diverting blood away from the extremities, thus limiting heat loss from the body to the environment

• Piloerection – body hairs are erected, trapping warm air against the body surface (skin)

• Shivering – generates heat

• Reduced sweating – facilitates heat conservation.

Behavioural responses include putting on more clothes, exercising or moving towards a source of heat.

Heat loss

If core temperature rises above the set point, the body initiates physiological mechanisms that promote heat transfer. These include:

• Vasodilatation – dilatation of peripheral blood vessels, which facilitates heat transfer to the cooler environment of the skin

• Increased sweating – facilitates heat loss as sweat evaporates from the skin

• Increased rate and depth of respirations – promotes heat loss in expired air

• Decrease in cellular metabolism – reduces heat production.

Behavioural mechanisms activated by the brain also promote heat loss. These include taking off clothes or wearing lighter clothes, drinking cold fluids or lifting the arms away from the body.

Physiological influences on body core temperature

There are several factors that influence BCT, as outlined below.

Diurnal cycles

BCT varies throughout the day. Variations are normally within a range of 0.5–1.0°C over 24 hours, with the highest point of 37.2°C at around 18 : 00 hours and lowest (36.7°C) around 06:00 hours. People having their temperature measured daily should therefore have this carried out at the same time each day to avoid normal diurnal variations.

Age

In infants, temperature regulation is labile because their physiological heat-regulating mechanisms are immature, and this can continue until puberty. Babies and small children therefore need to be dressed appropriately for the environmental temperatures around them. Heat production is increased in infants and children due to deposits of brown fat around the neck, back and viscera (the organs within the abdominal cavity). The only role of brown fat is to generate heat, and therefore shivering is not usually observed in this age group. Children also have a higher basal metabolic rate than adults, due to increased tissue growth rates. The consequence of a higher metabolic rate is a higher mean BCT.

Older adults may have a lower mean BCT that is also more influenced by ambient temperature. Therefore, should an older person develop an infection, BCT may not rise significantly. Ageing processes tend to reduce muscle mass, which reduces heat production capability in older adults. Additionally, loss of subcutaneous tissue (insulating fat) and reduced basal metabolic rate influence heat loss and production.

Menstrual cycle

Hormones released throughout the menstrual cycle also influence temperature. Increased cellular metabolism occurs at ovulation and body temperature rises by up to 1°C for the remainder of the cycle.

Other factors

Exercise increases heat production. Stress, pain and illness can also increase body temperature, whereas fatigue and headache can decrease it.

Environmental influences on body temperature

Environmental temperature extremes can raise or lower body temperature. The changes depend on the extent of exposure, air humidity and the presence of convection currents. Smoking cigarettes or cigars can increase oral temperature.

Care of people with temperature abnormalities

Body temperature can deviate from the normal range as a result of excess heat production, minimal heat loss or minimal heat production. It may:

• Rise resulting in pyrexia (fever, BCT above 37.5°C) or hyperthermia (BCT above 40°C) due to failure of heat loss mechanisms (see Further reading, Childs 2011)

• Fall, resulting in hypothermia (BCT below 35°C).

Disorders such as heatstroke, hypothermia and frostbite may occur when environmental temperatures are extreme. The first aid for people with heatstroke is outlined in this section.

Caring for patients with pyrexia or hyperpyrexia

Pyrexia is present when elevated temperature readings have been recorded at different times throughout the day, rather than a single raised reading. Pyrexia is often caused by an infection and has three stages. The first stage, during which BCT rises, can induce vigorous shivering or ‘rigors’. Shivering generates metabolic heat with a subsequent rise in BCT, which the body uses to mount a response against the invading pathogen. The stages and the nursing care required are outlined in Table 14.1. Elevated BCT increases basal metabolic rate and oxygen consumption and, in hyperpyrexia, there is serious disruption of brain and other organ function. Children under the age of 5 years are prone to febrile seizures and the first aid needed is described Box 16.32 (p. 391).

Table 14.1

Pyrexia: phases and nursing interventions

Condition	BCT	Phase	Signs and symptoms	Cause	Nursing interventions
Pyrexia	37.5–39.9°C	1. Chill	Skin is pale and feels cool and dry. Shivering, goose bumps (piloerection). Person complains of feeling cold. BCT rises and rigors may occur during this phase	Constriction of peripheral blood vessels. Immune response triggers heat generation strategies to kill invading bacteria	Keep person covered in light clothing. Add blankets to assist heat conservation
Hyperpyrexia	40.0–42.0°C	2. Plateau	Skin flushed and feels dry. Pulse and respiratory rates elevated. BCT remains high. Dehydration and dry mouth	Set point elevated. Increased cellular metabolism and oxygen consumption	Provide mouthwashes/oral hygiene and fluids or ice chips to suck. Provide an easily digestible diet high in energy to meet increased energy needs. If temperature above 39°C antipyretics and cooling measures may be prescribed
	42–36.4°C	3. Defervescence	BCT initially elevated but returns to normal. Pulse and respiratory rates remain elevated. Skin moist, flushed and hot. Profuse sweating. Dehydration may occur	Vasodilatation of peripheral blood vessels and sweating facilitate heat loss. Dehydration and increased cellular metabolism: contribute to raised pulse and respiratory rates	Provide cool dry clothes and bedding. Sponging with cool water may promote comfort. Continue oral hygiene and fluids as above; a fluid balance chart may be used to monitor hydration status (see Ch. 19). Assess risk of pressure ulcers (see Fig. 14.2 and Ch. 25) as moist skin increases this risk. Continue prescribed antipyretics and cooling measures

Two major strategies can be used to manage elevated body temperature:

• Antipyretic medication, e.g. paracetamol, ibuprofen, aspirin (not used for children under the age of 16 years because of the potential risk of Reye syndrome, see Ch. 23) that reduce BCT

• Cooling interventions. The rationales to support cooling strategies are presented in Table 14.2. However, cooling patients remains an area of nursing practice that is ritualistic and lacking in conclusive evidence.

Table 14.2

Advantages and disadvantages of cooling interventions

Cooling intervention	Advantages	Disadvantages
Fanning – rotary mobile fans blowing over body surface, using a variety of speeds	Perceived patient comfort Convenient Cheap	Shivering and vasoconstriction Spread of airborne microorganisms No evidence to support use in ill patients
Cool water bathing – sponging with cloths soaked in either ice-cool water or tepid water	No shivering Reduction in BCT	Time consuming Discomfort and vasoconstriction with iced cloths
Ice cooling – ice packs applied to areas where major arteries are near the skin surface, e.g. axillae, groins, neck	Surface cooling on area surrounding pack Rapid cooling	Vasoconstriction, which limits heat transfer from core to the skin causing heat conservation
Cooling blankets/mattresses – can be water filled and placed under patient, or air filled and put over patient Temperature controlled thermostat	Rate of fever reduction faster than traditional methods Control over temperature setting	Expensive to buy or rent Uncomfortable, so generally only used on comatose patients No more effective than traditional methods

Aggressive forms of cooling such as the use of cooling mattresses or covering the whole body with ice are sometimes required for patients who develop temperatures above 41°C as this may cause serious and sometimes fatal consequences.

Prolonged exposure to hot sunlight or high environmental temperatures can result in the development of a serious condition known as heatstroke where measured BCT can be as high as 45°C. People at risk include:

• Those exercising or engaging in strenuous activity in high environmental temperatures, especially when combined with high humidity

• Children

• Older adults

• Those with co-existing heart disease or metabolic disturbances, e.g. diabetes or hypothyroidism

• Those taking recreational drugs such as Ecstasy, alcohol or medications such as diuretics (see Ch. 22) that may impair heat loss mechanisms.

Recognition of heatstroke and the necessary interventions are shown in Box 14.14.

Box 14.14    First aid

Heatstroke

Recognition

Usually there is sudden onset of some or all of the following signs and symptoms:

• Hot dry skin

• Flushed skin

• Headache

• Excessive thirst

• Nausea

• Numbness, tingling, muscle cramps

• Dizziness

• Restlessness

• Mental confusion.

Observations

• Temperature above 40°C

• Tachypnoea (increased respiratory rate)

• Tachycardia (pulse rate >100 b.p.m. in an adult).

Aims of treatment

• To recognize the presence of heatstroke

• To remove the cause

• To reduce body temperature

• To transfer the casualty to hospital.

Treatment

• Remove the source of heat – move casualty into shade or out of the sun

• Lie casualty down and provide reassurance

• Loosen clothing and remove any items of unnecessary clothing if possible

• Sponge with cool water

• Dial 999 (or 112) for an ambulance

• Check and record respiratory rate, pulse rate and level of response.

Caring for patients with hypothermia

Hypothermia is present when BCT is below 35°C. It is described as mild, moderate, severe or profound and can be fatal if untreated. Hypothermia usually occurs accidentally as a result of exposure to low environmental temperatures and people at the extremes of age are the most vulnerable. Awareness of and providing interventions that will minimize the risk factors for hypothermia can often prevent its occurrence. Risk factors in infants, adults and older adults are outlined in Box 14.15.

Box 14.15   Risk factors for hypothermia

Infants

• A large surface area in relation to body weight. As the skin is a heat exchanger, heat loss is relatively high

• Their inability to put on more clothes or turn the heating up when feeling cold.

Adults

• Cold environmental conditions such as when hillwalking or skiing, especially when not wearing appropriate clothing, and water sports accidents, which result in immersion in cold water that leads to very rapid heat loss

• Excessive alcohol consumption and drug misuse both cause vasodilatation and impair perception of the cold. As a result, people may become inadvertently exposed for prolonged periods.

Older adults

• Impaired ability to control body temperature

• A reduction in temperature sensor (thermoreceptor) effectiveness

• Poor nutrition due to loss of appetite or physical constraints that make it difficult to cook; a low dietary energy intake will reduce heat production

• Loss of the shivering reflex

• Environmental factors such as living in a cold house with little money for heating.

Hypothermia can also occur in hospital. For example, some anaesthetic drugs lower BCT, as do some interventions, e.g. infusing large volumes of unwarmed fluids or irrigating body cavities with cool fluids in theatre. It is therefore important that temperature is carefully assessed and monitored postoperatively (see Ch. 24).

Restoring low BCT to normal requires careful management. The following parameters should be assessed: blood pressure (see p. 327); heart rate (see p. 325); respirations (see p. 330); oxygen saturation (see Ch. 17); temperature (which should be measured using a tympanic thermometer, see p. 323, or an internal probe) and urine output.

Management involves warming, which can be active or passive depending on the severity of hypothermia; however, it is dangerous to rewarm a patient too quickly. In mild hypothermia, the aim is to increase BCT by 1–2°C per hour and this can be achieved by: closing windows and doors; leaving clothing on if the room is cold, but taking off any wet clothes and wrapping the person in blankets. Other strategies include: wearing a hat to minimize heat loss through the head; particularly for babies and young children, blowing warm air over the body and warming intravenous fluids in moderate and severe hypothermia.

Body temperature assessment tools

Estimation of body core or peripheral temperature can be made at different sites using a variety of instruments, which include tympanic membrane probes, electronic thermometers and disposable chemical dot thermometers.

Each device has advantages and limitations (see Table 14.3) and therefore individual needs must be assessed. Should intervention to manage abnormal body temperature be required, it is necessary to select a thermometer that can be used to make frequent or continuous measurements. This must be accurate and reliable at the top and bottom of the scale, and be appropriate for the person's age and individual needs.

Table 14.3

Sites and thermometers – a comparison

Thermometer	Site used	Advantages	Limitations
Electronic thermometer probes	Oral cavity, axilla Rectum	Easy access Good blood supply Well insulated from external environmental influences on temperature	Does not correlate with tympanic or pulmonary artery temperature Not recommended for use with newborns or children
Tympanic membrane thermometer	Auditory canal	Good blood supply Fast measurement (<5 seconds) Easy to use Accurate and reliable	Expensive Ambient temperature may influence temperature within auditory canal Use without specific training may cause unreliability of measurement Poor correlation with oral electronic thermometry Earwax, blood, foreign bodies and other matter in the canal lower the temperature reading so use is precluded in patients who have recently had ear or neurosurgery Hearing aids must be removed before measurement is carried out
Chemical dot thermometers	Oral cavity, axilla, forehead	Ease of access Disposable – reduces cross-infection Low cost	Lacks sensitivity in measuring elevated body temperature Underestimates oral temperature, overestimates axillary temperature Some require 3-minute placement time

Electronic thermometers

The electronic thermometer (Fig. 14.6) is a battery-operated device that displays a digital readout of the temperature measured during a preset recording time, usually between 20 and 50 seconds. Attached to the device by a cable is a probe, which is most commonly placed in the mouth, axilla or rectum. Protecting rigid probes with a plastic disposable cover and cleaning them between each use prevents cross-infection.

However, the device requires regular calibration, and the site used to measure temperature influences reliability. For example, the axillary placement is affected by environmental temperature and the oral placement depends on its position within the mouth and the cooperation of the patient.

Tympanic thermometers

Tympanic thermometers measure temperature at the tympanic membrane (eardrum). Because the tympanic membrane is in close proximity to the hypothalamus, measurement here accurately reflects the BCT. The tip of the instrument contains a probe, protected by a disposable sheath, which is placed into the ear. Some manufacturers recommend that the pinna is pulled upward and back for an adult and down and back for a child. This action straightens the external ear canal, creates a seal from external air temperature and facilitates correct insertion of the probe (Fig. 14.7).

The probe detects heat emitted from the tympanic membrane in the form of infrared energy. The resulting signal is processed and displayed as a digital readout. Temperature is measured and displayed within 3 seconds of activation and the instrument bleeps on completion. The tympanic thermometer measures body temperature accurately between 25° and 43°C.

Tympanic thermometers are widely used in healthcare settings, because they are convenient, easy and quick to use, and reliable. Their limitations are summarized in Table 14.3.

Single-use thermometers

Single-use thermometers, such as chemical dots, are convenient, easy to use, non-invasive and also disposable. The thermometer consists of a plastic strip, with a series of chemically impregnated paper dots, which is placed in the oral cavity or the axilla. The dots change colour with heat. The final reading can usually be taken in up to 3 minutes, depending on the manufacturer's instructions. Their limitations are summarized in Table 14.3.

Glass-and-mercury thermometers

These were used for many years, however risks to health from mercury toxicity and dealing with spillages in healthcare settings means these are now seldom used in healthcare settings.

Thermometer placement sites

Temperature varies widely throughout the body (see Fig. 14.5, p. 320) and it is therefore important to remember that, if a temperature trend is required, the same site is used for each measurement. As a result of site variation of temperature, it is erroneous to believe that one location is more accurate than another. For example, BCT measured at the pulmonary artery is usually higher than the oral or axillary sites because the mouth and skin are exposed to the cooling influences of ambient temperature. In contrast, BCT will be lower than that found in the rectum due to the heat generated from metabolic activity of microorganisms in the rectum. Commonly used sites for measuring body temperature include the oral cavity, the tympanic membrane, the axilla and the rectum, which are discussed below. Measurement of blood temperature within the pulmonary artery is considered to be the most accurate reflection of BCT – the ‘gold standard’. This is because blood returning from major organs to the heart reflects the average temperature of the major internal organs. However, measuring pulmonary artery blood temperature is an invasive technique that is confined to critical care areas as are other sites including the pharynx, oesophagus and bladder.

Oral cavity

The thermometer is placed in the sublingual pocket at the junction with the tongue, which is close to the sublingual artery and therefore equates well with BCT. This site may not be suitable for young children who are at risk from biting the probe, especially if they are afraid and/or uncooperative.

Tympanic membrane

The probe is placed in the auditory canal and can be used for adults or children (Fig. 14.7).

Axilla

An electronic or chemical dot thermometer is placed under the axilla and the arm holds it in place. This site can be used for adults, infants and children. In children, the arm is held gently against the body to keep the thermometer in place.

Rectum

The rectum can be used for adults, although it is not commonly used in children in the UK. It is never used in newborns because of the risk of rectal perforation. If a non-disposable temperature probe is used, a disposable sheath is applied and discarded after use. The thermometer is cleaned according to local policy before and after use.

Skin

A disposable probe attached to the skin surface can be used for adults or children.

Interpreting temperature measurements

The temperature measured should be recorded. In hospitals, this is usually on a clinical observation chart (see Fig. 14.14). Measuring and recording the temperature onto the chart, either every few hours (1–4 hourly) or daily, will reveal a trend for body temperature. If body temperature is elevated above the normal range, then cooling interventions can be initiated (see p. 321). Recording the body temperature every few hours while a patient is being cooled will demonstrate whether the strategy is lowering the temperature effectively. The temperature reading should be entered on the clinical observation chart and also contributes to the Early Warning Score (see Fig. 14.14, p. 333).

Pulse

Nurses frequently perform assessment of the pulse, which is the rhythmic expansion and relaxation of an artery caused by ejection of blood from the left ventricle when it contracts. Knowledge of the rate, volume and rhythm produces information that assists in assessment and evaluation of health status or response to interventions. This section outlines anatomy and physiology of the pulse and explains how it is assessed.

Principal pulse points

The pressure wave, or ‘pulse’, of blood travelling along some arteries can be felt using the fingers at points of the body, where an artery lies close to a bone (Fig. 14.8). This is the ‘peripheral’ pulse, and it can be assessed by palpation (gentle compression of an artery using the fingers, against a bone). The most commonly used site is the radial artery at the wrist (Fig. 14.9).

The carotid arteries are located in the neck at each side of the larynx (see Fig. 14.8). They supply blood to the brain and are easily accessible. This is sometimes referred to as a central pulse. However, only light pressure should be applied to one artery at a time, in case the blood supply to the brain is restricted. During cardiopulmonary resuscitation, the carotid artery is palpated by trained healthcare practitioners to detect the return of a pulse (see Ch. 17).

The femoral artery may be used to assess the pulse, especially when the blood pressure is low as peripheral pulses in the arm and lower leg can be difficult to palpate. Peripheral vascular disease restricts blood flow to the lower limbs and it may be necessary to establish the presence of pulses in the legs to confirm blood flow to the extremities. The popliteal, posterior tibial and dorsalis pedis (also known as ‘pedal’) pulse sites are used to assess whether circulation is present in specific parts of the leg and foot. The popliteal pulse can be difficult to palpate and considerable practice may be required to master this.

Normal pulse rate

The rhythmic pulsation of blood in the arterial system is counted and recorded as the pulse rate (Box 14.16) and normally represents the rate at which the heart beats, i.e. the heart rate. The normal resting rate in adults is between 60 and 100 beats per minute (b.p.m.). In adults, tachycardia is the term given to pulse rates greater than 100 b.p.m.; bradycardia describes a pulse rate below 60 b.p.m.

Box 14.16    Nursing skills

Taking the pulse

Equipment

• Watch with second hand

• Observation chart.

Preparation

• Explain the procedure and seek verbal consent; maintain respect and dignity at all times

• The person should be lying or sitting down. Allow the person to rest for 30 minutes after physical activity, emotional upset or smoking

• Wash hands as per local policy.

Procedure

• Select the pulse site

• Apply pressure gently but firmly with flat fingers until the pulse is palpated

• Count the number of beats for 1 minute using a watch with a second hand. If a regular rhythm is noted, the pulse can be counted for 30 seconds and the number of beats is doubled

• Note further characteristics of the pulse:

• rhythm (regular or irregular)

• force or volume

• If the respiratory rate is to be measured, this is usually carried out discreetly while recording the pulse (see Fig. 14.13)

• Wash hands according to local policy

• Record pulse rate on the observation chart (see Fig. 14.14)

• Report and document any changes/abnormalities.

This important skill forms part of Essential Skills Cluster 9 (NMC 2010b).

Factors that affect heart rate

The pulse rate varies depending on the degree of activity within the autonomic nervous system. Stimulation of the sympathetic nervous system and the release of adrenaline increase heart rate, whereas parasympathetic activity decreases it. Due to their higher metabolic rate, children have a faster pulse rate than adults (see Table 14.4).

Table 14.4

Pulse rates for children

Age (years)	Pulse rate (b.p.m.)
0–1	110–160
1–2	100–150
2–5	95–140
5–12	80–120
Over 12	60–100

(Reproduced with permission from Mackway-Jones, K., Molyneux, E., Phillips, B., et al. (Eds.), 2005. Paediatric life support: the practical approach, fourth ed. BMJ Books/Blackwell, Oxford.)

Stressors such as pain, fear and anger increase the pulse rate as they increase sympathetic activity. The rate also increases with exercise and pyrexia, and may alter due to the effects of medications and some diseases such as those involving the heart, lungs or blood (see Ch. 17). Medication such as digoxin is given to patients with heart failure, to improve myocardial contraction and reduce the heart rate. Salbutamol, used to control the symptoms of asthma, can cause tachycardia.

Assessing the pulse

The radial pulse can be found at the inner aspect of the wrist below the base of the thumb and medial to the radius, or wrist bone. It is palpated by placing two fingers, usually the index and third, and applying gentle pressure on the radial artery (see Fig. 14.9). Measuring the pulse is described in Box 14.16. The regularity and strength are also assessed (see below). Radial, popliteal and pedal pulses may be difficult to locate in adults who are cold or when the environment is cold and those with:

• Peripheral vascular disease, which impairs peripheral circulation

• Low blood pressure (hypotension, see Ch. 17)

• Cardiac arrhythmias (see Ch. 17)

• Peripheral oedema (see Chs 17, 19).

Regularity

When counting the pulse rate, the regularity is also noted, as this reflects the cardiac rhythm. Normally the rhythm is regular as the heart contracts regularly. However, young people may have a rhythm disturbance, known as sinus arrhythmia, which alters with inspiration and expiration. People who have heart disease may have an irregular rhythm due to disordered electrical conduction within the heart, e.g. atrial fibrillation (see Ch. 17). Heart irregularities can be investigated through an electrocardiogram (ECG) (see Ch. 17) and an irregular rhythm should always be reported immediately.

Volume

The force of the pulse is also assessed. The terms used to describe force or volume are:

• Normal – the pulse is easy to feel

• Bounding – pulse feels ‘springy’ due to an increase in force of cardiac contraction or circulating blood volume; usually found in the presence of infection

• Thready – pulse feels weak, difficult to palpate and difficult to count, which may be due to dehydration or haemorrhage

• Absent – indicates a blockage of the palpated artery or, together with other observations such as skin colour, cardiac arrest.

Factors that influence the force of the pulse include the circulating blood volume and the action of hormones on blood vessel walls causing vasoconstriction or vasodilatation.

The pulse reading is recorded on the clinical observation chart and contributes to the Early Warning Score (see Fig. 14.14, p. 333).

Features of the pulse in newborns, infants and children

Pulse rates in children vary with age; normal ranges are shown in Table 14.4. The pulse can be palpated over the radial, brachial or femoral artery. The pulse rate should be assessed while a baby or child is asleep or at rest as crying, eating or sucking increase heart rate.

Apical pulse

The apical pulse is a central measurement, which is the most common method of recording heart rate in infants and young children and also in adults who may have heart disease with rhythm disturbances. The apical (apex) beat is located at the apex of the heart. Measurement of the apex/radial pulse in adults is explained in Chapter 17.

The apical pulse is detected using a stethoscope and listening to heart sounds at the apex of the heart (the pointed end of the ventricle). In children, placement of the stethoscope is dependent on age. The stethoscope is placed:

• At the 4th intercostal space inside the nipple in children under 5 years of age

• At the 5th intercostal space at or inside the nipple for children over 5 years old (Trigg & Mohammed 2010).

Blood pressure

This section outlines what blood pressure (BP) is and the factors that affect it in health; for more detail you should consult your physiology textbook. The equipment needed and how to measure BP are explained. It is important to be familiar with the early material in this section before attempting to practise BP measurement.

BP corresponds to the pressure exerted on arterial walls as blood moves through them. BP measurements provide information about cardiovascular status, which can assist in the diagnosis of disease or evaluation of treatment. Two measurements are made and usually recorded in millimetres of mercury (mmHg):

• Systolic pressure, which represents the greatest pressure in the main arteries following contraction of the left ventricle

• Diastolic pressure, which is the lowest pressure in the main arteries and occurs at the end of ventricular relaxation while the heart is at rest, before the next cardiac contraction.

The convention for writing blood pressure is to put the systolic pressure first and then the diastolic, e.g. 120/70 mmHg.

Factors that determine blood pressure

BP is determined by several factors including the cardiac output, venous return, blood volume, peripheral vascular resistance (the resistance within arteries and arterioles) and elasticity of large arteries. BP is dynamic, and so varies over the course of the day depending on body demands. For more detail about factors that determine BP and its control, you should consult your physiology textbook.

Blood pressure values

Adult BP is normally in the range of 100–130 mmHg systolic and 60–90 mmHg diastolic. The National Clinical Guideline Centre (NCGC) recommends that optimal BP should be <120/<80 (NCGC 2011). Table 14.5 shows normal BP values for children.

Table 14.5

Normal BP values for children

Age (years)	Blood Pressure (mmHg)
	Systolic	Diastolic
0–2	95	55
3–6	100	65
7–10	105	70
11–15	115	70

(Reproduced with permission from Hull, D., Johnston, D.I., 1999. Essential paediatrics, fourth ed. Churchill Livingstone, Edinburgh.)

Hypertension (high blood pressure) is defined as systolic blood pressure >140 mmHg or diastolic blood pressure >90 mmHg. The NCGC (2011) recommends that hypertension should be confirmed using 24-hour ambulatory blood pressure monitoring (ABPM) rather than being solely based on measurements taken in the clinic; the use of ABPM is predicted to be more cost-effective for the NHS. Guidance is also provided for home blood pressure monitoring (HBPM) which empowers people to become more involved in the monitoring and management of their hypertension (NCGC 2011).

Hypotension describes BP lower than the normal range of 100 mmHg systolic and/or 60 mmHg diastolic. Hypertension and hypotension are explored further in Chapter 17.

Equipment used for BP measurement

BP is usually measured by non-invasive means, using either the auscultatory or electronic method. The equipment required includes a sphygmomanometer, which may be aneroid or electronic, and an appropriately sized cuff (Table 14.6). BP is sometimes continuously monitored through the invasive method using a catheter inserted into an artery, a technique beyond the scope of this book that is confined to the care of critically ill people.

Table 14.6

Estimated BP cuff sizes

Indication	Width (cm)	Length (cm)	BHS guidelines: bladder width and length (cm)	Arm/leg circumference (cm)
Small adult/child	10–12	18–24	12 × 18	<23
Standard adult	12–13	23–35	12 × 26	<33
Large adult	12–16	35–40	12 × 40	<50
Adult thigh cuff	20	42		<53

(Reproduced with permission from British Hypertension Society, 2011. How to measure blood pressure. Online. Available: www.bhsoc.org September 2011.)

Sphygmomanometers

Mercury sphygmomanometers were used for many years; however, health and safety concerns regarding the use and disposal of mercury in the workplace have emerged and therefore these may no longer be in use in practice. Increasingly common methods of BP measurement are the use of aneroid or electronic sphygmomanometers (Fig. 14.10).

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Aneroid sphygmomanometers are less bulky and more portable than other types. They do not use mercury and are a safe alternative that has quickly gained acceptance. However, they have been found to be less reliable as they often underestimate BP. These are not recommended for use in hospitals because they rapidly deteriorate due to high usage and also need frequent calibration to ensure their accuracy (NCGC 2011).

Electronic sphygmomanometers include a pressure sensor within the cuff that registers the systolic and diastolic pressures, which are then displayed digitally. The advantages of these machines are that they require little instruction, eliminate observer bias, and can also display heart rate, mean BP, and the time and date, simultaneously. However, they are often very sensitive to movement and can still be inaccurate in patients with irregular heart rhythms such as atrial fibrillation. No stethoscope is needed and therefore this is not an auscultatory method of BP measurement.

BP measurements may be influenced by a range of factors and all forms of non-invasive BP monitoring have limitations (Box 14.17).

Box 14.17    Critical thinking

How reliable is non-invasive BP measurement?

BP is often recorded on a single occasion and one-off readings do not necessarily reveal trends of a person's BP.

• Variability over the day: BP varies over the course of a day in order to meet different requirements such as exercise and other activities, e.g. eating, sleeping, smoking.

• White coat syndrome: This is an increase in BP ascribed to anxiety or anticipation of BP measurement by healthcare professionals.

• Postural hypotension: This is a drop in BP that occurs when standing up from a lying position. It is fairly common in older adults and people receiving antihypertensive medication. In this situation, BP should be measured in both lying and standing positions.

• Arrhythmias: Irregular heart rhythms may result in variations in the sounds heard from beat to beat as well as differences in the time between each beat. As a consequence, recordings made using the auscultatory method can be inaccurate.

• Pregnancy: BP is monitored closely during pregnancy as hypertension can have serious consequences. In addition, BP can fall when lying supine if the fetus obstructs the inferior vena cava, reducing venous return.

• Observer error: The wrong technique or faulty equipment can lead to inaccurate readings.

Student activities

1. Access the National Clinical Guideline Centre and read Clinical Guideline 127 and identify some of the factors that contribute towards a loss of accuracy when measuring BP.

2. BP equipment is frequently used in placements and needs regular checks to ensure that measurements will be accurate. In your placement:

• Identify the type(s) of sphygmomanometer used.

• Find out how often they are calibrated and how this is carried out.

• Identify the different sizes of BP cuffs available and whether they are suitable for use with all the patients/clients there (see Table 14.6).

• Find out when and how they are cleaned.

• Examine the cuffs for signs of wear and tear. If they are in need of repair, discuss the further actions required with your mentor.

Resource

National Clinical Guideline Centre. Hypertension: Clinical management of primary hypertension in adults. Online. Available www.nice.org.uk/nicemedia/live/13561/56007/56007.pdf, 2011. [September 2012].

BP cuffs

Some BP cuffs are supplied in two separate parts: the cover (or sheath) and an inner inflatable bladder. Both components should be inspected before use. The cuff should be clean and intact. The tubing attached to both the sphygmomanometer and the inflation bulb should also be intact with no leaks or signs of perishing.

It is important to use the correct size of BP cuff, irrespective of the type of sphygmomanometer used (see Table 14.6). The bladder within the cuff should encircle at least 75–80%, but not more than 100%, of the upper arm. The width of the cuff should be more than 50% of the length of the upper arm. An underestimation of BP will be recorded if the cuff is too large; overestimation of BP will occur if the cuff is too small (NCGC 2011).

Measuring BP

The important points are explained here and BP measurement is outlined in Box 14.18. BP readings are entered on the clinical observation chart and contribute to the calculation of the Early Warning Score (see Fig. 14.14, p. 333).

Box 14.18    Nursing skills

Measurement of BP

Equipment

• A sphygmomanometer (see p. 328)

• An appropriately sized cuff (see Table 14.6)

• A stethoscope for auscultatory methods

• An observation chart (Fig. 14.14, p. 333) or medical/nursing notes.

Preparation

• Wash hands as per local policy

• BP measurement should be explained, including the feeling of ‘tightness’ in the arm, and verbal consent obtained; maintain respect and dignity at all times

• The person should be seated, lying supine for at least 5 minutes, or standing for 1 minute before the procedure begins. They should be relaxed and not moving or speaking

• The arm is supported at the level of the heart (mid sternum) and held straight but relaxed, ensuring that no tight clothing constricts the arm

• The cuff (see below) is applied:

• with the centre of the bladder marked on the cuff over the brachial artery (see Fig. 14.11)

• with the lower edge of cuff 2–3 cm above pulsation of the brachial artery

• in aneroid sphygmomanometers so that the tubing emerges ‘up the arm’ as movement of the tubing across the antecubital fossa can create artefactual sounds.

Measurement using an aneroid sphygmomanometer

• Estimate the systolic pressure beforehand by:

• palpating the brachial artery

• inflating the cuff using the bulb until pulsation disappears

• deflating cuff until pulsation is felt; the point at which pulsation appears is an estimate of the systolic pressure

• Then inflate the cuff to 30 mmHg above the systolic level, estimated earlier; at this point the brachial pulse will no longer be felt

• Place the diaphragm of the stethoscope over the brachial artery and slowly deflate the cuff at a rate of 2–3 mm/s until you hear regular tapping sounds – this is phase 1, the systolic pressure (see Fig. 14.12)

• Systolic pressure and diastolic pressure are recorded to the nearest 2 mmHg

• Measure diastolic pressure – phase 4 (see Fig. 14.12): abrupt muffling sounds become soft and blowing in quality just before the sounds disappear (phase 5) – this point is recorded as the diastolic pressure

• Completely deflate and remove the cuff to prevent any further compression of the limb

• It may be necessary to repeat the procedure for both lying and standing positions

• Clean the diaphragm of the stethoscope according to local policy

• Wash hands according to local policy

• Record the pressures heard as soon as possible after assessment, noting the position of the patient/client (lying, standing or sitting down) and the arm used. This may be on an observation chart (see Fig. 14.14, p. 333) or in the notes

• Report and document any changes/abnormalities.

Notes: NCGC (2011) recommends that pressures in both arms should be recorded on the first visit and that the arm with the highest BP should be used in subsequent measurements.

This important skill forms part of Essential Skills Cluster 9 (NMC 2010b).

Resources

British Hypertension Society. How to measure blood pressure. Online. Available www.bhsoc.org/resources/how-to-measure-blood-pressure/, 2011. [September 2012].

National Clinical Guideline Centre. Hypertension. Clinical management of primary hypertension in adults. Clinical Guideline. Online. Available www.nice.org.uk/nicemedia/live/13561/56007/56007.pdf, 2011. [September 2012].

Measuring BP in newborns, infants and children

Although BP may be measured less frequently in children than in adults, consideration must be given to the following:

• It is hard to auscultate the antecubital fossa pulse, so an electronic blood pressure machine should be used in babies and young children

• The lower edge of cuff should be close to the antecubital fossa

• BP should be recorded when a baby is asleep or resting. Crying, sucking and eating increase BP

• Allay any anxiety before measurement. Young children may feel more secure if BP is taken while sitting in a parent's lap.

Further information can be found in Trigg and Mohammed (2010).

Inflating the cuff

Inflation of the cuff compresses the brachial artery (see Fig. 14.11) and the cuff is inflated automatically when using an electronic sphygmomanometer. When an aneroid sphygmomanometer is used, the bladder inside the BP cuff is attached to an inflation bulb with a release valve, which allows the cuff to be inflated manually.

Korotkoff sounds

The auscultatory method relies on the detection of a series of sounds. When using an aneroid sphygmomanometer, a stethoscope with clean, well-fitting earpieces is required. Earpieces are placed in the ears pointing towards the nose. The diaphragm is placed on the brachial artery in the antecubital fossa (Fig. 14.11) to listen to sounds in the brachial artery. These are known as Korotkoff sounds, which are divided into five phases (Fig. 14.12). The first phase can be heard as a clear tapping noise via the stethoscope as the cuff is deflated. This is the systolic blood pressure and represents phase 1. Muffled whooshing noises are usually heard during phases 2 and 3. The sound becomes much more muffled and softer during phase 4 before it disappears at phase 5. The diastolic pressure is normally recorded at the end of phase 4. However, if the sounds continue until 0 mmHg, then the point at which the sounds change at phase 4 is recorded.

Assessing respirations

The accuracy and frequency of recording of respirations is very important. Respiratory rate recording has been shown to be a crucial indicator of serious deteriorations in health status. Decreases in the respiratory rate (<8 breaths/min) and depth have been noted in the hours preceding cardiopulmonary arrest. It has also been suggested that assessment of respiratory rate is not performed as accurately or as frequently as it should be. Additionally, there appears to be an over-reliance on the use of peripheral oxygen saturation monitors to determine respiratory function (Hogan 2006; NICE 2007). However, both respiratory rate and peripheral oxygen saturation are required to calculate the EWS. Analysing and assessing respiratory status requires the observation of several factors, which are outlined below.

At rest, breathing should be regular, effortless and quiet. However, exercise or breathing difficulties may alter the rate, depth, rhythm and/or sound of breathing. Rate and depth of respirations may also change as a result of pain, pyrexia, emotional states and body position, as well as breathing difficulties such as ‘shortness of breath’ (dyspnoea). They are also influenced by the use of drugs such as nicotine in cigarettes, and opioids, e.g. morphine (see Ch. 23), as well as cocaine and amphetamines. Assessment of respirations is described in Box 14.19.

Respiratory rate

Breathing occurs in cycles. The first phase is inspiration, which is followed by a short pause before expiration (see Ch. 17). The rate and depth of breathing are controlled by the respiratory centre located in the medulla oblongata. Blood levels of carbon dioxide (CO₂) and oxygen (O₂), as well as pH (acidity), are the main influences on respiratory rate. Chemoreceptors located in the brain stem, carotid arteries and the aortic arch monitor and respond to changes in the blood levels of CO₂, O₂ and pH. An increase in blood carbon dioxide levels (PaCO₂) and a fall in blood pH (increased acidity) activate the chemoreceptors that respond by increasing the respiratory rate, which increases the elimination of CO₂ and raises blood pH. Breathing can also be influenced by external factors such as pain, emotion or voluntary control. For more information about breathing and its control, you should consult your physiology textbook.

Counting respiratory rate in adults

Respiratory rate is the number of respirations per minute and is recorded as RR. In adults, the normal rate is 12–18 respirations/min. Tachypnoea describes a respiratory rate that exceeds 20/min; absence of breathing is known as apnoea. The respiratory rate is entered on the observation chart (see Fig. 14.14, p. 333) and its calculation into the Early Warning Score (EWS).

Counting respiratory rate in infants and small children

In babies under 12 months old, it is recommended that a stethoscope is used to listen to air movement in the lungs to count the breaths per minute. Average respiratory rates for children are shown in Table 14.7. The child should be relaxed and quiet before measurement is made by lightly placing a hand on their abdomen to count the breaths. If this is not possible, it may be necessary to observe breathing while the child is quietly interacting with a parent or playing.

Table 14.7

Children's average respiratory rates

Age (years)	Respirations per minute
Under 1	25–35
1–5	20–30
5–12	20–25
Over 12	15–25

(Reproduced with permission from Hull, D., Johnston, D.I., 1999. Essential paediatrics, fourth ed. Churchill Livingstone, Edinburgh.)

Respiratory rhythm

Breathing is usually regular in healthy adults. It may be described as regular or irregular and can be influenced, e.g. by emotions such as fear or crying and during breath-holding or panic attacks. Babies often have a less regular rhythm, possibly due to incomplete development of the normal respiratory control systems (see Ch. 17).

Abnormal respiratory rhythms

Alterations in rhythm can also be observed in patients with neurological dysfunction that has impaired the respiratory centre within the brain stem.

Damage or poor blood supply to the brain stem can result in an irregular rhythm and rate called Cheyne–Stokes breathing. In this condition, breathing patterns change between shallow and slow and deep and rapid, with varying periods of apnoea in between. This type of breathing is often present at the end-of-life.

Depth of breathing

The depth of a breath is determined by the volume of air inhaled. In healthy adults, during relaxed breathing, this is about 500 mL and is called the tidal volume. This and other indicators of respiratory status may also be measured by nurses, especially in people with chronic respiratory conditions such as chronic bronchitis and asthma (see Ch. 17).

The depth of breathing is described as normal, shallow or deep and is observed by watching the rise and fall of the chest wall. These are, however, subjective observations and so open to interpretation. Expansion of both sides of the chest should be the same, i.e. ‘equal’.

The term hypoventilation is used to describe shallow slow breathing, which implies limited chest movement. Hyperventilation is used to describe fast and deep breathing, and considerable movement of chest wall may be observed.

Deep, regular breaths may be ‘Kussmaul’ respirations, caused by an increase in blood acidity (low blood pH). This can arise as a result of uncontrolled diabetes.

Effort of breathing

Normally, at rest, breathing is regular, effortless and quiet. During exercise, the breathing pattern becomes more active as body oxygen demand rises and blood carbon dioxide levels increase (hypercapnia). Exercise requires the movement of more air into and out of the lungs, more quickly and forcibly, and also employs the accessory muscles of respiration, i.e. the internal intercostal muscles and the muscles in the neck and shoulders. Forced expiration is facilitated by the abdominal muscles contracting and pushing the diaphragm upwards. Expiration is no longer passive, but becomes forced.

Noises associated with breathing

Although breathing is normally quiet, alterations to breathing patterns can also include changes to the sound of breathing. Whistling noises called wheezing due to constriction of the airways can be heard on expiration in people with chronic lung disease such as bronchitis or asthma. Obstruction of the larynx results in high-pitched noises during inspiration, which are termed stridor.

Children experiencing breathing difficulties can also develop associated vocal noises such as grunting, wheezing and stridor. In addition, they may hold themselves rigidly, have a retracted neck and nasal flaring (Trigg & Mohammed 2010).

Early Warning Score (EWS)

For patients who are acutely ill and at risk of developing a critical illness, vital sign recordings should be entered onto an EWS, Modified Early Warning Score (MEWS) or Track and Trigger chart. Those who are at high risk of deterioration include all patients admitted as an emergency, have a chronic health problem, have had surgery and those whose condition may be causing concern or is unstable. However, NICE (2007) recommends that all acute hospital in-patients should have their vital signs recorded and monitored via a track and trigger system. The Royal College of Physicians (2012) has advocated using a standardized NHS National Early Warning Score (NEWS) chart within a year.

The respiratory rate, pulse, systolic blood pressure and body temperature are entered on the EWS chart and awarded a score. Additional information that is scored and required for an EWS includes the patient's hourly urine volumes (see Ch. 20), the Glasgow Coma Score (GCS) or Level of response (AVPU) (see Ch. 16) and the oxygen saturation percentage (SpO₂) (see Ch. 17). The score is calculated by rating each parameter and recording it on the EWS chart (Fig 14.14).

Calling criteria

Once the EWS score is calculated, the assessor is directed towards making a decision about what to do next. This might be to:

• Increase the frequency of patient observations, monitor trends and inform the nurse in charge

• Communicate the results to a senior nurse if the score is 3 in any one category

• Contact the critical care outreach team and the senior nurse to assist in managing the patient's condition if the score is 4 or above or increasing by 2 or more or the GCS falls by 2 or more or if the patient's condition is a cause for concern (NICE 2007).

Height and weight

Measurement of height and weight should be made on admission to hospital or as part of a community assessment. Extremes of weight are associated with health risks. Body mass index (BMI, see Ch. 19) is a useful guide to whether an adult's body weight is appropriate for their height. Knowledge of people's height and weight is needed to calculate drug doses, including anaesthetics, and fluid and nutritional requirements, especially in children.

Children may also be regularly weighed and measured to monitor growth rates and weight gain, which are important in monitoring their health and development. In the UK, children's weight and height should be recorded on the appropriate centile chart produced by the Royal College of Paediatrics and Child Health (2009).

Measuring body weight requires the use of electronic calibrated scales and is recorded in kilograms (kg). A child under the age of 2 should have all clothing removed and placed on scales. Children over 2 years old should have underwear on and asked to sit or lie or stand on the scales.

If serial measurements are made, this should be at the same time each day or week and in similar clothing. Daily weight may be recorded to assess, e.g. fluid loss in response to diuretic drugs. When weight loss is a goal, e.g. in obesity, weight may be monitored weekly.

Children are measured to the nearest centimetre and metres are used for adults; e.g. 65 cm for a child and 1.65 m (165 cm) for an adult.

A fixed measure is used for adults and children over the age of 2 years, standing with the back against a wall or scale. The head should be in the midline and the heels, buttocks and backs of shoulders should touch the wall. A moveable rod is placed on the top of the head, to assist in reading the measurement. For children under 24 months, length is measured instead of height. The child is placed on their back and their head is gently held in the midline. The knees should be held and pushed down until the legs are flat on the table and the child's body is extended (Fig. 14.15). Length, in centimetres (cm), is measured using a measuring tape. In children, the circumference of the head, chest and abdomen may also be measured.

Key words and phrases for literature searching

Assessment tool

Early Warning Score

Blood pressure

Body core temperature

Holistic assessment

Hypothermia

Nursing history

Nursing model

Nursing process

Person-centred care

Pulse

Pyrexia

Respiratory rate

Sphygmomanometer

Tachycardia

Thermometry