Policy 20 - Vital Signs

What age must a patient be to require blood pressure as part of a complete set of vital signs?

Over 3 years old

Are NIBP readings acceptable for blood pressure?

Yes, if abnormal a manual blood pressure should be taken

What sites can be used to palpate pulse rate?

Radial, femoral, brachial, or carotid site

What respiratory parameters are part of a complete set of vital signs?

Respiratory rate and quality of respirations

What oxygenation parameter is part of a complete set of vital signs?

Pulse oximetry

What neurological score is part of a complete set of vital signs?

GCS (Glasgow Coma Score)

What measurement is required for suspected altered mental status patients?

A documented blood glucose measurement

What evaluations are required for suspected stroke patients?

Pupillary evaluation/response and NIHSS

What measurement is required for suspected sepsis patients?

A temperature to be measured and recorded

What should be recorded for suspected environmental emergencies?

Patient temperature and environmental conditions

What monitoring is required for all patients with significant respiratory complaints?

Pulse oximetry and ETCO2

What monitoring is required for the duration of intubation with advanced airways?

ETCO2 measurements documented

When is an APGAR score required?

For all newborn patients at the first and fifth minute of life

What additional parameters may vital signs include?

Capillary refill, lung sounds, pain level, skin color/moisture, pupillary response, and extremity movements

What must be documented if waveform capnography is required by protocol?

Waveform capnography

How many individual completed sets of vital signs does the State of Texas require for every patient transport?

At least two (2)

How often must a complete set of vital signs be obtained for patients with an extended transport time?

Every 15 minutes

When must a complete set of vital signs be obtained relative to medication administration?

Prior to administration of the medication

When must vital signs be repeated after medication administration?

Within 5 minutes after administration

What may critically ill or injured patients require regarding vital signs?

More than the required number of vital signs

What must be documented and followed by a complete set of vital signs?

Any acute change in the patient's condition

How many complete sets of recorded vital signs are required for an AMA?

At least one

What must be done if any vitals are abnormal for an AMA?

An additional set of vitals must be obtained and documented