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Nursing Vital Signs Referral Parameters

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Nursing Vital Signs Referral Parameters WISCONSIN DEPARTMENT OF CORRECTIONS Governor Tony Evers / Secretary Kevin A. Carr GUIDANCE DOCUMENT CERTIFICATION I have reviewed this guidance document or proposed guidance document and I certify that it complies with sections §227.10 and §227.11 of the Wisconsin Statutes. I further certify that the guidance document or proposed guidance document contains no standard, requirement, or threshold that is not explicitly required or explicitly permitted by a statute or a rule that has been lawfully promulgated. I further certify that the guidance document or proposed guidance document contains no standard, requirement, or threshold that is more restrictive than a standard, requirement, or threshold contained in the Wisconsin Statutes. Kristin Nissen Name of Individual Certifying this Document / Proposed Document Program and Policy Chief Title Signature 4/17/2020 Date Signed Department of Corrections – Wisconsin Office of the Secretary Wis. Stat. § 227.112(6) DOC-2910 (Rev. 12/2019) 3099 E. Washington Ave. PO Box 7925 Madison, WI 53707 Phone: (608) 240-5000 doc.wi.gov EFFECTIVE DATE PAGE NUMBER WISCONSIN enterStatus 1 of 4 MANUAL REFERENCE DEPARTMENT OF CORRECTIONS ☒ New ☐ Revision DJC POLICY # Original Date: Division of Juvenile Corrections 500.30.72 [Comments] ORIGINATED BY Ron E. Hermes, Administrator Policy and Procedure X Date Signed: DISSEMINATION PRIORITY ☐ All Staff ☐ Confidential – Security Related ☒ Policy/Directive ☐ Information ☐ Facilities Discuss at Staff Meeting Read/Route/Post ☐ Field Offices ☒ Health Services ☐ Supervisory Staff Only REPLACES POLICY [Category] SUBJECT: Nursing Vital Signs Referral Parameters Purpose The purpose of this policy is to provide guidance to DJC nursing staff in the collection, monitoring, and referral of youth vital sign measurement. Policy The Division of Juvenile Corrections (DJC) shall ensure nursing staff monitor and relay to an advanced care provider changes in youth vital signs that may indicate a change or decline in a youth’s health condition. References Standards for Health Services in Juvenile Detention and Confinement Facilities – National Commission on Correctional Health Care, 2015, Y-E-11 – Nursing Assessment Protocols Emergency Nurses Association. Clinical Practice Guidelines: Orthostatic Vitals, revised March 2013 National Heart, Lung, and Blood Institute (NHLBI). The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents, revised May 2005. Retrieved at: www.nhlbi.nih.gov Normal Ranges of Heart Rate and Respiratory Rate in Children from Birth to 18 Years of Age: A Systematic Review of Observational Studies, 2011, 377 (97), 1011-1018. Pediatric Vital Signs. Retrieved at: www.emedicine health.com, 2018 Wisconsin Administrative Code Ch. N 6 – Standards of Practice for Registered Nurses and Licensed Practical Nurses Wisconsin Statute § 302.386 - Medical and dental services for prisoners and forensic patients DJC Policy 500.30.11 – Daily Handling of Non-Emergency Health Care Requests and Services DJC Policy 500.30.18 – Nursing Protocols Definitions, Acronym, and Forms Advanced Care Provider (ACP) – Provider with prescriptive authority EFFECTIVE DATE PAGE NUMBER Nursing Vital Signs Referral Parameters enterStatus 2 of 4 Procedure I. Overview A. There are both urgent and emergent situations with different parameters that require ACP notification. B. Reference ranges for blood pressure, pulse, and respiratory rate change as a youth grows or ages and may vary by sex, height, weight, and clinical circumstances. C. Vital signs shall be used as part of an overall assessment of a youth’s health status, and interpretation of measured values shall also take into account any factors that may affect them, including age, sex, and health history of a youth. D. Temperature shall be recorded in Celsius, weight shall be recorded in kilograms, and height shall be recorded in centimeters. E. The parameters listed in this policy and reference section serve as a guideline that nursing should notify the ACP. Nursing shall not hesitate to contact an ACP in circumstances when a youth’s vitals do not meet these call parameters, but the nurse’s clinical judgment determines a call is warranted. F. Nurses are expected to ensure complete vital signs are taken in a consistent manner and shall include each of the following on each assessment: 1. Blood pressure, pulse, respiratory rate, temperature, oxygen saturation. 2. Optional values can be added based on nursing judgment or physician orders to include weight and orthostatic measurements. II. Training A. Nursing staff shall be trained on the proper use of the vital sign equipment. B. Vital signs shall be taken after the youth has remained seated quietly for about 5-10 minutes, whenever possible. C. Nurses shall document reasons for not checking complete vital signs. III. ACP Notification A. The table below lists general parameters for which an ACP shall be notified for urgent and emergent vital sign measurements. B. There will be situations when a youth’s vital signs are not in the urgent or emergent range. Nursing shall use their clinical judgment to make additional contact with an ACP if the nurse feels the vital signs measured signify a concern for the youth’s health. Examples may include: 1. Immunocompromised youth or those on prolonged corticosteroid therapy or other immunosuppressive agents 2. Youth with underlying cardiac or chronic debilitating diseases 3. Youth with implanted prosthetic devices 4. Youth’s varying age IV. Orthostatic Vital Signs A. A youth shall rest in a flat, supine position 5-10 minutes prior to the first blood pressure measurement. B. Blood pressure measurements shall be taken at one and three minutes after standing. EFFECTIVE DATE PAGE NUMBER Nursing Vital Signs Referral Parameters enterStatus 3 of 4 C. Position change from supine to standing has better diagnostic accuracy in volume depleted youth compared to position changes from supine to sitting and then to standing. Sitting measurements are not required but may be added. D. Symptoms such as dizziness and syncope, in combination with orthostatic vital signs, are more sensitive indicators of volume loss than vital sign changes alone. Symptoms present shall be documented with the orthostatic variables. V. Vital sign parameters for youth 18 years and older Vital Signs Urgent Referral Emergent Value Referral Same day referral to on-site ACP or Requires immediate referral to on-site with on-call physician for further care. ACP or on-call physician. High Low High Low Temperature > 38.61 °C < 35.55 °C > 39.72°C < 34°C Pulse > 120 < 50 > 140 < 40 Respiration > 24 < 12 > 30 < 12 Pulse Oximetry N/A < 90 N/A < 85 Systolic Diastolic Systolic Diastolic Blood Pressure > 170 > 105 > 200 > 120 < 85 < 45 < 80 < 40 Orthostatics Systolic BP Pulse Systolic BP Pulse Change from supine to ≥ 10 point drop ≥10 point increase ≥ 20 point drop ≥ 20 point increase standing cc: Office of the Secretary DJC Leadership Team EFFECTIVE DATE PAGE NUMBER Nursing Vital Signs Referral Parameters enterStatus 4 of 4 Division of Juvenile Corrections Facility/Region Implementation Procedure Facility/Region: DJC Policy Number: 500.30.72 Subject: Nursing Vital Signs Referral Parameters New Effective Date: Original Effective Date: [Comments] Will Implement: ☐ As Written ☐ With following procedures for facility implementation Superintendent’s/Regional Chief’s Approval: REFERENCES DEFINITIONS, ACRONYMS, AND FORMS FACILITY PROCEDURE I. A. B. 1. 2. a. b. c. 3. C. II. III. RESPONSIBILITY I. Staff II. Youth III. Other .
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