Download INTRODUCTION TO CLINICAL PRACTICE AND CLINICAL SKILLS

INTRODUCTION TO CLINICAL PRACTICE AND CLINICAL SKILLS
2nd Year/3rd Year
MEDICAL YEAR 2009/2010
VITAL SIGNS
Educational objectives and program outputs to be satisfied in this session:
Clinical Competence
The student will:
•
•
Obtain a sufficient level of medical knowledge to understand the basic facts,
concepts and principles essential to competent medical practice.
Exhibit the highest level of effective and efficient performance in clinical skills
data gathering, organization, interpretation and clinical decision-making in
the prevention, diagnosis and management of disease.
The student should have mastery of the concepts and skills upon completion of each session.
Aim:
To teach the means of collecting and recording the vital signs from a patient. These are the
temperature, pulse, blood pressure, respiratory rate and oxygen saturation.
Objectives:
• Know the 5 vital signs and normal ranges.
•
Be able to correctly measure and record the vital signs.
Method:
Provide instruction and practice for each vital sign.
Assessment:
Correctly record all 5 vital signs on SIM man in a period of 4 mins.
1
Temperature:
Temperature is usually maintained between 36-37.5oC (Marini & Wheeler,
2006). Temperature range of an adult depends on several factors including:
site of measurement, physical activity, time of day, age, ovulation, hydration
status, presence of infection and general state of health.
Assessment:
•
Record admission temperature as a baseline.
•
Note patient’s risk for alteration - this will dictate necessary frequency of
measurement.
Planning:
Equipment required: Appropriate thermometer for chosen site.
Check that the thermometer is clean/sterile.
Procedure:
•
Introduce yourself to the patient.
•
Explain to the patient what you are about to do and gain consent.
•
Place the thermometer correctly in the appropriate place:
a. Oral: under the tongue
b. Axilla: properly place in centre of the axilla.
c. Rectal: inserted gently into the rectum (using lubricant)
d. Tympanic: insert into ear canal.
•
Measurement time depends on device used. Please check manufacturer’s
instructions.
•
Read temperature and record on patient’s temperature chart.
•
Thank and reassure the patient.
Evaluation:
•
Compare findings with previous observations to identify change.
•
Any abnormal findings should be noted, recorded and reported.
(Elkin et al, 2007)
2
Thermometer
Advantages
Oral
•
Easily accessible
•
Comfortable
•
Accurate
Disadvantages/Limitations
•
Delay in measurement if
hot/cold drinks taken.
•
Do not use if recent: oral
surgery or trauma; epilepsy
or shaking chills;
uncooperative/confused or
unconscious.
Axilla
• Non Invasive
•
Risk of body fluid exposure.
•
Long measurement time: 3-5
• Safe
• Can be used if patient
mins.
•
unconscious
Tympanic
•
Easily accessible
•
Rapid: 2-5 seconds
•
Accurate
•
Minimal
disturbance/repositioning
resulting in temperature loss.
•
Cerumen impaction/otitis
media can lower readings.
•
Disposable – infection
•
•
Accurate
•
Reliable when oral
temperature cannot be
Requires removal of hearing
aid before measurement.
•
control
Rectal
Do not use if surgery to ear
or tympanic membrane.
required
•
Requires exposure of thorax
Sensor cover available in
only one size.
•
Disposable/expensive.
•
Poor during rapid
temperature change.
•
obtained
Do not use with diarrhoea,
rectal surgery or bleeding
tendencies.
•
Embarrassment and anxiety.
•
Requires lubrication.
•
Body fluid exposure.
3
Pulse:
The pulse can be palpated in any artery that lies close to the surface of the
body. The radial artery is easily accessible and most often used. Carotid,
femoral and brachial arteries can also be used (Marieb, 2001)
Pulse is palpated to note rate, rhythm and amplitude.
A normal pulse rate is 72 bpm (average) but can be between 48 and 86
bpm. For descriptions of other pulse characteristics see a clinical methods
textbook.
Assessment:
•
Note risk factors for alterations in pulse – age, exercise, medications,
fluid balance, temperature and medical conditions.
•
Determine previous baseline pulse, if available.
Planning:
Equipment required: A watch with a seconds hand
Vital signs flow sheet/record form
Procedure:
•
Wash your hands.
•
Introduce yourself to the patient.
•
Explain to the patient what you are about to do and gain consent.
•
Palpate the radial artery (or brachial or carotid).
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Confirm the presence of equal bilateral pulses.
•
Count the pulse for at least 20 secs (X 3 for beats per minute) if pulse is
regular. If irregular, count for 60 seconds.
•
Comment on the rate, rhythm and volume/amplitude.
•
Record findings on patient’s chart.
•
Thank and reassure the patient.
Evaluation:
•
Compare findings with pervious observations to identify change.
•
Any abnormal findings should be noted, recorded and reported.
(Elkin et al, 2007)
4
Blood Pressure Measurement: (BP)
Blood pressure defines the force exerted by blood against the arterial walls.
Normal blood pressure generally ranges from 100/60mmHg to 140/90mmHg.
Assessment:
•
Note risk factors for alteration in BP – age, gender, daily variation, position,
exercise, medications, stress, anxiety, smokers, race and medical conditions.
Planning:
Equipment: Aneroid sphygmomanometer, stethoscope and alcohol swabs (to
clean the diaphragm of stethoscope), vital signs flow sheet/record form.
Needle gauge should point to 0 when not in use and move freely when cuff
pressure is released.
Procedure:
•
Introduce yourself to patient.
•
Explain to patient what you are about to do and gain consent.
•
Patient should be relaxed and lying down on a flat surface for 5 mins.
•
Patient’s arm should be exposed, resting horizontally and extended. Tight
sleeves should be removed.
•
Apply the deflated cuff of the sphygmomanometer firmly, but comfortably.
The lower border should be 2cm from the antecubital fossa on the medial side
(over the brachial artery – at the heart level) Note: the tubing should exit
inferiorly with the brachial artery between the two tubes.
•
Remember to select the right cuff size. It should cover at least 80% of arm
circumference (Pickering et al, 2005). An incorrect cuff size can cause false
readings.
•
First check B.P. by palpation :
o
Palpate the radial pulse.
o
Inflate the cuff by squeezing the balloon.
o
Watch the sphyg. The rising dial indicates the cuff pressure.
5
o
Note the reading on the gauge at the point at which the radial pulse
disappears.
o
•
This is the estimated systolic BP by palpation.
Next, check BP by auscultation:
a. Deflate the cuff (to allow patient’s arm to recover)
b. Re-inflate the cuff to a pressure of 20mmHg higher than the palpated
systolic BP.
c. Place the diaphragm of the stethoscope on the brachial artery &
auscultate.
d. Now deflate the cuff 5 mmHg at a time (i.e. 1mmHg / sec)
e. Ascertain the points at which you first hear the heart sounds (phase I=
systolic BP), at which the sounds become muffled (phase IV) and at which
they disappear (phase V= diastolic BP).
•
BP is described to the nearest 5 mmHg as phase I over phase V. i.e. 120/80
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Phase IV is used if there is no phase V.
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BP in a hypertensive patient should be measured in both arms.
•
Diagnosis of hypertension should not be made from a single reading (usually a
series of BPs over few days or with a 24 hour BP monitor).
•
Record findings on patient’s chart.
•
Remove the cuff and thank and reassure the patient.
Evaluation:
•
Compare findings with previous observations to identify changes.
•
Any abnormal findings should be noted, recorded and reported.
(Elkin et al, 2007)
Hints:
•
If using a mercury sphyg ensure mercury is at eye level.
•
Postural hypotension is the drop of > 20 mmHg in systolic BP upon standing.
•
Pulse pressure is the difference between systolic and diastolic BP.
6
Respirations
Assessment:
Note risk factors for alteration in respirations – exercise, fever (approx 7
breaths for every 1ºC), pain, anxiety, injury to chest, medications,
medical conditions. A normal rate is approx 14 bpm in an adult (Cox,
2005).
Planning:
Equipment required:
- A watch with a seconds hand
- Vital signs flow sheet/record form
Procedure:
•
Introduce yourself to the patient.
•
Explain to the patient what you are about to do. (In fact you should
probably NOT tell the patient that you are counting their breathing.
Rather talk to them about counting their pulse. While palpating the
pulse you should take additional time to inconspicuously count the
respiratory rate).
•
Observe the patient’s chest and count the respirations over at least
30 secs (X2 to calculate breaths per minute).
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Note colour of skin, lips, mucous membranes, nail beds and also
observe for signs of restlessness, irritability, confusion.
•
The nature of the breathing should also be observed and recorded
(see next page for some examples).
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Record findings on patient’s chart.
•
Thank and reassure the patient.
Evaluation:
•
Compare findings with previous observations to identify change.
•
Any abnormal findings should be noted, recorded and reported.
(Elkin et al, 2007)
7
Observations:
•
Rate :
Normal - approx 12-18 bpm in adults and faster in
infants and children.
Tachypnoea - an increased respiratory rate.
Causes:
Fever (approx 7 breaths for every 1ºC)
Pneumonia
Obstructive airway disease
Respiratory insufficiency
Lesion in the pons of the brainstem.
Bradypnoea - a decreased respiratory rate
Causes:
Depression of the respiratory centre in
the medulla secondary to raised
intracranial pressure.
Excessive sedation (e.g. opiate narcotics).
•
Depth:
Volume with each respiration. Observed by chest
movement during inspiration and can be described
as deep or shallow.
- Symmetry should also be observed.
•
Rhythm:
Normally regular. However, irregular respirations may
occur, for example, in apnoea or Cheyne-Stokes.
•
Sounds:
Dry cough - Viral infection, bronchial CA, CCF
Moist cough - Chronic bronchitis or asthma (white or
opalescent sputum), bacterial
- Infection (thick, viscous, discoloured)
- Frothy sputum may indicate pulmonary
oedema.
- Haemoptysis (coughing up blood) can
occur with trauma, malignant disease,
infection or pulmonary oedema.
Wheeze
- Bronchospasm or bronchial obstruction.
•
Signs of respiratory distress:
Pursed lips
Nasal flaring
Use of accessory muscles.
For a more in depth description of abnormal breathing patterns see a
clinical methods textbook.
8
Oxygen Saturation
Not a classical vital sign but is now often included because of the
availability of oxygen saturation meters in many hospitals.
The oxygen saturation reading measures the percentage of haemoglobin
molecules saturated with oxygen in the arterial blood.
Pulse oximetry works on the principle that blood saturated with oxygen is
different in colour to that depleted of oxygen.
The oximeter probe has a light emitting diode (LED) connected by cable
to an oximeter. The LED probe shines through the tissues and measures
the colour difference between the oxygenated and deoxygenated blood
and then calculates the percentage of oxygen (SpO2).
Assessment:
Note risk factors for alteration in oxygen saturation: for example,
recovery from sedation, chronic respiratory conditions, chest wall injury,
change in O2 therapy, haemoglobin level, temperature.
Planning:
Equipment required:
-Oxygen saturation monitor, alcohol swab.
-Check that equipment is clean and working.
-Assess for most appropriate site for probe
placement- finger/earlobe.
-Consider/avoid possible sources of error:
o Artificial nails, nail polish, moisture, dirt
o Movement, tremors, rigors, poor
circulation, anaemia
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Procedure:
•
Wash your hands, introduce yourself to the patient.
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Explain the purpose of procedure and obtain consent.
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Check that the probe is correctly placed on the finger or ear lobe.
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Allow the reading to stabilise.
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Record the reading and document this in the patient’s chart. Document
oxygen administration, if applicable, or note if measurement was taken
on room air.
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Remove the probe unless continuous monitoring is required (if
continuous monitoring is required, alternate site of probe regularly to
prevent tissue ischaemia).
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Thank and reassure the patient.
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Wash hands.
Evaluation:
•
Compare findings with previous observations to identify change.
•
Any abnormal findings should be noted, recorded and reported.
(Elkin et al, 2007)
References
Cox, N. & Roper, T.A. (2005) Clinical Skills. Oxford university Press;New York.
Marieb, E.N. (2001) Human Anatomy and Physiology. Benjamin Cummings;San
Francisco.
Maini, J.J & Wheeler, A.P. (2006) Critical Care Medicine. 3rd edition. Lippincott;
Philadelphia.
Pickering, T.G., Hall, J.E., Appel, L.J., Falkner, B.E., Graves, J., Hill, M.N., Jones, D.W.,
Kurtz, T., Sheps, S.G. & Edward J. Roccella, E.J. (2005) Recommendations for Blood
Pressure Measurement in Humans and Experimental Animals: Part 1: Blood Pressure
Measurement in Humans: Hypertension. 2005;45:142-161;
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