2010F Vital signs (temperature, pulse, respiratory rate, and blood pressure) documented and reviewed (CAP) (EM)

Name of the Procedure:

Vital Signs Documentation and Review (CAP) (EM)

• Common Names: Checking vital signs, vitals assessment
• Technical Terms: Vital signs measurement, physiological parameter assessment

Summary

The process of measuring and reviewing key vital signs—temperature, pulse, respiratory rate, and blood pressure—to monitor overall health and identify any potential medical issues.

Purpose

Medical Condition Addressed: General health assessment, diagnosis of acute and chronic conditions. Goals: To monitor the body's essential functions, detect abnormalities early, and guide treatment decisions.

Indications

• Symptoms: Fever, irregular heartbeat, shortness of breath, dizziness.
• Conditions: Hypertension, infections, heart conditions, respiratory illnesses.
• Patient Criteria: Routine check-ups, pre-surgical evaluation, chronic disease management.

Preparation

• Pre-procedure Instructions: Usually none, but patients are advised to rest before measurement.
• Tests/Assessments: No specific pre-tests required.

Procedure Description

1. Temperature: Measured using a thermometer (oral, rectal, axillary, or tympanic).
2. Pulse: Checked at various points (wrist, neck) with fingers or a digital device.
3. Respiratory Rate: Counted over a minute by observing chest movements.
4. Blood Pressure: Measured using a sphygmomanometer (manual or automated).

• Tools/Equipment: Thermometer, watch, sphygmomanometer, stethoscope (if needed).
• Anesthesia/Sedation: Not required.

Duration

Typically takes about 5-10 minutes.

Setting

Performed in various settings including hospitals, outpatient clinics, and even at home.

Personnel

• Nurses, medical assistants, or other trained healthcare professionals.

Risks and Complications

• Common Risks: Minor discomfort from blood pressure cuff.
• Rare Risks: None significant.

Benefits

• Early detection of health issues.
• Continuous monitoring of existing medical conditions.
• Real-time data to guide treatment decisions.

Recovery

• Post-procedure Care: No specific care required.
• Recovery Time: Immediate, with no physical restrictions.
• Follow-up may involve consultation with a physician if abnormalities are detected.

Alternatives

• Self-monitoring with home medical devices.
• Pros: Greater convenience; Cons: Less accurate without professional oversight.

Patient Experience

• During: Minimal discomfort (blood pressure cuff inflation).
• After: Immediate results with instant feedback from the healthcare professional.
• Pain Management/Comfort: Not necessary as procedure is non-invasive.