Vital signs of acutely ill infants in intensive care are continuously monitored. Nurses should record the temperature, heart rate, respiratory rate, blood pressure, and pulse oximeter reading q1 – 4 hours based on the infant’s clinical status.

The heart rate and respiratory rate should be documented q1 hour in an infant requiring assisted ventilation. For an infant requiring mechanical ventilation, the FiO₂, ventilator settings, and pulse oximeter reading should be recorded q1 hour.

The blood pressure should be documented q1 hour if unstable or if the infant has a UAC or peripheral arterial line. If a heart murmur is present or a PDA is suspected, baseline 4 extremity blood pressures should be obtained.

In surgical infants, pain should be assessed q4 hours for at least the first 3 days post-operatively. Thereafter, and in other infants, pain assessment should be documented q shift.

At a minimum, vital signs in a neonate in the intermediate nursery should be assessed q 4 hours with blood pressure measurement and a pain assessment performed q shift.

Infants rooming-in with their parents should have vital signs recorded q8 hours; blood pressure does not need to be recorded unless specified by the physician.

For further reference, see NICU Nursing Guidelines 40:08.14 and 40:08.55 and the 2001 NICU Manual pgs. 5-10 to 5-11.