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Vital Signs in the Emergency Department (31.4)

Vital Signs in the Emergency Department (31.4) - Policies, Clinical, UWHC Clinical, Department Specific, Emergency Department

31.4


NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
04/10/2017

Administrative Manual
Nursing Manual
X Emergency Department

Policy #: _31.4

Original
X Revision

Page
1
of 3

Title: Vital Signs in the Emergency Department

I. PURPOSE
To clearly define the expectations for obtaining vital signs for patients being seen in
the Emergency Department.

II. PROCEDURE
A. Adult patients (> 18 years of age)
1. A complete set of vital signs is obtained with the initial assessment. A
complete set of vital signs includes a temperature, blood pressure,
heart rate, respiratory rate and pulse oximetry. Fetal Heart Tones
(FHTs) will be assessed and documented if the patient is at least 12-16
weeks gestation, for related chief complaints (i.e.: abdominal pain,
vaginal discharge, and other related pregnancy concerns)
2. Repeat temperature will be obtained at a minimum of every two hours
for all patients who enter the ED with the complaint of fever,
presentation likely consistent with infectious process, are
immunocompromised, or have had recent (within past two hours) anti-
pyretic use.
3. Repeat vital signs (minimum HR, BP, RR, pulse oximetry) will be
obtained every 15 minutes for a hemodynamically unstable patient or
an acutely ill patient at imminent risk of hemodynamic compromise.
a. Patients will not be placed on continuous monitoring unless
indicated by their condition or ordered by a physician.
4. Repeat vital signs (minimum HR, BP, pulse oximetry – as appropriate)
will be obtained every 2-4 hours for stable patients (i.e. abdominal
pain- every 2 hours and isolated minor injury- every 4 hours).
5. Repeat full set of vital signs will be obtained within one hour of
disposition.
6. Of note, if it appears the patient’s clinical condition is worsening, more
frequent vital signs should be obtained.
7. Vital signs will be assessed for patients receiving sedation according to
hospital policy 8.38- UWHC Adult Sedation Policy.
8. Scale beds will be zeroed before placing patient/weighing patient


B. Pediatric patients (< 18 years of age)
1. A complete set of vital signs, as defined below by age, is obtained with
the initial assessment.
a. Temperature




1. Rectal temperatures will be taken on all patients < 6
months of age, UNLESS the child is immunocompromised
or has had a bowel, perineal or rectal surgery.
2. The temporal artery (TA) thermometer can be used on all
patients > 6months of age. If child is able to have an oral
temperature, this route is preferred
3. No axillary temperatures are to be obtained in the ED.
b. Blood pressure
1. All patients > 3 years of age will have a BP taken.
2. Patients < 3 years of age will have a BP taken if they have
one of the following complaints.
ξ Cardiac history or complaint
ξ BP and pulse oximetry will be obtained on
all 4 extremities if infant or child is
symptomatic
ξ Neurological history or complaint
ξ Renal history or complaint
ξ Signs or symptoms of dehydration
c. Heart rate
1. Auscultated for one full minute in children < 1 year of age.
d. Respiratory rate
1. Auscultated for one full minute in children < 1 year of age.
e. Weight (in kg only)
1. All pediatric patients will have actual weights, not stated
weights.
ξ < 1 year of age- naked
ξ 1-2 years of age- dry diaper only
ξ > 2 years of age- dry diaper (if applicable), no
shoes or heavy clothing
f. Glucose
1. Glucometer checks should be obtained as soon as possible
for any child with a decreased level of consciousness.
2. Vital signs will be repeated based on clinical status and interventions,
but at least every one to two hours.


3. A complete set of vital signs is obtained with the initial assessment. A
complete set of vital signs includes a temperature, blood pressure,
heart rate, respiratory rate and pulse oximetry.
4. Repeat temperature and heart rate will be obtained within every one
to two hours for all pediatric patients who enter the ED with the
complaint of fever, presentation likely consistent with infectious
process, are immunocompromised, or have had recent (within past two
hours) anti-pyretic use.
5. Repeat vital signs (minimum HR, BP, RR, pulse oximetry , as
appropriate) will be obtained every 2-4 hours for stable patients (i.e.
abdominal pain- every 2 hours and isolated minor injury- every 4
hours).
6. Repeat vital signs (minimum HR, BP, RR, pulse oximetry, as
appropriate) will be obtained within one hour of disposition.
7. Of note, if it appears the patient’s clinical condition is worsening, more
frequent vital signs should be obtained, including repeat vital signs
(minimum HR, BP, and O2).
8. Vital signs will be assessed for patients receiving sedation according to
hospital policy 8.56- Pediatric Sedation Policy.
C. Data validation
1. When data validation is utilized, the nurse will continue to reassess the
patient.
a. A narrative note that reflects assessment and patient condition
will be entered in the electronic health record (EHR).
2. The monitor may be set to cycle vital signs for patients with the
potential of worsening status. All vital signs will be reviewed prior to
validation of the vital signs. Vital signs will be validated (recorded)
frequently at least every hour
3. Vital signs will be recorded manually, at the time of assessments for
stable patients
D. Documentation
1. Narrative documentation for physician notification of abnormal vital
signs will be entered in the EHR.
E. Chart Audits
1. Chart audits will occur periodically for peer and self-review of
documentation.

UWHC CROSS REFERENCE
F. UWHC Hospital Administrative Policy 13.16 Basic Care - Inpatient Pediatrics
(Birth-18 years of age)

III. REFERENCES



Howard, P.K. & Steinmann, R.A. (2010). Sheehy’s emergency nursing principles
and practice (6th ed.). St. Louis, MO.: Mosby

IV. REVIEWED BY

Nurse Co-Managers, Emergency Department
PECC, Emergency Department
CNS, Emergency Department
Director, Emergency Services
ED Clinical Operations


SIGNED BY

Anne Rifleman, RN
Director, Emergency Services

Val Mack, RN
Co-Manager ED

Anne Rikkers RN
Co-Manager ED

Joshua Ross, MD
Clinical Vice Chair
Emergency Services