Vitals and History Taking

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Vitals and History Taking. Where are we going?. What are vital signs? How do you take them? So, whats normal? SAMPLE History. What are the vitals. They provide information about the status of a patient Temperature Breathing (Respirations) Pulse Skin and Pupils Blood Pressure. - PowerPoint PPT Presentation

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  • Vitals and History Taking

  • Where are we going?What are vital signs?How do you take them?So, whats normal?SAMPLE History

  • What are the vitalsThey provide information about the status of a patientTemperatureBreathing (Respirations)PulseSkin and PupilsBlood Pressure

  • TemperatureOne of the first assessments done.Normal Adult temp. 98.6F or 37CVariations range from 96.8F-100.4F 36.0C-38.0CChanges within the body or exposure to the environment can cause variationsTime of day, allergic rxns, illness, stressExposure to heat/cold

  • Temperature ContdWhen a temp. is above 100.4F (38.0C) you will document in the pt. chart, that the pt. is febrile.If a temp. is w/in normal range, you will use the term afebrile.

  • Temperature ContdTemperature Sites:Oral-within the mouth or under the tongueAxillary - in the armpitTympanic - in the ear canalRectal - through the anus, in the rectumTypes of ThermometersGlass (picture page 323)Rounded tip- rectal Long tip - oral (more surface area)Security tip - can be used for bothThermometer Handles:Red:rectalBlue: oral and axillaryElectronic

  • PulseA wave of blood flow created by a contraction of the heartHow to take a pulse (P)Palpate - feel by using 2 fingersAuscultate - listening using a stethoscope or electronic vital signs machineProvides information on how many pumps of the heart it takes to circulation all 5.2L of blood (in an adult)

  • PulseDetermined by counting for 30 sec and multiplying by 2.Irregular pulse counted for 60 sec.Provides information about heart, blood volume and perfusion.Taken at a pulse pointDont use your thumb

  • Common Pulse PointsCentral PulsesCarotidFemoralApical

    Peripheral PulsesRadialBrachial (children under 1)Posterior Tibial, Dorsalis PedisTemporalPopliteal

  • Pulse ContdApical PulseStethoscope5-6 intercostal space, left of sternumMust be taken before giving certain meds that may slow the HRDigitalisUse table 9-1 as a reference pg. 326

  • Normal Pulse Rate (BPM, bpm)AdultAdulthood 72-80Late adulthood 60-80Child Newborn 120-1601 mo.-1 yr 80-1401-6 yrs 80-1206-adolescence 75-110

  • Pulse RateTachycardia:Rapid pulse rateStress, medicationsInfection, pain, exerciseLack of oxygenLow BPBradycardia:Slow pulse rateHeart meds, physically fitSevere low BP or oxygen levels

  • Pulse QualityStrength: scale of 0-30 -absent, unable to detect1-thready, weak, diff. to palpate2-strong, normal3-bounding, Regular/Irregular pulse rhythmArrhythmia or dysrhythmiaBilateral Presence

  • Blood PressureTaken with manual or automatic BP cuffTaken by auscultation

  • Key TermsSystolic (SBP)Pressure on arterial walls when heart is pumpingDiastolic (DBP)Resting pressure on arterial walls when heart relaxes between contractions

  • BP by AuscultationSize using guides on cuffPosition on upper arm hoses pointing downInflate 30mmHg past pulse (no greater than 180mmHg)Position stethoscope over brachial arteryDeflate Note first sound and last soundRecord as systolic/diastolic (140/80)Pay attention to SAFETY on pg. 331read and record in your notes NOW

  • Normal Blood PressureMaleSystolic = 100+age until 50Diastolic =60-90FemaleSystolic=90+age until 50Diastolic = 50-80

  • RespirationsThe act of breathing, or the exchange of oxygen and carbon dioxideIncludes: inhalation and exhalation

    When you count respirations, you count one inhalation and one exhalation as one respiration or a complete breath

  • Counting RespirationsMethods to counting Respiration Rate (RR)Observe a clients chest movement upward and outward for a complete minuteChildren
  • Normal RespirationsAdult 12-20/minChild 15-30/minInfant 25-50/min

  • Respiration QualityNormalShallow (low tidal volume)Labored Use of accessory musclesFlaringTripod BreatingNoisy breathingVentilation: hyper and hypo

  • SkinColorPink (Normal)PaleCyanotic (Oxygen problems)Red (CO or heat problems)Yellow (Jaundice)

    TemperatureWarm (Normal)HotCoolColdConditionDry (Normal)Moist

  • PracticeGet pulse and respirations from at least two peopleTry to get pulse from carotid, radial, and brachial pulse points

  • Assessing SkinColor assessed using lips, nail beds, inside of mouth, membranes of the eyePull back glove to determine temp and conditionIn children under 6 capillary refill is useful for determining perfusionRefill should take less than 2 seconds

  • PupilsSizeConstrictedDilatedEqual/UnequalReactivity to lightCan check with pen light or by shielding eyes from light

  • One last note on VitalsFirst set of vitals is the baseline, you are interested in changesOn not sick patients, repeat every 15 minutesOn sick patients, repeat every 5 minutesTreat patient, not the vital signs or the equipment

  • PracticeGet BP from two people

  • History Taking

  • SAMPLEOrganized technique to obtain pertinent medical informaitonCan obtain information from patient, family or bystandersSAMPLE is an acronym

  • SAMPLESigns/SymptomsAllergiesMedicationsPast Pertinent Medical ConditionsLast Oral IntakeEvents Leading to Injury or Illness

  • Signs/SymptomsSigns things you can see or hearSymptoms things the patient reports

  • AllergiesEnvironmental and Medical allergies are importantMedic Alert tags are also useful

  • MedicationsPrescription and OTCIncluding vitamins, herbal remediesBirth Control PillsIllicit DrugsAlways get a list of meds, or take them withHome O2 rate is also importantWhat did you take, when, how much?

  • Past Pertinent Medical HistoryUnderlying medical problemsRecent visits to hospitals/doctorsRecent medical proceduresRecent accidents/falls/traumaMedic Alert tags may be usefulLook for signs of medical equipment in the house

  • Last Oral IntakeWhat, how much, whenImportant for trauma patients, diabetics

  • Events Leading to CallGet as much information as you canWhat happened, what were you doingHas anything unusual happened?If this is a chronic problem, whats different this time?

  • Final SAMPLE notesTry to ask open ended questions (avoid yes/no questions)Wait for the patient to respond5-10 seconds is not out of lineNote pertinent negativesWrite everything down

  • PracticeLets go through a couple of scenarios

    *Patient can fake a respiration rate May need to pretend to take a pulse and count respirations*Patient can fake a respiration rate May need to pretend to take a pulse and count respirations**Patient can fake a respiration rate May need to pretend to take a pulse and count respirations*Patient can fake a respiration rate May need to pretend to take a pulse and count respirations*Abnormally dry skin can be heat or dehydration related*If you note color change, especially cyanosis, note where you see the color change. Cyanosis in the extremities is different from cyanosis at the core (mouth)

    Cap refill is not a reliable indicator of perfusion for adults, or when temp is low. Can be used to determine perfusion to extremities if distal pulse can not be found (especially in the feet)*Dialated Cardiac Arrest, LSD, Amphetamines, darknessConstricted CNS disorder, Narcotics, bright lightUnequal Head Trauma,stroke, artificial eye, normal conditionUnreactive could be CNS problem, head trauma, drug use*Nausea is a symptom, vomiting is a sign*Had a patient brought in with chest pains (I believe) problem was an overdose of a vitamin suplement

    If patient is unresponsive, where can you go to get the meds?*Scenario 1: Called to scene of 86 M who has fallen and cant get up. You are first on scene. After determining ABCs are Ok you are asked to do vitals. What do you check?P: 78 regularR: 18 normalB/P 168/82Skin:warm, pink, dryPupils: PERLA

    (What do you think about vitals)S: Pain in left hip (sign or symptom), leg is shortened and rotated outward (sign or symptom)A: PenecilinM: Glucagon, Asprin qday, vitaminsP: Hip replacement 8 years agoL: Dinner last evening, glass of water while waiting for ambulanceE: Climbing on chair, slipped and fell about 9:00am

    Scenario 2: 60M difficulty breathing. Upon arrival pt sitting on edge of bed. You are first on scene and once you determine that there are no ABC issues that you can address before additional assistance arrives, you obtain vitals and history

    P: 50 weak, irregularR: 26 a bit noisyB/P: 50/80PERLACyanotic, clammy

    S: Shortness of breath, posture, noisy breathingA: NKAM: Digoxin, Lasix and occasionally nitro sublingualP: Heart attack 5 years ago, L: bowl of soup for lunch, no dinnerE:shoveled snow earlier today. No chest pain, sob began following shoveling

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