Download Vital Signs

Vital Signs Assessment In
Emergency Department
Mitra ahmadi MD
Emergency Medicine
Resident
General
Vital signs
Vital sign
For all ED patients:
1. Respiratory Rate
2. Pulse Rate
3. Blood Pressure
4. Tempreture
5. Pulse Oximetry
6. Pain Assessment
(some patient)
Vital sign
Vital Signs :
 Severity of illness
 Urgency of intervention
 V/S should measured at
intervals:
 Clinical judgement
 Patients clinical state
 After significant change in
these parameters
Vital sign
Normal vital signs
change with gender,
race, pregnancy,
residence in an
industrialized nation.
Vital sign
All measurements
are made while the
patient is seated.
Vital sign
Prior to measuring
vital signs, the patient
should have had the
opportunity to sit for
approximately five
minutes.
Respiratory rate
Vital signs
What is the respiration rate?
The respiration rate is
the number of breaths
a person takes per
minute.
Respiratory Rate
Increased RR:
Pulmonary or cardiac
diseases
Acidosis
Anemia
Fever
Stress
Drugs(stimulants &
salicylates)
Respiratory Rate
Contraindications to
careful measurement
of RR:
Respiratory distress
Apnea
Upper airway
obstruction
Immediate
Intervention
Respiratory Rate
Patient should be
unaware about
checking of his
RR
Respiratory Rate
Count for a full
minute
(most accurately)
Respiratory Rate
Cheyne – Stokes Respiration
Respiratory Rate
Biots (Cluster) Respiration
Respiratory Rate
Kussmaul Respiratory Hyperpnea
Respiratory Rate
Apneustic Respiration
Respiratory Rate
Ataxic Respiration
Abnormal Respiratory Rate
Respiration rates
over 24 or under
16 breaths per
minute (when at
rest) may be
considered
abnormal in ED
under 16 breaths
over 24 breaths
Pulse
Vital signs
Pulse rate
The normal
pulse for healthy
adults ranges
from 45 to 95
beats per minute
in ED.
Pulse rate
Don’t use of PULSE
as an absolute gauge
of BP
Avoid bilateral carotid
artery palpation
Palpate the carotid
pulse at or below the
level of the thyroid
cartilage
Pulse rate
Avoid carotid sinus
massage
Adult + Atherosclerotic
disease:
prior auscultation of
carotid artery. If a bruit is
present, gently palpate
the carotid pulse.
Pulse
radial pulse
is routinely used
Use the tips of the
first and second
fingers to palpate the
pulse.
Pulse
The two advantages of this
technique:
(1) the fingertips are
quite sensitive
(2) the examiner’s own
pulse may be counted if
the thumb is used instead
of the first and second
fingers.
Pulse: Quantity
Measure the rate of
the pulse (recorded in
beats per minute).
Count for 30 seconds
and multiply by 2 (or
15 seconds x 4).
Pulse: Quantity
If the rate is
particularly slow or
fast, it is probably
best to measure for
a full 60 seconds in
order to minimize
the error.
Pulse: Regularity
Is the time between
beats constant?
Irregular rhythms
are quite common.
(atrial fibrillation or
flutter)
Pulse: Volume
Does the pulse volume
feel normal?
This reflects changes
in stroke volume. In
hypovolemia, the pulse
volume is relatively low
Blood pressure
Vital signs
Preparation for
measurement
Preparation for measurement
Patient should
abstain from eating,
drinking, smoking and
taking drugs that
affect the blood
pressure one hour
before measurement.
Preparation for measurement
Painful procedures
and exercise should
not have occurred
within one hour.
Patient should have
been sitting quietly for
about 5 minutes.
Position of the Patient
Position of the Patient
The patient may
be lying or sitting,
as long as the site
of measurement is
at the level of the
right atrium and the
arm is supported.
Equipment
In order to measure the Blood
Pressure (equipment)
Adult Cuff size
– Cuff Width: 40% of
limb's
circumference
– Cuff Length:
Bladder at 80% of
limb's
circumference
In order to measure the Blood
Pressure (equipment)
Pediatric Cuff size
– Minimum Cuff
Width: 2/3 length of
upper arm
– Minimum Cuff
length: Bladder
nearly encircles
arm
Blood Pressure
If it is too small, the
readings will be
artificially elevated.
The opposite occurs if
the cuff is too large.
Cuff Position
In order to measure the Blood
Pressure (Cuff Position)
Patient's arm
slightly flexed at
elbow
Push the sleeve up,
wrap the cuff
around the bare arm
In order to measure the Blood
Pressure (Cuff Position)
Cuff applied directly
over skin (Clothes
artificially raises
blood pressure )
Position lower cuff
border 2.5 cm
above antecubital
Center inflatable
bladder over
brachial artery
Measurement of the pulse rate
The manometer scale
should be at eye
level, and the column
vertical. The patient
should not be able to
see the column of the
manometer
Technique of BP
measurement
In order to measure the BP
Feel for a pulse
from the artery
coursing through
the inside of the
elbow
(antecubital
fossa).
In order to measure the BP
Wrap the cuff around
the patient's upper
arm
Close the thumbscrew.
In order to measure the BP
With your left hand
place the bell of the
stethoscope directly
over the brachial
artery with as little
pressure as possible.
Technique of BP measurement
Use your right hand to
pump the squeeze
bulb several times
and inflate the cuff to
30 mm Hg above the
level at which the
palpable pulse
disappears.
Technique of BP measurement
Deflate cuff slowly at
a rate of 2-3 mmHg
per second until you
can again detect a
radial pulse
In order to measure the BP
Avoid moving your
hands or the head of
the stethescope while
you are taking
readings as this may
produce noise that
can obscure the
Sounds of Koratkoff.
In order to measure the BP
The two arm readings
should be within 1020 mm Hg.
Differences greater
then 20 imply
differential blood flow.
Blood pressure may be affected by
many different conditions
Various medications
"White coat hypertension" may occur if the
medical visit itself produces extreme anxiety
Blood pressure may be affected
by many different conditions
Falsely low BP:
Falsely high BP:
 wide cuff
 narrow cuff
 excessive pressure
 Anxiety
on the head of the
stethoscope
 rapid cuff deflation
 pain
 tobacco use
 Exertion
 unsupported arm
 slow inflation of the
cuff
Orthostatic Hypotention
Orthostatic Hypotention
Orthostatic (postural)
measurements of
pulse and blood
pressure are part of
the assessment for
hypovolemia.
Orthostatic Hypotention
1. Blood pressure and pulse are recorded
after the patient has been supine for 2 to
3 minutes.
2. Blood pressure, pulse, and symptoms
are recorded after the patient has been
standing for 1 minute; the patient should
be permitted to resume a supine position
immediately if syncope or near-syncope
develop.
Orthostatic Hypotention
POSITIVE TEST
1. Increase in pulse of 30 beats/min or
more in adults or
2. Presence of symptoms of cerebral
hypoperfusion (e.g., dizziness
Temperature
Vital signs
Temperature
Core Body Temperature:
the distal third of the esophagus
the tympanic membrane (TM)
pulmonary artery
the rectum when the temperature is obtained
at least 8 cm from the anus
the bladder
Temperature
Acceptable times
in oral
7 min
rectal
3 min
axillary
10 min
Temperature
Oxygen Saturation
Vital signs
Oxygen Saturation
Over the past decade,
Oxygen Saturation
measurement of gas
exchange and red
blood cell oxygen
carrying capacity has
become available in
all hospitals and
many clinics.
Oxygen Saturation
Oxygen Saturation
provide important
information about
cardio-pulmonary
dysfunction and is
considered by many
to be a fifth vital sign.
THANKS FOR
YOUR ATTETION