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Vitals and History Taking. Hillcrest Fire Training December, 2000. 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 Breating (Respirations) Pulse Skin Pupils

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vitals and history taking

Vitals and History Taking

Hillcrest Fire Training

December, 2000

where are we going
Where are we going?
  • What are vital signs?
  • How do you take them?
  • So, what’s normal?
  • SAMPLE History
what are the vitals
What are the vitals
  • They provide information about the status of a patient
  • Breating (Respirations)
  • Pulse
  • Skin
  • Pupils
  • Blood Pressure
counting respirations
Counting Respirations
  • Respiration is one inhalation and exhalation.
  • Determined by counting for 30 sec, and multiplying by 2.
  • A hand on the stomach/chest may help
normal respirations
Normal Respirations
  • Adult 12-20/min
  • Child 15-30/min
  • Infant 25-50/min
respiration quality
Respiration Quality
  • Normal
  • Shallow (low tidal volume)
  • Labored
    • Use of accessory muscles
    • Flaring
    • Tripod Breating
  • Noisy breathing
pulse
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

Carotid

Femoral

Peripheral Pulses

Radial

Brachial (children under 1)

Posterior Tibial, Dorsalis Pedis

Common Pulse Points
pulse quality
Pulse Quality
  • Normal
  • Bounding
  • Weak
  • Thready
  • Regular/Irregular
normal pulse rate
Normal Pulse Rate
  • Adult 60-80/min
  • Child 80-120
  • Infant 120-150
slide11
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
practice
Practice
  • Get pulse and respirations from at least two people
  • Try to get pulse from carotid, radial, and brachial pulse points
assessing skin
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
pupils
Pupils
  • Size
    • Constricted
    • Dilated
    • Equal/Unequal
  • Reactivity to light
  • Can check with pen light or by shielding eyes from light
blood pressure
Blood Pressure
  • Taken with manual or automatic BP cuff
  • Can be taken by auscultation or palpation
key terms
Key Terms
  • Systolic
    • Pressure when heart is pumping
  • Diastolic
    • Pressure when heart is at rest
bp by auscultation
BP by Auscultation
  • Size using guides on cuff
  • Position on upper arm hoses pointing down
  • Inflate 30mmHg past pulse
  • Position stethoscope over brachial artery
  • Deflate
  • Note first sound and last sound
  • Record as systolic/diastolic (140/80)
one last note on vitals
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
bp by auscultation19
BP by Auscultation
  • Size using guides on cuff
  • Position on upper arm hoses pointing down
  • Inflate 30mmHg past pulse
  • Position stethoscope over brachial artery
  • Deflate
  • Note first sound and last sound
  • Record as systolic/diastolic (140/80)
bp by palpation
BP by Palpation
  • Size using guides on cuff
  • Position on upper arm centered over brachial artery
  • Inflate 30mmHg past pulse
  • Deflate
  • Record point at which pulse returns
  • Record as Systolic/P (135/p)
normal blood pressure
Male

Systolic = 100+age until 50

Diastolic =60-90

Female

Systolic=90+age until 50

Diastolic = 50-80

Normal Blood Pressure
practice22
Practice
  • Get BP from two people
  • Try at least two techniques for obtaining BP
    • Auscultation, Palpation, or Automatic Cuff
sample
SAMPLE
  • Organized technique to obtain pertinent medical informaiton
  • Can obtain information from patient, family or bystanders
  • SAMPLE is an acronym
sample25
SAMPLE
  • Signs/Symptoms
  • Allergies
  • Medications
  • Past Pertinent Medical Conditions
  • Last Oral Intake
  • Events Leading to Injury or Illness
signs symptoms
Signs/Symptoms
  • Signs – things you can see or hear
  • Symptoms – things the patient reports
allergies
Allergies
  • Environmental and Medical allergies are important
  • Medic Alert tags are also useful
medications
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?
past pertinent medical history
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
Last Oral Intake
  • What, how much, when
  • Important for trauma patients, diabetics
events leading to call
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
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
practice33
Practice
  • Let’s go through a couple of scenarios