Question: What are the standards and frequency recommendations for taking “routine” and “post-operative” vital signs?

Complete Question: I am a permanent member of the Nursing Policy and Procedure Committee as an employee of the Risk Management Department. Does AMSN have standards/ recommendations for frequency and times for post-op vital signs?

Several members of the Clinical Practice Committee reviewed and investigated the answer to this question.

Answer:

Routine Vital Signs:

Vital signs are generally considered to include temperature, heart rate, respiratory rate, and blood pressure. Pain is described as the “fifth vital sign” and is frequently assessed at the same time. In medical-surgical settings, pulse oximetry is often evaluated when vital signs are assessed.

There are no clear evidence-based guidelines for how often vital signs should be assessed (Kowalak, 2015). In medical-surgical settings, vital signs are generally assessed every 4-8 hours. Some patient care units may decide, based on patient acuity or population, that vital signs should be assessed more frequently.

The following should be considered when deciding on the frequency of vital sign assessment:

  • The patient’s diagnosis and comorbidities
  • The patient’s level of acuity and risk for complications
  • Treatments and medications that the patient is receiving
  • Trends in the patient’s vital signs
  • Provider orders
  • Agency policy

In addition to assessing vital signs per unit policy, they should also be evaluated at the following times:

  • Admission, transfer or discharge
  • At the time of any change in condition
  • Before and after a surgical or diagnostic procedure
  • Before administering medications, which may affect cardiac or respiratory function (Taylor, Lillis & Lynn, 2016).

Many facilities also use other strategies in addition to vital signs for evaluating a patient’s stability and acuity. For example, the Modified Early Warning System (MEWS) includes temperature, heart rate, respiratory rate, blood pressure and level of consciousness and can be used to detect early signs of decompensation (Mathukia, WuQiang, Biege & Krishnamurthy, 2014).

Post-operative Vital Signs:

There is also little evidence-based information to provide guidance on how often vital signs should be evaluated in the postoperative patient. The American Society of PeriAnesthesia Nursing (ASPAN) recommends 15 minute vital monitoring and documentation in the first hour of the post anesthesia recovery period (ASPAN, 2016).

Although unit policies vary, postoperative vital signs (temperature, heart rate, respiratory rate, blood pressure, pain and pulse oximetry) on a medical-surgical unit are generally recommended:

  • Every 15 minutes x 4
  • Every 30 minutes x 2
  • Every 1 hour x 4  (Menez, 2016)
  • then every 4 hours (if stable) until 24 hours post-op

We encourage you to review these references, and work with the interdisciplinary team within your organization to establish the standard for frequency of vital signs specific to your patient population.

References:

  • American Society of PeriAnesthesia Nurses. (2016). 2017-2018 Perianesthesia nursing standards practice recommendations and interpretive statements, (1st ed.). Cherry Hill, NJ: ASPAN
  • Kowalak, J.P. (Ed.). (2015). Lippincott's nursing procedures (7th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.
  • Mathukia, C., WuQiang, F., Biege, C., & Krishnamurthy, M. (2014). Modified early warning system improves patient safety and clinical outcomes in an academic community hospital. Journal of Community Hospital Internal Medicine Perspectives, 5(2). https://doi.org/10.3402/jchimp.v5.26716
  • Menez, J.A. (2016). Perioperative nursing care. In H. Craven (Ed.) Core curriculum for medical-surgical nursing practice, (5th ed.) (pp. 171-189). Pitman, NJ: Academy of Medical-Surgical Nurses.
  • Taylor, C., Lillis, C., & Lynn, P. (2016). Fundamentals of nursing: The art and science of person-centered nursing care. Philadelphia: Wolters Kluwer.

(Updated April 2019)
(Updated January 2015)
(Published 2013)