POLICY STATEMENT
Vital signs (VS) are clinical measurements that provide an index of essential bodily functions to assist the provider in assessing a patient’s condition and making an accurate diagnosis. VS measurements include body temperature (T), blood pressure (BP), pulse rate (P), and respiratory rate (R). In some cases, a pulse oximetry measurement (SpO2) may also be included. Height and weight apply in certain instances.
REASON FOR THIS POLICY
To provide guidance for nursing staff in obtaining the appropriate vital sign measurements when a patient presents for medical care.
ENTITIES AFFECTED BY THIS POLICY
Campus Health Services
WHO SHOULD KNOW THIS POLICY
Campus Health Services medical providers, Registered Nurses, Medical Assistants
DEFINITIONS
NA
POLICY
1. ALL new patients will have a complete set of VS taken. This includes temperature, pulse rate, respiratory rate, and blood pressure. Height and weight will also be recorded.
2. Full VS (T, P, R, BP) will be taken and recorded at the start of all patient visits and more often during the visit as ordered by the provider.
3. A pulse oximetry (SpO2) measurement should be obtained for any patient complaining of shortness of breath, a respiratory-related complaint, or being seen for a chronic respiratory condition.
4. A current weight will be recorded:
a. At least every three (3) months OR
b. More often, depending on the patient’s presenting condition:
i. Any patient presenting with a chronic health condition, including (but not limited to) diabetes, metabolic syndrome, thyroid disorders, hypertension, cardiac conditions
ii. Any patient presenting with an acute complaint with symptoms in which a current weight would be beneficial for accurate diagnosis (e.g. gastrointestinal complaints, weight loss/gain concerns, appetite concerns, etc.
c. On any patients presenting for a routine physical exam, including annual exams, well-woman exams, travel physicals, and work-related physicals
d. On patients with known eating disorders (only with patient consent)
5. A current height will be recorded annually.
6. If a patient chooses to decline VS or a height/weight measurement, appropriate documentation indicating this must be made in the patient record.
7. If it is determined by the provider, Registered Nurse (RN), or Medical Assistant (MA) that VS are not necessary, appropriate documentation indicating the rationale, must be placed in the patient record.
8. Other Visits:
a. Triage visits: All patients seen by ONLY by a triage RN, will have full VS taken and recorded, as their condition dictates.
b. Allergy Clinic: All patients will receive full VS at their intake or update visit each semester. VS may be taken more often as their condition dictates.
c. Nurse Clinic: Patients being seen for continuing care (i.e., hormone injections, birth control, medications) will have a full set of VS at their first visit if not already documented each semester. All other patients will have VS taken as their condition dictates.
9. If a patient is seen only by a provider, it is at the provider’s discretion to obtain and record VS.
10. Discharge vital signs: Full vital signs are required following:
a. IV rehydration, with or without use of IV medications.
b. Prolonged stay in an observation room.
c. Following IM injections for treatment (e.g. antibiotics, pain medications, antiemetics, migraine medications).
11. Orthostatic vital signs: Patients with certain complaints may require orthostatic vital signs. Complaints may include prolonged vomiting and/or diarrhea, bleeding, dizziness, weakness, syncope, or other symptoms as recognized by the provider.
a. Have patient lie quietly for 5 or more minutes; check pulse and BP while patient is supine.
b. Assist patient to standing position; after 3 minutes, recheck pulse and BP.
c. If pulse increases by at least 30 bpm, systolic BP decreases by at least 20 mm Hg, or the diastolic pressure falls by more than 10 mm Hg, the orthostatic VS are considered positive, indicating orthostatic hypotension.
d. If patient is unable to stand, orthostatics may be taken while patient is sitting with feet dangling.
e. Checking BP and P immediately upon standing or sitting can helpful, but a drop at this time is NOT indicative of orthostatic hypotension
12. Following SVN treatments: Obtain pulse with SpO2 5-10 minutes after completion of treatment and document in the patient record. Perform full VS if ordered by provider or as patient’s condition dictates.
RESPONSIBILITIES
Medical Assistants
Medical Providers
Registered Nurses
Sources
Tool 3F: Orthostatic Vital Sign Measurement. January 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk-tool3f.html