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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