Transcript Vitals and History Taking

Vitals and History Taking
Where are we going?
What are vital signs?
How do you take them?
So, what’s 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
Temperature
One of the first assessments done.
Normal Adult temp. 98.6ºF or 37ºC
Variations range from 96.8ºF-100.4ºF
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36.0ºC-38.0ºC
Changes within the body or exposure to
the environment can cause variations
Time of day, allergic rxns, illness, stress
 Exposure 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.
Temperature Cont’d
Temperature Sites:
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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
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Glass (picture page 323)
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Thermometer Handles:
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Rounded tip- rectal
Long tip - oral (more surface area)
Security tip - can be used for both
Red:rectal
Blue: oral and axillary
Electronic
Pulse
A wave of blood flow created by a contraction
of the heart
How to take a pulse (P)
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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)
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
Common Pulse Points
Central Pulses
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Carotid
Femoral
Apical
Peripheral Pulses
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Radial
Brachial (children
under 1)
Posterior Tibial,
Dorsalis Pedis
Temporal
Popliteal
Pulse Cont’d
Apical Pulse
Stethoscope
 5-6 intercostal space, left of sternum
 Must be taken before giving certain meds
that may slow the HR
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Digitalis
Use table 9-1 as a reference pg. 326
Normal Pulse Rate (BPM, bpm)
Adult
Adulthood 72-80
 Late adulthood 60-80
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Child
Newborn 120-160
 1 mo.-1 yr 80-140
 1-6 yrs 80-120
 6-adolescence 75-110
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Pulse Rate
Tachycardia:
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Rapid pulse rate
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Stress, medications
Infection, pain, exercise
Lack of oxygen
Low BP
Bradycardia:
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Slow pulse rate
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Heart meds, physically fit
Severe low BP or oxygen levels
Pulse Quality
Strength: scale of 0-3
0 -absent, unable to detect
 1-thready, weak, diff. to palpate
 2-strong, normal
 3-bounding,
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Regular/Irregular pulse rhythm
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Arrhythmia or dysrhythmia
Bilateral Presence
Blood Pressure
Taken with manual
or automatic BP cuff
Taken by
auscultation
Key Terms
Systolic (SBP)
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Pressure on arterial
walls when heart is
pumping
Diastolic (DBP)
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Resting pressure on
arterial walls when
heart relaxes
between contractions
BP by Auscultation
Size using guides on cuff
Position on upper arm hoses pointing down
Inflate 30mmHg past pulse (no greater than
180mmHg)
Position stethoscope over brachial artery
Deflate
Note first sound and last sound
Record as systolic/diastolic (140/80)
Pay attention to SAFETY on pg. 331…read
and record in your notes NOW
Normal Blood Pressure
Male
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Systolic = 100+age
until 50
Diastolic =60-90
Female
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Systolic=90+age
until 50
Diastolic = 50-80
Respirations
The act of breathing, or the exchange of
oxygen and carbon dioxide
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Includes: inhalation and exhalation
When you count respirations, you count
one inhalation and one exhalation as
one respiration or a complete breath
Counting Respirations
Methods to counting Respiration Rate
(RR)
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Observe a client’s chest movement
upward and outward for a complete minute
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Children <7yrs: use abdominal breathing,
abnormal for adults (dyspnea)
Auscultation with stethoscope
A hand on the stomach/chest may help
Normal Respirations
Adult 12-20/min
Child 15-30/min
Infant 25-50/min
Respiration Quality
Normal
Shallow (low tidal volume)
Labored
Use of accessory muscles
 Flaring
 Tripod Breating
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Noisy breathing
Ventilation: hyper and hypo
Skin
Color
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Pink (Normal)
Pale
Cyanotic (Oxygen
problems)
Red (CO or heat
problems)
Yellow (Jaundice)
Temperature
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Warm (Normal)
Hot
Cool
Cold
Condition
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Dry (Normal)
Moist
Practice
Get pulse and
respirations from at
least two people
Try to get pulse from
carotid, radial, and
brachial pulse points
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 perfusion
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Refill should take less than 2 seconds
Pupils
Size
Constricted
 Dilated
 Equal/Unequal
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Reactivity to light
Can check with pen light
or by shielding eyes
from light
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
Practice
Get BP from two
people
History Taking
SAMPLE
Organized technique to obtain pertinent
medical informaiton
Can obtain information from patient,
family or bystanders
SAMPLE is an acronym
SAMPLE
Signs/Symptoms
Allergies
Medications
Past Pertinent Medical Conditions
Last Oral Intake
Events Leading to Injury or Illness
Signs/Symptoms
Signs – things you can see or hear
Symptoms – things the patient reports
Allergies
Environmental and Medical allergies are
important
Medic Alert tags are also useful
Medications
Prescription and OTC
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Including vitamins, herbal remedies
Birth Control Pills
Illicit Drugs
Always get a list of meds, or take them
with
Home O2 rate is also important
What did you take, when, how much?
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
Last Oral Intake
What, how much, when
Important for trauma patients, diabetics
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?
Final SAMPLE notes
Try to ask open ended questions (avoid
yes/no questions)
Wait for the patient to respond
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5-10 seconds is not out of line
Note pertinent negatives
Write everything down
Practice
Let’s go through a
couple of scenarios