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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.

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Vitals and History Taking

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  1. Vitals and History Taking

  2. Where are we going? • What are vital signs? • How do you take them? • So, what’s normal? • SAMPLE History

  3. What are the vitals • They provide information about the status of a patient • Temperature • Breathing (Respirations) • Pulse • Skin and Pupils • Blood Pressure

  4. Temperature • One of the first assessments done. • Normal Adult temp. 98.6ºF or 37ºC • Variations range from 96.8ºF-100.4ºF • 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

  5. 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.

  6. Temperature Cont’d • Temperature 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

  7. 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)

  8. 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

  9. Central Pulses Carotid Femoral Apical Peripheral Pulses Radial Brachial (children under 1) Posterior Tibial, Dorsalis Pedis Temporal Popliteal Common Pulse Points

  10. 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 • Digitalis • Use table 9-1 as a reference pg. 326

  11. Normal Pulse Rate (BPM, bpm) • Adult • Adulthood 72-80 • Late adulthood 60-80 • Child • Newborn 120-160 • 1 mo.-1 yr 80-140 • 1-6 yrs 80-120 • 6-adolescence 75-110

  12. 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

  13. Pulse Quality • Strength: scale of 0-3 • 0 -absent, unable to detect • 1-thready, weak, diff. to palpate • 2-strong, normal • 3-bounding, • Regular/Irregular pulse rhythm • Arrhythmia or dysrhythmia • Bilateral Presence

  14. Blood Pressure • Taken with manual or automatic BP cuff • Taken by auscultation

  15. Key Terms • Systolic (SBP) • Pressure on arterial walls when heart is pumping • Diastolic (DBP) • Resting pressure on arterial walls when heart relaxes between contractions

  16. 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

  17. Male Systolic = 100+age until 50 Diastolic =60-90 Female Systolic=90+age until 50 Diastolic = 50-80 Normal Blood Pressure

  18. 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

  19. Counting Respirations • Methods to counting Respiration Rate (RR) • Observe a client’s chest movement upward and outward for a complete minute • Children <7yrs: use abdominal breathing, abnormal for adults (dyspnea) • Auscultation with stethoscope • A hand on the stomach/chest may help

  20. Normal Respirations • Adult 12-20/min • Child 15-30/min • Infant 25-50/min

  21. Respiration Quality • Normal • Shallow (low tidal volume) • Labored • Use of accessory muscles • Flaring • Tripod Breating • Noisy breathing • Ventilation: hyper and hypo

  22. Color Pink (Normal) Pale Cyanotic (Oxygen problems) Red (CO or heat problems) Yellow (Jaundice) Temperature Warm (Normal) Hot Cool Cold Condition Dry (Normal) Moist Skin

  23. Practice • Get pulse and respirations from at least two people • Try to get pulse from carotid, radial, and brachial pulse points

  24. 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 • Refill should take less than 2 seconds

  25. Pupils • Size • Constricted • Dilated • Equal/Unequal • Reactivity to light • Can check with pen light or by shielding eyes from light

  26. 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

  27. Practice • Get BP from two people

  28. History Taking

  29. SAMPLE • Organized technique to obtain pertinent medical informaiton • Can obtain information from patient, family or bystanders • SAMPLE is an acronym

  30. SAMPLE • Signs/Symptoms • Allergies • Medications • Past Pertinent Medical Conditions • Last Oral Intake • Events Leading to Injury or Illness

  31. Signs/Symptoms • Signs – things you can see or hear • Symptoms – things the patient reports

  32. Allergies • Environmental and Medical allergies are important • Medic Alert tags are also useful

  33. Medications • Prescription and OTC • 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?

  34. 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

  35. Last Oral Intake • What, how much, when • Important for trauma patients, diabetics

  36. 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?

  37. Final SAMPLE notes • Try to ask open ended questions (avoid yes/no questions) • Wait for the patient to respond • 5-10 seconds is not out of line • Note pertinent negatives • Write everything down

  38. Practice • Let’s go through a couple of scenarios

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