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 patientTemperatureBreathing (Respirations)PulseSkin and PupilsBlood Pressure

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

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’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

Pulse

A wave of blood flow created by a contraction of the heartHow 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)

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 pointDon’t use your thumb

Common Pulse Points

Central Pulses Carotid Femoral Apical

Peripheral Pulses Radial Brachial (children

under 1) Posterior Tibial,

Dorsalis Pedis Temporal Popliteal

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

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

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

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

Blood Pressure

Taken with manual or automatic BP cuffTaken by auscultation

Key Terms

Systolic (SBP) Pressure on arterial

walls when heart is pumping

Diastolic (DBP) Resting pressure on

arterial walls when heart relaxes between contractions

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

Normal Blood Pressure

Male Systolic = 100+age

until 50 Diastolic =60-90

Female Systolic=90+age

until 50 Diastolic = 50-80

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

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

Normal Respirations

Adult 12-20/minChild 15-30/minInfant 25-50/min

Respiration Quality

NormalShallow (low tidal volume)Labored Use of accessory musclesFlaringTripod Breating

Noisy breathingVentilation: hyper and hypo

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

Practice

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

Assessing Skin

Color 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

Pupils

SizeConstrictedDilatedEqual/Unequal

Reactivity to lightCan 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 changesOn not sick patients, repeat every 15 minutesOn sick patients, repeat every 5 minutesTreat patient, not the vital signs or the equipment

Practice

Get BP from two people

History Taking

SAMPLE

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

SAMPLE

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

Signs/Symptoms

Signs – things you can see or hearSymptoms – things the patient reports

Allergies

Environmental and Medical allergies are importantMedic Alert tags are also useful

Medications

Prescription and OTC Including vitamins, herbal remedies

Birth 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 History

Underlying 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 Intake

What, how much, whenImportant for trauma patients, diabetics

Events Leading to Call

Get as much information as you canWhat happened, what were you doingHas 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 respond5-10 seconds is not out of line

Note pertinent negativesWrite everything down

Practice

Let’s go through a couple of scenarios