Alteration in vital signs and clinical outcome of patients admitted to an emergency unit
DOI:
https://doi.org/10.5902/2179769242559Keywords:
Registros de enfermagem, Cuidados de enfermagem, Sinais vitais, Serviço hospitalar de emergência, EmergênciasAbstract
Objective: to describe the characteristics of the nursing records, including the vital signs, and to compare the patient’s clinical outcome according to the presence of alterations in the vital signs in the emergency setting. Method: a cross-sectional study, with retrospective analysis of patient records of adult individuals admitted in May 2018 in an Emergency Room of São Paulo. The data collected from the nursing records were inserted in the REDCap® system and descriptive and inferential analyses were carried out. Results: of the 194 patient records (54.1% male, mean age of 59.7 years old), the complaints at admission, comorbidities and first care measures carried out in the emergency room were the most written down records. Heart and respiratory rates and blood pressure were the most altered and death-associated vital signs. Conclusion: the clarity and frequency of the nursing records, as well as the correct interpretation of the vital signs, are essential components for the safety of the care provided to the emergency patient.Downloads
References
Araujo MM, Diniz SOS, Silva PS. Registros de Enfermagem: reflexões sobre o cotidiano do cuidar. ABCS Health Sci. 2017;42(3):161-5. doi: 10.7322/abcshs.v42i3.920
Paese F, Sassol GTMD, Collal GW. Metodologia de estruturação do processo de Enfermagem informatizado para as Unidades de Emergência. Rev Bras Enferm. 2018;71(3):1079-84. doi: 10.1590/0034-7167-2016-0619
BRASIL. Conselho Federal de Enfermagem. Resolução Cofen Nº 0514/2016. Brasília, DF: Conselho Federal de Enfermagem, 2016. Disponível em: http://www.cofen.gov.br/resolucao-cofen-no-05142016_41295.html. Acesso em: 20 fev. 2019.
Caldeira MM, Souza TV, Morais RCM, Moraes JRMM, Nascimento LCN, Oliveira ICS. Anotações da equipe de enfermagem: a (des)valorização do cuidado pelas informações fornecidas. Rev Pesq Cuid Fundam. 2019;11(1):135-41. doi: 10.9789/2175-5361.2019.vllil.135-141
Aquino MJN, Cavalcante TMC, Abreu RNDC, Scopacasa LF, Negreiros FDS. Anotação de enfermagem: avaliação da qualidade em uma unidade de terapia intensiva. Enferm Foco. 2018;9(1): 07-12. Disponível em: http://revista.cofen.gov.br/index.php/enfermagem/article/view/1314/419
Johnson KD, Mueller L, Winkelman C. The nurse response to abnormal vital sign recording in the emergency department. J Clin Nurs. 2016;26:148-56. doi: 10.1111/jocn.13425
Considine J, Trotter C, Currey J. Nurse documentations of physiological observations in three acute care setting. J Clin Nurs. 2015;25:134-43. doi: 10.1111/jocn.13010
Alam N, Hobbelink EL, Van Tienhoven AJ, Van de Ven PM, Jansma EP, Nanayakkara PWB. The impact of the use of the Early Warning Score (EWS) on patient outcomes: a systematic review. Ressuscitation. 2014;85(5):587-94. doi: 10.1016/j.resuscitation.2014.01.013
Smith GB, Recio-Saucedo A, Griffiths P. The measurement frequency and completeness of vital signs in general hospital wards: an evidence free zone? Int J Nurs Stud. 2017;74:A1-4. doi: 10.1016/j.ijnurstu.2017.07.001
Hung SK, Ng CJ, Kuo CF, Goh ZNL, Huang LH, Li CH, et al. Comparison of the mortality in emergency department sepsis score, modified early warning score, rapid emergency medicine score and rapid acute physiology score for predicting the outcomes of adult splenic abscess patients in the emergency department. PLoS One. 2017;12(11):e0187495. doi: 10.1371/journal.pone.0187495
Gök RGY, Gök A, Bulut M. Assessing prognosis with modified early warning score, rapid emergency medicine score and worthing physiological scoring system in patients admitted to intensive care unit from emergency department. Int Emerg Nurs. 2019;43:9-14. doi: 10.1016/j.ienj.2018.06.002
Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap) - A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-81.
Barreto JA, Lima GG, Xavier CF. Inconsistência das anotações de enfermagem no processo de auditoria. R Enferm Cent Oeste Min. 2016;1(6):2081-93. doi: 10.19175/recom.v0i0.917
Lambe K, Currey J, Considine J. Frequency of vital sign assessment and clinical deterioration in an Australian emergency department. Australas Emerg Care. 2016;19(4):217-22. doi: 10.1016/j.aenj.2016.09.001
Goulden R, Hoyle MC, Monis J, Railton D, Riley V, Martin P, et al. qSOFA, SIRS and NEWS for predicting inhospital mortality and ICU admission in emergency admissions treated as sepsis. Emerg Med J. 2018;35(6):345-9. doi: 10.1136/emermed-2017-207120
Royal College of Physicians (UK). National Early Warning Score (NEWS) 2 [Internet]. 2017 [cited 2018 Nov 18]. Available from: https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2
Pittappilly M, Sarao MS, Bambach WL, Helmuth A, Nookala V. Vital signs on hospital discharge and re admission rates. QJM. 2019;112(4):275-9. doi: 10.1093/qjmed/hcz002
Lee M, Taylor DMcD, Ugoni A. The association between abnormal vital groups and undesirable patient outcome. Hong Kong J Emerg Med. 2018;25(3):37-45. doi: 10.1177/1024907917752959
Griffiths P, Ball J, Bloor K, Böhning D, Briggs J, Dall’Ora C, et al. Nurse staffing levels, missed vital signs and mortality in hospitals: retrospective longitudinal observational study. Health Serv Deliv Res. 2018;6(38):1-120. doi: 10.3310/hsdr06380
Dall’Ora C, Griffths P, Redfern O, Recio-Saucedo A, Meredith P, Ball J. Nurses’ 12-hour shifts and missed or delayed vital signs observations on hospital wards: retrospective observational study. BMJ Open. 2018;9(1):e024778. doi: 10.1136/bmjopen-2018-024778
Published
How to Cite
Issue
Section
License
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
