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Chapter 5 Baseline Vital Signs and SAMPLE History Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 1 Case History You respond to a call and find a 52-year-old female complaining of crushing chest pain for one hour with pale, cool and sweaty skin. She states that the pain radiates to her left arm and she also feels nauseous and dizzy. Her vital signs are: pulse 110 and regular, blood pressure 90/70, and respirations 28 and labored. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 2 Overview History and vitals signs are a standard part of every patient assessment. History is often the most important information in identifying the cause of the patient’s condition. Vital signs are the primary indicators of the severity of the patient’s condition. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 3 General Information Chief complaint The problem, as described by the patient • “I have a pressure-like feeling in my chest” • “I have a pain in my wrist” • “I feel like I am going to faint” Age – years, months, days Sex – male or female Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 4 Baseline Vital Signs Respirations Pulse Blood pressure Temperature Pupils Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 5 Respirations Rate Number of breaths in 30 seconds x 2 Quality Normal Shallow Labored Noisy Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 6 Pulse Assess rate and quality Rate Number of beats in 30 seconds x 2 Quality Strong, weak Regular, irregular Assess carotid pulse, if peripheral pulse not present Use caution when palpating carotid pulses on geriatric patients Never palpate both sides of carotid pulses simultaneously Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 7 Pulse Adults and children (> 1 y/o) Radial pulse – anterior-lateral side of the wrist Carotid when peripheral pulse is not palpable Infants Brachial pulse Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 8 Assess Skin Assess skin, nail beds, oral mucosa, and conjunctiva Color Temperature Normal, pale, cyanotic, flushed, jaundiced (yellow) Assess using back of hand on patient’s skin Normal, cool, warm Condition Flushed Normal, moist, dry Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 9 Assess Capillary Refill Used in infants and children to assess perfusion Compress nail bed and release Observe time to return of color Normal – < 2 seconds Delayed – > 2 seconds Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 10 Blood Pressure Measured in every patient > 3 y/o Measurements Systolic – First sound, reflects pressure generated by ventricular contraction Diastolic – Sound disappears or diminishes, reflects pressure during relaxation phase of the ventricle Techniques Auscultation • 120/80 Palpation • 80/palp Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 11 Selecting the Proper Cuff Blood pressure cuffs come in several sizes, which affect the accuracy of the reading. Index lines are used to ensure correct sizing. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 12 Pupils Briefly shine light in eye Observe Size, equality, and reactivity to light Size Dilated (wide) Normal Constricted (small) Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 13 Reassessment of Vital Signs Stable – every 15 minutes Unstable patient – every 5 minutes Should be assessed after all medical interventions Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 14 SAMPLE History Signs and symptoms Allergies Medications Pertinent past medical history Last oral intake Events Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 15 Signs/Symptoms Signs (Observations) Examples • Hear – respiratory distress • See – bleeding • Feel – cool, clammy skin Symptoms (Complaints) Examples • Shortness of breath • Chest pain • Dizziness • Nausea Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 16 Allergies Medications Food Environmental allergies Medical identification tag Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 17 Medications Prescription Birth control pills Nonprescription Consider medical identification tag Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 18 Pertinent Past History Medical Surgical Trauma Consider medical identification tag Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 19 Last Oral Intake Events Leading to Injury or Illness Last oral intake Time Quantity Events Examples • Chest pain on exertion • Chest pain while at rest • Fainted, then injured arm Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 20