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Baseline Observations. All information is taken from the IHCD Green Book or JRCALC 2004 / 2006. It is aimed at CFR level. Pulses. We use 3 factors when examining a pulse Rate Rhythm Volume. Rate.
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Baseline Observations All information is taken from the IHCD Green Book or JRCALC 2004 / 2006. It is aimed at CFR level.
We use 3 factors when examining a pulse • Rate • Rhythm • Volume
Rate • The rate of a pulse (or speed) gives us an indication of the oxygenation and volume of the blood. • If it is pumping fast, it may mean the heart is working faster to get blood and the oxygen attached to it around the body.
Rhythm • Is it regular or irregular? • This gives us an indication of how well the conductive system of the heart is working (the electrical side of it!) • A normal heart should beat in a set rhythm
Volume • How strong is a pulse? • A strong pulse at the wrist (radial) suggests the patient has a good blood pressure. • If you are unable to find a pulse at the wrist, or a very weak pulse, this may suggest the patient has a low blood pressure (so check it!)
Useful Information When you can find a pulse at the following site you can assume your patient has a systolic BP greater than…… Carotid (Neck) Femoral (Groin) Radial (Wrist) 60 mm/Hg 70 mm/Hg 80 mm/Hg
Pulse Sites • Carotid • Brachial • Radial • Femoral • Pedal • In the ambulance service we look at 5 different pulse sites. We use them to assess our patients
Distal Pulses When dealing with an injury we look for something called the distal pulse. This is the pulse further away from the injury. I.e. if you break your arm we check the radial pulse (wrist) and compare it with another pulse site to make sure that there is no vessel damage to the extremity because of the injury. We would do the same with the paedal pulse for a broken leg / ankle / hip etc
Respirations • What are normal respirations? • An adult takes between 12 – 20 breaths a minute. • A child of school age (5-12) between 18 – 30 • A toddler (3-5) between 24 – 40 • An infant (0-3) between 30-60 • Their chest should rise and fall without noticeable effort. • It should be a relatively quiet action
So what changes are we looking for when assessing respirations • Rate • Depth (shallow or excessively deep) • Use of accessory muscles • Noticeable sounds when breathing in or out • Is their difficulty with breathing in, or breathing out? • Abnormal smells
Rate • What is normal for the patients age? • Children breath much quicker than adults. A newborn babies rate could range from 30 – 60 breaths a minute. • Is the patient anxious? • Is their body desperately trying to take on more oxygen? • Is there an injury that may effect the respiratory centre in the brain, which in turn is not telling the body to breath? • Is there the chance they may have taken an overdose?
We are told - • Anyone with a respiratory rate of under 10 breaths a minute should be supported using the BVM. • What if they are conscious? A: Coached breathing – breathe in, breathe out (prompt them)
Depth of Breathing • Is the patient only able to take very shallow breaths. Why? • Is it due to a medical condition affecting their lungs? • Is it too painful due to an injury to the chest?
Are they using accessory muscles • Do their shoulders rise noticeably when taking a breath? • Does their stomach move on inspiration? • Do they have a painful / anxious look on their face? • Nasal flaring
Listen to their breathing • Can you hear a wheeze? Crackles? A type of bark? • What could these be? • Wheeze – Lower airway – Asthma • Stridor – Upper airway – Obstruction or Airway Burn • Crepitations – Air spaces popping – Oedema i.e. mucus from a chest infection. • When can you hear it? On inspiration or on expiration?
Listen to their breathing • If heard audibly you should ideally be using a stethoscope to further listen to their breathing. • Is it in all lung fields • On inspiration or expiration • Does position change the sound (sitting or lying) • Are they coughing anything up? (colour, frothy, blood stained - take a sample).
Listen to their breathing • Stethoscope positioning
Smells! • What can you smell on their breath? • Alcohol – this may depress the respiratory rate if the patient has drunk enough • Sweet, sickly (pear drops smell). Is the patient diabetic and having a hyperglycaemic attack. This would normally be coupled with ‘kussmaul’ respirations. This is deep laboured breathing commonly associated with metabolic acidosis.
So respirations, summed up • Look at the patients breathing. Compare it with normal respirations. • What is different, when is it different. • Report your findings in your handover and on your paperwork.
Monitoring respirations using equipment. The easiest way to count someone's respirations is to put them onto oxygen and count the times the mask mists up as they take a breath. New O2 masks
Monitoring the effectiveness of respirations using a Oxygen Saturations Monitor • SATS monitors will come in a variety of forms.
Monitoring the Patient • As a general rule the SATS monitor will only work well if – • The patient is not cold • They are wearing no nail varnish • Their finger sits snugly into the machines probe.
So what does it show? • The patients pulse rate (ongoing) • The oxygen saturation of the extremity (finger) that is being monitored. • Some models show you the strength (and reliability) of the reading. Sometimes using a Red/Amber/Green light.
What would be normal • A normal adult should have saturations of between what? • 95-100% • Smokers may have a slightly lower reading of between 96 – 98% • Get the patient to take a deep breath and see if their saturations will rise higher before automatically giving oxygen to non-dependant patients.
If the reading is low - • Try another finger and check the strength indicator. • If still low, administer oxygen and alter the positioning of the patient (sitting up etc) and monitor any changes on the SATS probe. • The hospital will need to know the patients SATS before oxygen and after oxygen, so remember to record it.
Saturations showing as 98 – 100%, but you’re not sure! • If you feel the patient is cyanosed, or very pale and the SATS machine is showing good saturations, act on what you see, not what the machine tells you. • Remember to think ‘hyperventilation’ first though. These patients look in extreme distress, but are always a good colour and will have good SATS.
PRACTICAL EXERCISE • In groups – • Monitor each other on the SATS probe, check the monitors pulse rate with a manual check of the pulse. • Is anyone a smoker? What are their SATS levels compared to a non smoker? • Hold your breath. Does it change the reading? • Practice counting each others resp. rate without using an oxygen mask. • Practice counting each others resp. rate watching the misting on an oxygen mask. • Which method do you prefer?
What is blood pressure? • Blood pressure is defined as the pressure which blood exerts on the walls of the blood vessels. The pressure is greater in the large arteries leaving the heart and lowest in the large veins approaching the heart. • When the left ventricle contracts and pushes the blood into the aorta, the pressure produced is called the ‘Systolic’ pressure. • When the heart is relaxing after the ejection of blood, the pressure within the arteries is called the ‘Diastolic’ blood pressure. • So a BP of 120/80 is a systolic pressure of 120mm Hg and a diastolic pressure of 80mm Hg. Remember SOD, systolic over diastolic it will help you remember how to write a blood pressure.
What is a normal BP? • In an adult your systolic should be 100 plus your age upto 40. (i.e. a 20 year old should have a systolic of 120, and a 39 year old should have one of 139). • Diastolic should always be about 80, and would be treated if above 100 with drugs. (by your GP)
What could effect blood pressure? • Reduction in blood volume. Fluids can be lost through wounds, burns, dehydration and fractures. • Problems with the nerves that effect the resistance of the blood vessels. • Damage to the vessels, or the heart (the pump of the system) • Shock • Stress
What could cause low blood pressure? (hypotension) • Loss of blood (hypovolaemic shock) through a visible injury, a hidden injury (i.e. internal injury), large bone fractures, dehydration (could be associated with D and V) and burns. • Postural Hypotension (sitting or standing up too quickly). Common in the elderly as their reflexes are slower. Sometimes call syncope.
What could cause high blood pressure (hypertension) • Strokes (CVA / TIA) • Stress • Anxiety • Some cardiac problems • Old age, due to the arteries being clogged up with plaque. (these patients will usually be on blood pressure lowering medication from their GP) • Head injuries after the initial drop in BP (late stages)
How can we monitor a patients blood pressure? • Electronic cuff • Manual blood pressure (using a stethoscope and cuff) • Systolic check using pulse points • Systolic check using cuff and pulse points • What is the preferred and most accurate method? • Manual method!!!
How can we raise someone’s blood pressure if it is low? • Lay them down and raise their feet. (unless their injuries do not allow this)
How do we lower a patients blood pressure? • Some raises in BP are due to anxiety and stress, so try to calm and reassure the patient and remove anything stressing the patient out. E.g. relatives, remove the patient from a public place if they are embarrassed as everyone is watching them. • HCP’s may give drugs that have the side effect of lowering BP’s (e.g. GTN)
BP Cuff Placement • Most have an arrow on to identify where it should be placed in relation to the brachial artery. Follow this. • If it doesn’t place it so the tube follows the artery down the arm. • Wrap it firmly around the upper arm above the elbow crease. • On or under clothing?
Stethoscope • Ensure the ear tips of the stethoscope point slightly forward. • Just try to put your fingers in your ears pointing them straight. • Now try by pointing them slightly forward. • The bell should sit over the brachial artery, generally this is in the centre of the elbow crease but can be slightly medial.
PRACTICAL SESSION • Watch the following video then get into pairs and away you go. http://www.youtube.com/watch?v=u6saTO8_o2g&feature=related • Try using the cuff and pulse site technique to determine your patients systolic BP. • If you are really brave, try taking a Blood Pressure with a cuff and steth. Ask if you want someone to come and check it with you using the training dual ear stethoscope if we have one!
Basic First Line Check • AVPU • A – Alert and orientated • V – Responds to voice (when spoken to) • P – Responds to painful stimuli / or withdraws from it. ear pinch, finger bed irritation or firm tap on the shoulders • U - Unresponsive
More Advanced Method • GCS – Glasgow Coma Scale • The GCS tests three different neurological responses from aspects of the patients behaviour • Eye opening • Verbal Response • Motor Response
GCS – Glasgow Coma Scale • Eye Opening -Scored out of 4 • 4: Spontaneous when approached they may well be open. • 3: Opening to Speech if they are not opening spontaneously, first speak and if necessary shout. • 2: Opening to Pain exerting a little pressure on the finger nail bed is the most effective method. • 1: No Eye Opening neither eye opens to painful stimulation.
GCS – Glasgow Coma Scale • Verbal Response -Scored out of 5 • 5: Orientated Ask who they are, where they are and what year/month it is. /if accurate the pt is orientated. • 4: Confused Conversation When they can produce meaningful phrases or sentences but are unable to give accurate answers to questions. • 3: Inappropriate Words Pt saying only one or two words (often swearing) for no apparent reason. • 2: Incomprehensible Words Groans, mutterings or mumblings. No intelligible words. • 1: No Verbal Response Prolonged or repeated stimulation produces no verbal response.
GCS – Glasgow Coma Scale • Motor Response -Scored out of 6 • 6: Obeys commands Pt can accurately respond to instructions with a number of different movements i.e. open your eyes, raise your left arm, put out your tongue. • 5: Localises Pain If the pt can move an arm to locate a painful stimulus on head or trunk in an effort to remove it. • 4: Withdraws from Pain Pulls away from painful stimulus. • 3: Abnormal Flexion Painful stimulus at the fingertips causes abnormal flexion of the limbs. Decorticate posture • 2: Extensor Response The stimulus causes limb extension (adduction, internal rotation of the shoulder, pronation of forearm). Decerebrate posture • 1: No Response to Pain No detectable response to pain.
Motor Response • Decorticate and Decerebrate responses are never easy to remember; but are to picture!
GCS Chart • Most find it easier to carry a copy of a chart than remembering it.
Quick summary • Just remember – you do not need to include all of this for each patient. • Key things are: • Alertness – on arrival and current state. • Obs – first and current if more than one set. • Saturation – pre and post O2. • Any history you feel is relevant • Anything else you have come across • The most important thing is to reassure the patient before any of this and do any treatment to prevent them deteriorating!
