Clinical Guidelines (Nursing)

Observation and Continuous Monitoring

  • Introduction


    Definition of Terms

    Guideline Details

    Companion Documents

    Evidence Table


    1. Introduction

    Regular measurement and documentation of physiological observations (i.e. clinical observations) are essential requirements for patient assessment and the recognition of clinical deterioration.

    The Victorian Children’s Tool for Observation and Response (ViCTOR) charts are a set of 5 age-specific ‘track and trigger’ paediatric observation charts for use in Victorian hospitals, and are designed to assist in recognising and responding to clinical deterioration in children.

    An age appropriate ViCTOR chart must be used for all inpatients at RCH. The charts are available for the following 5 age groups: less than 3 months, 3 to 12 months, 1 to 4 years, 5 to 11 years and 12 to 18 years. At RCH there are no adult charts and the 12-18 years chart should be used for young people older than 18 years.

    These ‘track and trigger’ charts mandate a response by the clinician once the patient’s observations reach a designated ‘zone’. Concerning changes in any one observation, or vital sign, are indicated by two coloured zones (Orange and Purple). If a child’s observation transgresses the Orange or Purple zone an escalation of care response is triggered. The type and urgency of the escalation response depends on the degree of clinical abnormality.

    Electronic Medical Record (EMR): In the electronic medical record at RCH (EMR), observations are to be entered numerically in the Flowsheets activity. Trending of observations can be viewed via the ViCTOR graph. In EMR, age-specific ViCTOR parameters are automatically set by the child's age in the system and when breached a notification for escalated care is triggered. The orange and purple zones in EMR will appear as below:

    EMR OrangeandPurple

    Information regarding the documentation of observations and viewing the ViCTOR graph in the EMR can be found in flowsheet learning resources

    2. Aim

    To provide guidance to clinical staff regarding the:

    • Measurement of clinical observations;
    • Use of the Victorian Children’s Tool for Observation and Response; and
    • Role of continuous cardio-respiratory monitoring and pulse oximetry monitoring.

    3. Definition of terms (abbreviations and acronyms)

    • AUM- Associate Unit Manager
    • CPMS – Children’s Pain Management Service
    • ECG - Electrocardiograph
    • ED - Emergency Department
    • ICP - Intracranial Pressure
    • MET - Medical Emergency Team
    • PACU - Post Anaesthetic Care Unit
    • PCA - Patient Controlled Analgesia
    • PICU - Paediatric Intensive Care Unit
    • Rapid Review – review of patient by Bed-card doctor within 30 minutes of request.

    4. Guideline details

    A. Clinical Observations

    Clinical observations include estimation of haemoglobin-oxygen saturation (SpO2, pulse oximetry), oxygen delivery, respiratory rate, respiratory distress, heart/pulse rate, blood pressure (systolic, diastolic and mean), temperature, level of consciousness OR level of sedation, and a pain score. In certain clinical circumstances further observations (for example, neurological observations or neurovascular observations) may be required.

    Clinical observations will be recorded by the nurse as part of an admission assessment, at the commencement of each shift and at a frequency determined by the child’s clinical status. Further guidelines about Nursing Assessment can be found here.

    The frequency of observations should be documented, unless they are to be performed routinely, 4 hourly. 

    The type and frequency of observations must reflect the therapies and interventions being delivered to the child and be consistent with requirements of other individual guidelines and procedures. For example, required observations during blood product transfusions and all fresh blood products can be found here.

    Observations should be performed at least once per hour if the patient:

    • Has previous observations within the shaded orange or purple zone (unless modified)
    • Was transferred from PICU/NICU (for 8 hours or as clinically indicated)
    • Is receiving PCA, Epidural, or Opioid infusion
    • Is receiving an Insulin infusion
    • has ICP monitoring
    • is receiving oxygen therapy

    (Note, some children will require hourly observations and continuous monitoring as described later in this guideline).

    Clinical observations must be recorded before transfer from one area to another, for example from ED to ward, PICU to ward or PACU to ward. If a child's observations are transgressing the Orange or Purple zone, this must be addressed prior to transfer.

    The nurse responsible for the child’s care will determine the type and frequency of observations based on the results of previous observations and the child’s clinical condition, and in consultation with others involved in the child’s treatment.

    B. Observation Charts (ViCTOR)

    Ensure that observations are entered onto the correct medical record by checking the patient's identification. 


    Coloured zones

    There are 3 distinct coloured ‘zones’ within the ViCTOR graph.

    The White zone is considered the ‘acceptable zone’. That is, most patients trending in this area are considered to have acceptable age-related vital signs ( Normal Ranges for Physiological Variables.) Nevertheless, it is important to be vigilant – for example, a heart rate that is steadily rising in this White zone should trigger attention before crossing into the Orange zone.

    The Orange zone is the first zone to signal that the patient may be deteriorating. It triggers the clinician to escalate care to the AUM (at a minimum) to decide if a medical review or other emergency response is required. The Purple zone is the second and more concerning trigger and signals that the patient may be deteriorating or is seriously ill. If the patient is in the Purple zone, an emergency call must be initiated, that is, a Rapid Review or MET call.

    Appropriate escalation of care must occur as per the Deteriorating Patient: Escalation of Care flow chart and the Medical Emergency Response Procedure

    Remember, regardless of what zone the patient is in, if a staff member or parent is very worried about the child’s clinical state, initiate an emergency response.

    O2 Saturation and oxygen delivery

    Haemoglobin-oxygen saturations (SpO2) should be entered numerically in the allocated box.

    Oxygen delivery refers to the flow (L/min) or percentage (%) of oxygen that the patient is receiving. If no oxygen is given, write 'RA' (room air).

    The device used to deliver oxygen should be noted as follows:

    • Nasal prongs (NP)
    • Hudson Mask (HM)
    • Humidified Nasal Prongs (HNP)
    • High Flow Nasal Prongs (HFNP)
    • Non-rebreather mask (NRM)
    • Tracheostomy (T)

    Oxygen delivery guidelines can be found by clicking on this web-link. Standing medical orders for alteration of oxygen therapy by nurses for patients in PICU can be found by clicking on this web link .

    For children on continuous pulse oximetry monitoring, the saturation probe site should normally be re-sited every 4 hours for infants <1year (2 hourly may be necessary for some infants) and 4-6 hourly for >1year. This should be indicated on the chart.

    Note: It is not recommended to secure oxygen saturation probes with CombanTM stretch compression bandage.  

    Respiratory rate and pulse rate

    Respiratory rate and pulse rate must be entered on the flowsheet activity in EMR. In EMR, ViCTOR graphs will be automatically populated to enable review of trends. 

    Respiratory Distress

    Respiratory distress should be recorded as Nil, Mild, Moderate or Severe and be determined by assessing the following features (see  

    Assessment of Respiratory Distress

    Blood Pressure

    Blood pressure (BP) must be recorded as systolic, diastolic and mean BP. Only systolic BP triggers an escalation of care response. A measurement in the Orange zone reflects hypertension (upper zone) and in the Purple zone, hypotension (lower zone).

    BP should be assessed at least once on admission, and thereafter at a frequency appropriate for the child’s clinical state. If a child's pulse/heart rate falls in the Orange or Purple zone, BP must be measured and documented.


    For infants less than 3 months, the temperature section contains an Orange zone to escalate care for the infant with a low (≤ 36°C) or high temperature (≥38.5°C).

    For neonates, the temperature should be > 36.5°C ( link to Temperature Management Clinical guideline)

    For other age groups, in the observation frequency section (EMR), an order can be placed when, and if an alteration in temperature should be reported to medical staff (e.g. febrile neutropenic patient, temperature rise >1°C and at least 38°C during blood product transfusion).

    Level of Consciousness  

    Level of Consciousness assessment should be made by using the AVPU scale:

    A = child is Alert (opens eyes spontaneously when approached).
    V = child responds to Voice.
    P = child responds to a Painful stimulus.
    U = the child is Unresponsive to any stimulus.

    The AVPU score may be difficult to determine for infants. Some infants may respond to the voice of a parent, but not a clinician.

    Children should be woken before scoring AVPU. Conversely, in an otherwise clinically stable patient, it may not be appropriate to wake a sleeping child to assess the level of consciousness, with every set of observations (e.g an infant with bronchiolitis who is on hourly observations for ongoing evaluation of respiratory distress and has just settled to sleep).

    A more comprehensive neurological assessment must be performed for any patient who has, or has the potential, to have an altered neurological state. Neurological observations should be made, including an assessment of the Glasgow Coma Score, limb movements and pupils. These observations should be recorded on a separate Neurological Observation Chart.

    Children who require neurological observations include those with:

    • Increasing, or potential for increased, intracranial pressure
    • Neurosurgical procedures
    • Encephalopathy (e.g. metabolic disorder, liver failure)
    • Endocrine disorders (e.g. Diabetic ketoacidosis, Diabetes Insipidus)
    • Electrolyte disorders (e.g hyponatraemia)
    • Demyelinating neurological conditions (e.g. Guillain - Barre syndrome)
    • Seizures –consider underlying diagnosis, or new onset. AVPU scoring may be appropriate for children with pre-existing seizure conditions.

    Level of Sedation

    Level of Sedation assessment should be made ONLY for patients receiving sedation (e.g. chloral hydrate, midazolam, nitrous oxide, and opiates at higher doses) and the Level of Sedation score is to be used instead of the AVPU score.

    The University of Michigan Sedation Score (UMSS) is used to score the Level of Sedation. 

    0  Awake and alert
    1  Minimally sedated: may appear tired/sleepy, responds to verbal conversation +/- sound
    2  Moderately sedated: somnolent/sleeping, easily roused with tactile stimulation or verbal command
    3  Deep sedation: deep sleep, rousable only with deep or physical stimulation
    4 Unrousable


    Guidelines for procedural sedation can be found by clicking on this web-link.


    Pain scores

    Pain scores should be calculated by using a Pain Assessment tool appropriate for the age, developmental level and clinical state of the child. Suggested ages are as follows:

    Other Pain assessment tools include the neonatal Pain Assessment Tool (PAT) ( link to the Neonatal Pain Assessment clinical guideline) and COMFORT- B scale (used in PICU).

    Contact the Children's Pain Management Service (CPMS) for any pain related issues, including all children with PCA and epidural infusions.  


    Additional Observations

    Further observations may be required. 

    These may include:

    • Blood sugar level
    • Capillary refill time
    • Non-invasive ventilation parameters
    • Ventilation parameters
    • Isolette/radiant heater temperature ( <1 year only)
    • Nausea/Vomiting 

    Neurovascular observations should be performed in the Neurovascular section. Further details about neurovascular observations can be found here.

    Adding a comment 

    Comments that help interpret the observations and vital sign trends (e.g decreased heart rate observed with administration of procedural sedation, or mother concerned about increased drowsiness of her child, or commencement or completion of blood product transfusion) can be made in the Notes Activity or Progress Notes.  

    If the child’s observations transgress into the Orange or Purple zone, then further details must be provided, including details of the Escalation of Care plan and response.

    Other nursing assessment details, plan of care and real time progress notes should be made in accordance with the Nursing Documentation clinical guideline.

    Modification of the Orange or Purple zone

    Emergency response criteria may be made by medical staff, in accordance with the Medical Emergency Response Procedure and must be ordered by medical staff. A ViCTOR modification order can be viewed through the flowsheet activity sidebar. 

    C. Continuous monitoring

    Continuous monitoring includes either cardio-respiratory monitoring or pulse oximetry monitoring.

    Continuous monitoring supplements manually performed intermittent clinical observations. If used appropriately it can assist clinicians to identify rapid changes in condition. Some monitors enable the review of trends in physiological parameters over time.

    Cardio-respiratory monitoring

    Continuous cardio-respiratory monitoring is the technological measurement of heart rate/pulse rate, respiratory rate and SpO2. Children who are clinically unstable or are at risk of sudden changes in condition should have cardio-respiratory monitoring. Indications for continuous cardio-respiratory monitoring include:

    • apnoeic or bradycardic episodes
    • abnormalities of heart rate and rhythm
    • use of temporary pacing
    • prostaglandin infusion, medications that compromise cardiac function including concentrated electrolyte therapy, therapies associated with a high risk of anaphylaxis, administration of toxic medications)
    • high risk of respiratory failure (e.g., infants with severe bronchiolitis)
    • post-operative assessment as ordered by medical staff (e.g. 24-48 hours post spinal surgery)

    Pulse oximetry monitoring

    Continuous pulse oximetry monitoring measures oxygenation (SpO2) and pulse rate. Indications for its use include the child who:

    • is receiving oxygen therapy and clinically unstable
    • is clinically unstable and the need for oxygen therapy is yet to be determined
    • has a nasopharyngeal airway or tracheostomy and requiring acute nursing care
    • is receiving respiratory support (e.g., invasive or non-invasive ventilation)
    • is undergoing a procedure where respiratory depressants are used
    • is a high risk patient receiving an opioid infusion
    • is in the immediate post-operative period  
    • has a decreasing conscious status  

    Whenever continuous monitoring of heart rate, SpO2 or respiratory rate is in use, clinical observations must be documented hourly, at a minimum.

    It is important to neither rely on nor ignore monitors. The heart rate indicated by a monitor should be cross checked by palpation of the pulse or auscultation of the heart at least once per shift and whenever there is concern about the child’s physiological condition, a change in heart rhythm or when there is doubt about the accuracy of the monitoring technology. The pulse volume and regularity of heart rate should also be assessed at this time.

    The respiratory rate, usually derived from the ECG monitor, should be cross checked with the patient’s counted rate at least hourly. Further respiratory assessment including the pattern and effort of breathing should also be evaluated at this time.

    Alarm settings

    The alarm limits should be set at the appropriate age related profile selected on the monitor, where the default settings reflect the ViCTOR escalation of care parameters.  Subsequent adjustment of the alarms may be required as the patient’s clinical status changes. That is, it may be necessary to set the alarm limits within a narrower range for some patients. Widening of the alarms limits must only be done in accordance with the procedure outlining the modification of emergency response criteria (Orange zone).

    The patient profile and alarm settings should be checked at the beginning of each shift and as otherwise indicated. The key principle is to provide safe alarm settings for the child and minimise the number of false alarms. A high frequency of false alarms has the potential to desensitize staff and decrease their responsiveness, thereby compromising patient safety.

    When commencing cardio-respiratory monitoring, make sure that the patient’s name is correctly entered into the monitor. Similarly, when discontinuing monitoring, it is important to ensure that the previous child’s alarm settings are not inappropriately maintained.

    All alarms must be “enabled” (activated) and audible from the nurses’ station. When an alarm sounds clinicians should respond immediately, assess the child, determine and apply the appropriate intervention and rectify problems with monitoring devices if necessary. Parents are not permitted to disable or alter alarm settings.

    Discontinuation of continuous monitoring

    As the condition of the child stabilises and the risk of sudden deterioration lessens, the decision to continuously monitor the child should be reviewed.

    The need for close observation and monitoring should be balanced against unnecessary dependency on the monitors.

    5. Companion documents


    6. Evidence Table

    Click here to view the evidence table.

    7. References

    • Victorian Paediatric Clinical Network, Melbourne, AUSTRALIA, The Victorian Children's Tool for Observation and Response (ViCTOR), available from (retrieved Jan 2015)
    • Australian Commission on Safety and Quality in Healthcare (2011). National Safety and Quality Health Service Standards. Sydney: ACSQHC.
    • Bonafide CP, Brady PW, Keren R, Conway PH, Marsolo K, Daymont C. (2013). Development of heart and respiratory rate percentile curves for hospitalized children. Pediatrics,131 (4), e1150-e1157.
    • Dionne, J., Abitbol, C., & Flynn, J. (2012). Hypertension in infancy: diagnosis, management and outcome. Pediatric Nephrology, 27(1), 17-32.
    • Dionne, J., Abitbol, C., & Flynn, J. (2012). Erratum to: Hypertension in infancy: diagnosis, management and outcome. Pediatric Nephrology, 27(1), 159-160.
    • Graham, K. C., & Cvach, M. (2010). Monitor alarm fatigue: Standardizing use of physiological monitors and decreasing nuisance alarms. American Journal of Critical Care. 19(1), 28-34.
    • Haque, I., & Zaritsky, A. (2007). Analysis of the evidence for the lower limit of systolic and mean arterial pressure in children. Pediatric Critical Care Medicine, 8(2), 138-144.
    • Lawless, S. T. (1994). Crying wolf: false alarms in a pediatric intensive care unit. Critical Care Medicine, 22(6), 981-985.
    • Kinney, S., Sloane, J., & Moulden, A. (2014). Statewide Paediatric Observation and Response Chart (SPORC) Project: Phase One and Phase Two Report. Paediatric Clinical Network: Department of Health, Victoria, Australia.
    • Lurbe et al. (2009).Management of high blood pressure in children and adolescents: recommendations of the European Society of Hypertension. Journal of Hypertension September, 27(9), 1719-1742.
    • National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents (2004). Pediatrics, 114 (2 suppl 4th report), 555– 576.
    • Royal College of Nursing (2007). Standards for assessing, measuring and monitoring vital signs in infants, children and young people. RCN: London
    • Teasdale, D. (2009). Physiological monitoring. In, Dixon, M., Crawford, D., Teasdale, D., & Murphy, J. Nursing the highly dependent child or infant. Chichester: Blackwell Publishing Ltd.
    • Tibballs, J., Kinney, S., Duke, T., Oakley, E., & Hennessy, M. (2005). Reduction of paediatric in-patient cardiac arrest and death with a medical emergency team: Preliminary results. Archives of Disease in Childhood, 90(11), 1148-1152.
    • Townley, C., Theisen, E., Stanzel, B., Chang, C., Goddard, J. & Kinney, S. An investigation into the use of MET criteria in setting cardiac monitors and the effect on the rate of false alarms. Master of Nursing Science Presentation Day (27th May, 2011), The University of Melbourne.

    Please remember to read the disclaimer.

    The development of this nursing guideline was coordinated by Sharon Kinney, Nurse Consultant, Nursing Research, and approved by the Nursing Clinical Effectiveness Committee. Updated December 2014.