Transcript Chapter_005 530KB Jan 14 2015 08:21:50 AM

Chapter 5
Baseline Vital Signs
and SAMPLE History
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 1
Case History
You respond to a call and find a 52-year-old
female complaining of crushing chest pain
for one hour with pale, cool and sweaty skin.
She states that the pain radiates to her left
arm and she also feels nauseous and dizzy.
Her vital signs are: pulse 110 and regular,
blood pressure 90/70, and respirations 28
and labored.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 2
Overview

History and vitals signs are a standard part of every
patient assessment.

History is often the most important information in
identifying the cause of the patient’s condition.

Vital signs are the primary indicators of the severity of
the patient’s condition.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 3
General Information

Chief complaint

The problem, as described by the
patient
• “I have a pressure-like feeling in
my chest”
• “I have a pain in my wrist”
• “I feel like I am going to faint”

Age – years, months, days

Sex – male or female
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 4
Baseline Vital Signs





Respirations
Pulse
Blood pressure
Temperature
Pupils
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 5
Respirations

Rate


Number of breaths in 30
seconds x 2
Quality




Normal
Shallow
Labored
Noisy
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 6
Pulse

Assess rate and quality

Rate
 Number of beats in 30 seconds x 2

Quality
 Strong, weak
 Regular, irregular

Assess carotid pulse, if peripheral pulse not
present
 Use caution when palpating carotid pulses on
geriatric patients
 Never palpate both sides of carotid pulses
simultaneously
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 7
Pulse

Adults and children (> 1 y/o)



Radial pulse – anterior-lateral side of the
wrist
Carotid when peripheral pulse is not palpable
Infants

Brachial pulse
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 8
Assess Skin


Assess skin, nail beds, oral mucosa, and
conjunctiva
Color


Temperature



Normal, pale, cyanotic, flushed, jaundiced (yellow)
Assess using back of hand on patient’s skin
Normal, cool, warm
Condition

Flushed
Normal, moist, dry
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 9
Assess Capillary Refill



Used in infants and children
to assess perfusion
Compress nail bed and
release
Observe time to return of
color
Normal – < 2 seconds
 Delayed – > 2 seconds

Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 10
Blood Pressure

Measured in every patient > 3 y/o

Measurements
 Systolic – First sound, reflects pressure generated by ventricular
contraction
 Diastolic – Sound disappears or diminishes, reflects pressure during
relaxation phase of the ventricle

Techniques
 Auscultation
• 120/80
 Palpation
• 80/palp
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 11
Selecting the Proper Cuff


Blood pressure cuffs come in several sizes, which affect the accuracy
of the reading.
Index lines are used to ensure correct sizing.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 12
Pupils


Briefly shine light in eye
Observe


Size, equality, and
reactivity to light
Size



Dilated (wide)
Normal
Constricted (small)
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 13
Reassessment of
Vital Signs



Stable – every 15
minutes
Unstable patient –
every 5 minutes
Should be assessed
after all medical
interventions
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 14
SAMPLE History






Signs and symptoms
Allergies
Medications
Pertinent past medical history
Last oral intake
Events
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 15
Signs/Symptoms

Signs (Observations)

Examples
• Hear – respiratory distress
• See – bleeding
• Feel – cool, clammy skin

Symptoms (Complaints)

Examples
• Shortness of breath
• Chest pain
• Dizziness
• Nausea
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 16
Allergies

Medications

Food

Environmental allergies

Medical identification tag
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 17
Medications




Prescription
Birth control pills
Nonprescription
Consider medical identification tag
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 18
Pertinent Past History




Medical
Surgical
Trauma
Consider medical identification tag
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 19
Last Oral Intake
Events Leading to Injury or Illness

Last oral intake



Time
Quantity
Events

Examples
• Chest pain on exertion
• Chest pain while at rest
• Fainted, then injured arm
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 20