Considine Julie, Trotter Carissa, Currey Judy
Deakin University, Eastern Health - Deakin University Nursing & Midwifery Research Centre, Box Hill, Vic, Australia.
School of Nursing and Midwifery, Burwood, Vic, Australia.
J Clin Nurs. 2016 Jan;25(1-2):134-43. doi: 10.1111/jocn.13010. Epub 2015 Sep 30.
To explore nurses' documentation of physiological observations in acute care; emergency department, medical and surgical units.
In Australia, physiological observations include respiratory rate, oxygen saturation, heart rate, blood pressure, temperature and level of consciousness. There is a clear relationship between abnormal physiological observations and adverse events. Nurses have highest level of responsibility for accurate measurement, interpretation and documentation of physiological observations.
A descriptive exploratory design was used and the study data were collected using a prospective point prevalence approach between 25 July 2012-22 August 2012.
The study was conducted in the emergency department, two 30-bed medical units and one 30-bed surgical unit of a 578 bed public health service in Melbourne, Australia. All adult patients aged ≥18 years present during data collection periods were eligible for inclusion. Patients in the emergency department resuscitation area were excluded. Patient characteristics and physiological observations for the preceding 24 hours in ward patients or eight hours in emergency department patients were collected.
One hundred and seventy-eight patients were included; 38 emergency department patients, 84 medical patients and 56 surgical patients. The median age was 72·5 years and 43·8% were males. The most frequently documented physiological observations were respiratory rate, oxygen saturation, heart rate and systolic blood pressure. The least frequently recorded physiological observations were temperature and conscious state. One or more abnormal physiological parameters was documented in 79·8% (n = 142) patients; evidence of reporting abnormalities was documented in 19·7% of patients (n = 28/142). When controlled for length of stay, physiological observations were more frequently documented in the emergency department.
There was variability in the number of parameters documented and frequency of physiological observations documented by nurses.
Physiological abnormalities that do not necessarily fulfil rapid response team activation criteria are common in acute care patients and provide nurses with an opportunity for early recognition of deteriorating patients.
探讨护士在急性护理环境（急诊科、内科和外科病房）中对生理观察指标的记录情况。
在澳大利亚，生理观察指标包括呼吸频率、血氧饱和度、心率、血压、体温和意识水平。生理观察指标异常与不良事件之间存在明确关联。护士对生理观察指标的准确测量、解读和记录负有最高责任。
采用描述性探索性设计，研究数据于2012年7月25日至2012年8月22日期间通过前瞻性时点患病率法收集。
该研究在澳大利亚墨尔本一家拥有578张床位的公共卫生服务机构的急诊科、两个拥有30张床位的内科病房和一个拥有30张床位的外科病房进行。所有在数据收集期间就诊的年龄≥18岁的成年患者均符合纳入标准。急诊科复苏区的患者被排除。收集了病房患者前24小时或急诊科患者8小时内的患者特征和生理观察指标。
共纳入178例患者，其中急诊科患者38例，内科患者84例，外科患者56例。中位年龄为72.5岁，男性占43.8%。记录最频繁的生理观察指标是呼吸频率、血氧饱和度、心率和收缩压。记录最少的生理观察指标是体温和意识状态。79.8%（n = 142）的患者记录了一个或多个异常生理参数；19.7%的患者（n = 28/142）有报告异常的记录。在控制住院时间后，急诊科对生理观察指标的记录更为频繁。
护士记录的生理观察指标参数数量和记录频率存在差异。
在急性护理患者中，不一定符合快速反应团队启动标准的生理异常情况很常见，这为护士提供了早期识别病情恶化患者的机会。
