4.1 Systematic Patient Assessment & Vital Sign Interpretation

4.1 Systematic Patient Assessment & Vital Sign Interpretation

Comprehensive physical assessment and accurate vital sign interpretation represent the core foundation of clinical decision-making in New Zealand nursing practice. Registered nurses must apply a systematic, prioritised approach to gather objective physiological data and subjective clinical narrative, enabling early identification of patient deterioration and appropriate intervention.

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Primary Assessment: The ABCDE Approach

The ABCDE (Airway, Breathing, Circulation, Disability, Exposure) structured approach ensures life-threatening physiological disturbances are identified and managed in immediate order of clinical priority. This framework is universally applicable across acute inpatient wards, emergency departments, and primary care settings.

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|                         ABCDE ASSESSMENT HIERARCHY                     |
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|  [A] Airway       --> Patent, Occluded, Stridor, Choking                |
|  [B] Breathing    --> RR, SpO2, Effort, Auscultation, Tracheal Alignment|
|  [C] Circulation  --> HR, BP, CRT, Central/Peripheral Pulses, Urine Out |
|  [D] Disability   --> AVPU, GCS, Pupillary Reflex, Blood Glucose Level  |
|  [E] Exposure     --> Temp, Rash, Wounds, Pressure Areas, Dignity       |
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1. Airway (A)

• Objective: Assess airway patency and security.
• Clinical Indications of Obstruction: Stridor, gurgling, snoring, intercostal retractions, paradoxical chest wall movement, or complete absence of breath sounds.
• Immediate Interventions: Head-tilt/chin-lift or jaw-thrust maneuver, suctioning secretions, insertion of an oropharyngeal (OPA) or nasopharyngeal (NPA) airway, positioning, and escalating for advanced airway support.

2. Breathing (B)

• Objective: Evaluate respiratory effort, ventilation effectiveness, and arterial oxygenation.
• Parameters Evaluated:
  • Respiratory Rate (RR): Count for a full 60 seconds; normal range 12–20 breaths/min.
  • Work of Breathing: Accessory muscle usage, nasal flaring, abdominal breathing, tachypnoea.
  • Oxygen Saturation (SpO2): Target ≥95% on room air for general patients; target 88–92% in hypercapnic respiratory failure (e.g., severe COPD).
  • Auscultation & Inspection: Bilateral air entry, wheezes, crackles, silent chest, tracheal deviation, chest asymmetry.

3. Circulation (C)

• Objective: Assess tissue perfusion, circulating blood volume, and cardiac performance.
• Parameters Evaluated:
  • Pulse / Heart Rate (HR): Rate, rhythm (regular vs. irregular), and strength/volume.
  • Blood Pressure (BP): Systolic and diastolic measurement; calculation of Mean Arterial Pressure (MAP = Diastolic + 1/3[Systolic - Diastolic]; target ≥65 mmHg).
  • Capillary Refill Time (CRT): Central (sternal) or peripheral (fingernail press); normal is <2 seconds.
  • Skin & Perfusion: Colour (pale, cyanotic, mottled), temperature (cool/clammy vs. warm), central vs. peripheral pulses.
  • Fluid Balance / Output: Target urine output ≥0.5 mL/kg/hour.

4. Disability (D)

• Objective: Assess central nervous system function and neurological status.
• Tools Utilised:
  • AVPU Scale: Alert, Responds to Voice, Responds to Pain, Unresponsive.
  • Glasgow Coma Scale (GCS): Evaluates Eye Opening (1–4), Verbal Response (1–5), and Motor Response (1–6); score ranges from 3 to 15.
  • Pupillary Assessment: Size, symmetry, and reactivity to light (PERRLA).
  • Blood Glucose Level (BGL): Mandatory baseline test for any patient with altered mental status; normal fasting 4.0–7.8 mmol/L.

5. Exposure (E)

• Objective: Complete physical examination while preventing hypothermia and preserving patient dignity.
• Assessment Targets: Core body temperature, skin integrity, surgical wounds, rash, deep vein thrombosis (DVT) signs, abdominal distension, and occult bleeding sites.

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Secondary Assessment & Clinical History

Once immediate life threats are excluded or managed, the nurse transitions to the secondary assessment, combining a focused history with a detailed physical examination.

Structured History Frameworks

• OLD CART Framework for Symptom Analysis:
  • Onset: When did the symptom start?
  • Location: Where is it located; does it radiate?
  • Duration: How long does it last?
  • Characteristics: Describe the quality (e.g., sharp, dull, throbbing).
  • Aggravating / Alleviating factors: What makes it better or worse?
  • Related symptoms: Any concurrent symptoms (nausea, diaphoresis)?
  • Treatment: What interventions or medications have been tried?
• SAMPLE History Framework:
  • Signs and Symptoms
  • Allergies (and nature of reaction)
  • Medications (prescribed, OTC, rongoā Māori, herbal)
  • Past medical & surgical history
  • Last oral intake (fluid/food)
  • Events leading up to the acute presentation

Systematic Physical Examination (IPPA)

1. Inspection: Visual observation of symmetry, colour, contour, movement, and distress.
2. Palpation: Tactile assessment of temperature, tenderness, masses, crepitus, and organomegaly.
3. Percussion: Tapping body tissues to assess resonance (e.g., dullness over fluid/consolidation, hyper-resonance over pneumothorax).
4. Auscultation: Listening to internal body sounds (heart sounds S1/S2, lung sounds, bowel sounds) using a stethoscope.

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Physiological Vital Sign Parameters: Baseline Reference Values

Accurate measurement and interpretation of baseline vital signs are vital for clinical safety. The following table establishes standard normal adult parameters alongside key clinical alerts.

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Lifespan Adaptations: Paediatric & Geriatric Considerations

Nurses must tailor vital sign interpretation to the patient's developmental age and physiological reserve.

Paediatric Adaptations

• Higher Baseline Rates: Infants and young children have higher baseline HR (100–160 bpm in infants) and RR (30–50 breaths/min in infants) due to high metabolic demand and smaller stroke volume.
• Compensation Mechanisms: Children maintain blood pressure through intense vasoconstriction until severe decompensation occurs; hypotension is a late sign of critical shock in paediatrics.

Geriatric Adaptations

• Blunted Febrile Response: Older adults may present with severe sepsis without developing a fever; confusion or acute decline in functional state is frequently the primary indicator.
• Medication Effects: Beta-blockers and anti-hypertensives may mask compensatory tachycardia or blood pressure changes during haemorrhage or shock.