Policy 20–Vital signs

What does the Vital Signs policy address?

The requirements set by the State of Texas and these protocols for obtaining and recording patient vital signs.

At what age is blood pressure required as part of a complete vital signs set?

Patients over 3 years old (NIBP is acceptable, but take a manual BP if the reading is abnormal).

What core vital signs make up a "complete set" for every patient?

Blood pressure (if applicable), pulse rate (palpated strength and rhythm), respiratory rate and quality, pulse oximetry, and GCS.

What extra vital sign is required for suspected altered mental status patients?

A documented blood glucose measurement.

What extra assessments are required for suspected stroke patients?

Pupillary evaluation/response and NIHSS.

What extra vital sign is required for suspected sepsis patients?

A measured and recorded temperature.

What extra vitals are required for suspected environmental emergencies?

Patient temperature and environmental conditions.

What monitoring is required for patients with significant respiratory complaints, and for those with advanced airways?

Pulse oximetry and ETCO2 for significant respiratory complaints; ETCO2 must be documented for the full duration of intubation with an advanced airway.

When is an APGAR score required?

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

What other measurements may also be part of a vital signs set?

Capillary refill, lung sounds, pain level, skin color/moisture, pupillary response, extremity movements, and waveform capnography (if required by protocol).

How many complete sets of vital signs does Texas require, at minimum, per patient transport?

At least two (2) individual completed sets.

How often must a complete set of vital signs be obtained during an extended transport?

Every 15 minutes.

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

Immediately prior to giving the medication, and then again within 5 minutes after administration.

What should trigger an additional complete set of vital signs mid-call?

Any acute change in the patient's condition.

What are the vital signs requirements for a patient who leaves Against Medical Advice (AMA)?

At least one complete set of recorded vital signs; if any are abnormal, an additional set must be obtained and documented.