Assessing, measuring and monitoring vital signs in infants, children and young people

The clinical assessment, measuring and monitoring of vital signs are core essential skills for all health care practitioners working with infants, children and young people.

The four main vital signs include body temperature, pulse rate, respiration rate and blood pressure. 

This guidance applies to professionals who work in acute care settings, as well as those who work in General Practice (GP) surgeries, walk-in clinics, telephone advice and triage services, schools, in the child or young person’s home and other community settings. 

Assessment of vital signs and monitoring patients 

Vital signs assessment take place as part of the observation and monitoring of an infant, child or young person. The term ‘assessment’ describes a broader process, which starts with a visual observation. Some signs, such as cyanosis, pallor, jaundice, and rashes, are not always as easy to recognise - for example, in children and young people with darker complexions. 

Assessment can include interactions, non-verbal communication and reactions to physical surroundings that infants, children or young people may display. When assessing, measuring and monitoring an infant, child or young person’s vital signs, their psychological needs should also be recognised to support their emotional wellbeing and to reduce distress. 

The aim of observing and monitoring fulfils many functions, including: 

• providing a baseline of ‘normal’ vital signs for children attending a procedure or surgical intervention so their health status can be re-evaluated following the procedure 
• providing a baseline of the sick child’s physiological state at presentation to hospitals or health care settings  
• triaging workload and identifying potential children at risk of deterioration 
• judging how unwell a child is, or whether they are in ‘compensated’ or ‘decompensated’ shock 
• allowing for planning to manage and mitigate risks 
• helping to make a diagnosis 
• monitoring an infant or child’s growth. 

Paediatric Early Warning Scores (PEWS) and community home assessment tools 

The Paediatric Early Warning Score (PEWS) system creates a standardised approach to identifying sick infants, children and young people who are at risk of any deterioration. The first published Paediatric Early Warning Score in the UK was launched in 2005, with nearly all hospitals in England now using some form of a score. 

The Royal College of Nursing (RCN) has been working with NHS England and the Royal College of Paediatrics and Child Health (RCPCH) since 20XX to establish a single National Paediatric Early Warning Score and system, (PEWS) for England. Read more about the RCN’s work to develop a single system across England. 

The use of PEWS and community home assessment scores can support individuals and teams, including junior staff or those new to caring for infants, children and young people. However, PEWS will not identify all children at risk of deterioration. Therefore, it is essential that all clinical staff are trained to recognise common patterns of deterioration, listening to parental concern and do not just use the PEWS score for reassurance.  

Education, training and standards for assessing vital signs

All registered nurses, students, nursing associates, health care support workers, and assistant practitioners who observe and monitor infants, children and young people, should be trained and competent in the accurate assessment and recording of vital signs.  

This includes visual observation, palpation (touch), listening and communication. More specifically, it includes recording:  

• temperature 
• heart/pulse rate 
• respirations, including the effort of breathing 
• oxygen saturations 
• glucose levels 
• blood pressure (manual, doppler and electronic) 
• capillary refill time (CRT) 
• pain assessment 
• level of consciousness 
• measuring of height and weight. 

With the above, age-appropriate methods will also need to be considered, for example, using the right sized equipment (for example, thermometers and stethoscopes), and supporting the young person to keep relaxed when taking a blood pressure reading. 

Risk factors for deterioration 

More frequent and rigorous monitoring of children will be needed for those with acknowledged risk factors for deterioration. This includes those undergoing high risk treatments, for example chemotherapy, blood transfusions and post-operative care. 

Health care practitioners (HCP’s) who assess, measure and monitor vital signs in infants, children and young people are expected to be competent when it comes to:  

• observing an infant/child/young person’s physiological status 
• being aware of ‘normal’ physiological parameters for blood pressure, respiratory rate and heart rate for different age ranges 
• recognising parental concern being aware of specific conditions that require observation recording to be undertaken on a more frequent basis, for example, in the case of a reduced level of consciousness or head injury where the risk of deterioration is increased 
• taking appropriate action in response to changes in vital sign assessment and measurement 
• effectively communicating/escalating concerns about a child’s deterioration using the Identification-Situation-Background (ISBAR) tool (PDF).  

Standards and practice criteria for vital signs assessment 

The Nursing and Midwifery Council (NMC) provides details of essential nursing procedures and practice criteria that students must be trained in by the point of registration. Visit the NMC website to read more about the standards of proficiency for registered nurses. 

In addition, children, parents or carers who are required to perform vital signs assessment, measurement and monitoring should be taught by a registered nurse who is competent in performing these skills in accordance with the NMC Code.  

The child, young person and/or parent/carer should consent to vital sign assessment and measurement. Where a child or young person under 16 is unaccompanied, local policies should be followed and RCN consent guidance can be used. 

Clear explanations should be given to parents/carers and where possible, children and young people, concerning vital sign assessment and the data collected.  

Tools to assist in the recognition of deterioration in a child or young person 

Nurses should ensure that on arrival to hospital, all children and young people with a decreased level of consciousness are assessed using either the alert, voice, pain, unresponsive (AVPU) scale or the Glasgow Coma Scale (GCS) (PDF) (adult or modified, depending on the age of the child).

If a child requires regular evaluation of their level of consciousness, GCS measurements should be used in addition to, or instead of, the AVPU scale. In addition, policies and procedures, specific to infants, children and young people, should be used for monitoring vital signs post-operatively, during blood transfusions and other therapies. In an acutely unwell child, the ABCDE approach should be used: Airway, Breathing, Circulation, Disability and Exposure.

Other tools, in addition to the PEWS track and trigger system, include the Situation, background, assessment, recommendation (SBAR) tool.

Vital signs equipment and medical devices regulation

All medical devices and equipment must have a CE marking to show the product meets European standards. However, this does not automatically guarantee the device is designed for infants, children or young people, or appropriate for use within a particular setting (hospital, community or home). 

All staff using a medical device should be made aware of local policies and procedures for safe management. They should also be aware of the limitations and risks associated with using the device as part of their competency training.

Along with alarms that are set to alert staff to changes in vital signs (which should not be used as a substitute for direct clinical observation), medical equipment must be:

• regularly cleaned during ongoing use by one child and between different children
• disposable or single use equipment
• serviced regularly by a local medical engineering department. 

Further information and resources

• Read the Medicines & Healthcare products Regulatory Agency's Managing Medical Devices guidance for health and social care organisations.
• Read the RCN's Futureproofing Community Children’s Nursing publication. 
• Read more about the role of the Medicines and Healthcare Products Regulatory Agency.
• Visit the Health and Social Care Quality Improvement (HSCQI) website for information on the Northern Ireland PEWS charts.  
• Visit Healthcare Improvement Scotland's Improvement Hub (ihub), for information on the Scottish PEWS charts. 
• Visit the Royal College of Paediatrics and Child Health website to read more about Paediatric Early Warning System (PEWS) - developing a standardised system for England. 
• Visit the Leeds University website for information on the Paediatric Observation Priority Score (POPS).