Patient Care Documentation of Vital Signs by Nurses

Running Head: EVIDENCE BASED NURSING RESEARCH
EVIDENCE BASED NURSING RESEARCH
Name of the student:
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EVIDENCE BASED NURSING RESEARCH1
Reducing health deterioration of the patient by the appropriate documentation of Vital
Signs by Nurses
Vital signs are considered as the important part of the patient care. Vital signs are
assessed to gather the information that is required in formulating the care plan of the patient. The
proper assessment of the vital signs is extremely necessary, as the further treatment of the patient
is based on the vital signs of the patient (Osborne et al., 2015). The monitoring and
documentation of the vital signs is very essential for the enhanced care of the patient. According
to Wong et al., (2017), the proper documentation of the vital signs is one of the important part of
the patient care. The nurse and the healthcare staff should have the proper knowledge of
assessing, monitoring and documenting of the vital signs. According to a study conducted by the
Moreno et al., (2016), there are four main set of the vital signs which includes, pulse rate,
respiratory rate, blood rate and the body temperature. These parameters are considered to be one
of the most crucial in the proper assessment of the patient as it assists in providing precise patient
data that leads to improved patient care. Despite of its importance, very few researches has been
conducted on appropriate documenting of the vital signs assessment.
Problem statement:
This project is proposed to enhance the health outcome of the patient and to reduce the
patient health deterioration by the aid of proper documentation of the vital signs are conducted
by the healthcare staff. Proper documentation of the vital signs of the patient provides the precise
mirror image of the care of the patient. According to Després (2016), proper documentation of
the vital signs is not followed properly in several which hinders the quality of the patient care by
delayed and inappropriate treatment and leads to further deterioration of the patient’s wellbeing.

EVIDENCE BASED NURSING RESEARCH2
According to IOM, to improve the patient care, the healthcare nurses should provide, safe,
efficient, timely, effective, and equitable and patient centered. If the vital signs are not measured
and documented, it hampers the aim of the IOM, which is safe and timely (Agency for
Healthcare Research & Quality, 2019).
National statistics:
According to the Safety and quality (2019), vital signs assessment and its proper
documentation is very important as it helps to reduce the patient health deterioration. It is
observed that one out of every 10 health care setting does not follow the proper assessment and
documentation of the vital signs, leads to negative impact on the patient’s health and delays the
recovery process. It is observed that due to the improper documentation patients have to stay
longer in the healthcare setting as compared to patient where proper documentation of the vital
signs are done.
Significance of the problem
Quality care in the healthcare setting is important to improve the patient health outcomes.
It is observed that there are several complications or error in the clinical area, which leads to
health deterioration. One of these is inappropriate or missing information in the documentation
of the vital signs is frequently observed in the healthcare setting which hampers the well-being of
the patient. The important parameters of the vital signs are often overlooked by the nurse, which
lead to inappropriate and delayed treatment of the patient (Kerr et al., 2016). Therefore, in order
to reduce the health deterioration of the patient, it is important to educate the nurse and the other
healthcare staff about the significance of the proper documentation in the patient care and its
consequences in the patient care quality.

EVIDENCE BASED NURSING RESEARCH3
Background:
According to a study conducted by Stevenson et al. (2016), it can be stated that
documentation of the vital signs is one of the most crucial aspect of the patient care. It aids in
detecting the risk factors that are responsible for the patient health deterioration. For accurate
documentation of the vital signs, Electronic Health Records, but very few healthcare staffs are
aware about it. In the study, it is identified that appropriate documentation of the vital signs tends
to increase the health outcome of the patient, whereas delayed and the inappropriate
documentation lead to further deterioration of the patient’s well-being (Stevenson et al., 2016).
According to Cardona-Morrell et al. (2016), early assessment, monitoring and proper
documentation of the vital signs helps in the detection of the signs and symptoms responsible for
deterioration of the patient’s physical and mental wellbeing. It also helps the nurse and the
healthcare staff to formulate the care plan which aims to treat the signs and the symptoms which
eventually lead to reduced harm resulted from the serious adverse incidents. Accurate and timely
assessment and documentation of the vital signs ensures the safety of the patient (Cardona-
Morrell et al., 2016). Vital sign is monitored at regular interval and the change in the signs
should be documented properly. Proper documentation also helps the other nurse, healthcare
staff or the general practitioner in analyzing the current health condition of the patient. In case of
chronic illness, the vital signs fluctuate frequently (Cardona-Morrell et al., 2016). Hence, in such
case proper documentation of the each assessment helps to determine the health issue of the
patient and aids in clinical judgment. In the study conducted by the Stevenson et al. (2018), it is
identified that there are two primary reasons for the improper documentation among the nurses
and other health care staff in the healthcare setting. First is the lack of appropriate guidelines of
assessing and documenting the vital signs and symptoms of the patient, which leads to the