Background: Nurses have the highest level of responsibility for vital sign assessment, so recognition and response to deteriorating patients is highly dependent on the accuracy of nurses’ patient assessment, data interpretation, and escalation of care when deterioration is identified
Aim: To explore the published research related to nurses’ documentation and use of vital signs in recognising and responding to deteriorating patients.
Methods: This scoping review of international, peer-reviewed research studies is reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. Cumulative Index to Nursing and Allied Health Literature (CINAHL)Complete, Medline Complete, American Psychological Association PsycInfo, and Excerpta Medica were searched on 25 July 2023.
Results: Of 3880 potentially eligible publications, 32 were included. There were 26 studies of nurses’ vital sign documentation: 21 adults and 5 paediatric. The most and least frequently documented vital signs were blood pressure and respiratory rate respectively. Seven studies focused on vital signs and rapid response activation or afferent limb failure. Five studies of vital signs used to trigger the rapid response system showed heart rate was the most frequent, and respiratory rate and conscious state were the least frequent. Heart rate was least likely and oxygen saturation was most likely to be associated with afferent limb failure (n=4 studies).
Conclusions: Nurses’ documentation of vital signs and use of vital signs to activate rapid response systems is poorly understood. A deeper understanding of nurses’ decisions to assess (or not assess) specific vital signs, analysis of the importance nurses place (or not) on specific vital sign parameters is warranted. The influence of patient characteristics (such as age) or the clinical practice setting, and the impact of nurses’ workflows of vital sign assessment warrants further investigation.