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Vital Signs Policy

Nursing Administrative Manual

Vital Signs Policy

Effective Date: [Original NPP Date]
Revised Date: [Current Date]

Goal

To monitor residents’ vital signs and report any abnormal signs to the attending physician and family/responsible party.

Policy

Vital signs will include Temperature, Pulse, Respirations, and Blood Pressure and will be taken monthly and as follows:

I. New Admissions

  • All vitals will be taken on admission/readmission and qshift for at least 72 hours.

II. Accidents and Incidents

  • All vital signs will be taken at the time of the incident and every shift for 72 hours.
  • Orthostatic blood pressures will be taken after a resident falls.

III. Change of Condition

  • Vital signs should be done at least every shift or as ordered by the physician until the resident is clinically stable.

IV. Antibiotics (Oral and IV)

  • Vital signs should be done every shift during the course of the antibiotics and for 24 hours after completion of the antibiotics.

V. Elevated Temperature

  • If a resident has an elevation in temperature, it should be monitored at least every shift until it returns to baseline for 24 hours.
  • A temperature of 101 degrees is considered to be elevated.

Procedure

APICAL PULSE:

  1. Using a stethoscope and a watch with a second hand, monitor the apical rate for a full 60 seconds.
  2. Assess the rate and rhythm.
  3. Document and notify the physician if there are any abnormalities in the above and/or if a medication is held as the result of the abnormality or if it is not within the acceptable range or parameter per Physician’s order.

BLOOD PRESSURE:

  1. Assemble equipment: sphygmomanometer and stethoscope.
  2. Explain the procedure, wash hands.
  3. Extend the resident’s arm and ensure clothing is not covering the antecubital area.
  4. Place the blood pressure cuff on the upper arm, above the elbow area with tubing extending towards the wrist. (The arrows on the cuff should be pointed towards the brachial artery).
  5. With the stethoscope in place over the brachial artery on the inner side of the arm above the elbow, inflate the blood pressure cuff and listen as the valve is released for a systolic reading and as the sound then changes from a softer faster thud or disappears for a diastolic reading.

TEMPERATURE:

  1. Follow manufacturer’s recommendations for the type of thermometer being used.

References:

  • Centers for Medicare & Medicaid Services. State Operations Manual, Appendix PP - Guidance to Surveyors for Long-Term Care Facilities. [Link to current CMS SOM]
  • CMS Requirements of Participation for Long-Term Care Facilities. [Link to current guidelines]

 

Tags
Vital Signs Policy
vital signs
resident monitoring
CMS Guidelines
SOM
Long-Term Care Facility
Section V. Nursing Administration Manual.
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