vitals and history taking. where are we going? what are vital signs? how do you take them? so,...
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Vitals and History Taking
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Where are we going?
What are vital signs?
How do you take them?
So, what’s normal?
SAMPLE History
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What are the vitals
They provide information about the status of a patient
Temperature
Breathing (Respirations)
Pulse
Skin and Pupils
Blood Pressure
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Temperature
One of the first assessments done.Normal Adult temp. 98.6ºF or 37ºCVariations range from 96.8ºF-100.4ºF 36.0ºC-38.0ºC
Changes within the body or exposure to the environment can cause variationsTime of day, allergic rxns, illness, stressExposure to heat/cold
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Temperature Cont’d
When a temp. is above 100.4ºF (38.0ºC) 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.
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Temperature Cont’dTemperature Sites: Oral-within the mouth or under the tongue Axillary - in the armpit Tympanic - in the ear canal Rectal - through the anus, in the rectum
Types of Thermometers Glass (picture page 323)
Rounded tip- rectal Long tip - oral (more surface area) Security tip - can be used for both
Thermometer Handles: Red:rectal Blue: oral and axillary
Electronic
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Pulse
A wave of blood flow created by a contraction of the heart
How to take a pulse (P) Palpate - feel by using 2 fingers Auscultate - listening using a stethoscope or
electronic vital signs machine
Provides information on how many pumps of the heart it takes to circulation all 5.2L of blood (in an adult)
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Pulse
Determined 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 point
Don’t use your thumb
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Common Pulse Points
Central Pulses Carotid Femoral Apical
Peripheral Pulses Radial Brachial (children
under 1) Posterior Tibial,
Dorsalis Pedis Temporal Popliteal
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Pulse Cont’d
Apical PulseStethoscope5-6 intercostal space, left of sternumMust be taken before giving certain meds
that may slow the HRDigitalis
Use table 9-1 as a reference pg. 326
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Normal Pulse Rate (BPM, bpm)
AdultAdulthood 72-80Late adulthood 60-80
Child Newborn 120-1601 mo.-1 yr 80-1401-6 yrs 80-1206-adolescence 75-110
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Pulse Rate
Tachycardia: Rapid pulse rate
Stress, medications Infection, pain, exercise Lack of oxygen Low BP
Bradycardia: Slow pulse rate
Heart meds, physically fit Severe low BP or oxygen levels
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Pulse Quality
Strength: scale of 0-30 -absent, unable to detect1-thready, weak, diff. to palpate2-strong, normal3-bounding,
Regular/Irregular pulse rhythmArrhythmia or dysrhythmia
Bilateral Presence
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Blood Pressure
Taken with manual or automatic BP cuff
Taken by auscultation
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Key Terms
Systolic (SBP) Pressure on arterial
walls when heart is pumping
Diastolic (DBP) Resting pressure on
arterial walls when heart relaxes between contractions
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BP by Auscultation
Size 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. 331…read and record in your notes NOW
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Normal Blood Pressure
Male Systolic = 100+age
until 50 Diastolic =60-90
Female Systolic=90+age
until 50 Diastolic = 50-80
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Respirations
The act of breathing, or the exchange of oxygen and carbon dioxide Includes: inhalation and exhalation
When you count respirations, you count one inhalation and one exhalation as one respiration or a complete breath
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Counting Respirations
Methods to counting Respiration Rate (RR)Observe a client’s chest movement
upward and outward for a complete minuteChildren <7yrs: use abdominal breathing,
abnormal for adults (dyspnea)Auscultation with stethoscope
A hand on the stomach/chest may help
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Normal Respirations
Adult 12-20/min
Child 15-30/min
Infant 25-50/min
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Respiration Quality
NormalShallow (low tidal volume)Labored Use of accessory musclesFlaringTripod Breating
Noisy breathingVentilation: hyper and hypo
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Skin
Color Pink (Normal) Pale Cyanotic (Oxygen
problems) Red (CO or heat
problems) Yellow (Jaundice)
Temperature Warm (Normal) Hot Cool Cold
Condition Dry (Normal) Moist
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Practice
Get pulse and respirations from at least two people
Try to get pulse from carotid, radial, and brachial pulse points
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Assessing Skin
Color assessed using lips, nail beds, inside of mouth, membranes of the eye
Pull back glove to determine temp and condition
In children under 6 capillary refill is useful for determining perfusionRefill should take less than 2 seconds
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Pupils
SizeConstrictedDilatedEqual/Unequal
Reactivity to lightCan check with pen light or by shielding eyes from light
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One last note on Vitals
First set of vitals is the baseline, you are interested in changes
On not sick patients, repeat every 15 minutes
On sick patients, repeat every 5 minutes
Treat patient, not the vital signs or the equipment
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Practice
Get BP from two people
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History Taking
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SAMPLE
Organized technique to obtain pertinent medical informaiton
Can obtain information from patient, family or bystanders
SAMPLE is an acronym
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SAMPLE
Signs/Symptoms
Allergies
Medications
Past Pertinent Medical Conditions
Last Oral Intake
Events Leading to Injury or Illness
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Signs/Symptoms
Signs – things you can see or hear
Symptoms – things the patient reports
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Allergies
Environmental and Medical allergies are important
Medic Alert tags are also useful
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Medications
Prescription and OTC Including vitamins, herbal remedies
Birth Control PillsIllicit DrugsAlways get a list of meds, or take them with
Home O2 rate is also importantWhat did you take, when, how much?
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Past Pertinent Medical History
Underlying medical problems
Recent visits to hospitals/doctors
Recent medical procedures
Recent accidents/falls/trauma
Medic Alert tags may be useful
Look for signs of medical equipment in the house
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Last Oral Intake
What, how much, when
Important for trauma patients, diabetics
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Events Leading to Call
Get as much information as you can
What happened, what were you doing
Has anything unusual happened?
If this is a chronic problem, what’s different this time?
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Final SAMPLE notes
Try to ask open ended questions (avoid yes/no questions)
Wait for the patient to respond5-10 seconds is not out of line
Note pertinent negatives
Write everything down
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Practice
Let’s go through a couple of scenarios