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EMS SKILL PATIENT ASSESSMENT / VITAL SIGNS ORTHOSTATIC PERFORMANCE OBJECTIVES Demonstrate competency in obtaining accurate orthostatic vital signs. CONDITION Demonstrate competency in taking an accurate blood pressure and pulse to determine orthostatic vital signs on a live model with the patient lying supine, sitting and standing. Necessary equipment will be adjacent to the patient or brought to the field setting. EQUIPMENT Live model, large/medium sphygmomanometer, stethoscope/dual teaching stethoscope, timing device, gloves. PERFORMANCE CRITERIA Items designated by a diamond () must be performed successfully to demonstrate skill competency. Items identified by double asterisks (**) indicate actions that are required if indicated. Items identified by (§) are not skill component items, but should be practiced. Reading must be within +/- 6 mm/Hg for blood pressure and +/- 4 beats/minute for pulse of examiner’s determination. PREPARATION Skill Component Key Concepts Take body substance isolation precautions Mandatory (minimal) personal protective equipment – gloves PROCEDURE Skill Component Key Concepts Have patient lie supine for 1 full minute: Appropriate cuff size must be selected or inaccurate readings will be obtained. Auscultate blood pressure Assess pulse for rate, quality, and regularity The supine position for 1 minute allows patient to equilibrate to the highest pressure reading. If hypovolemia is suspected, treat as orthostatic positive. DO NOT sit or stand patient up. Have patient sit for 1 full minute: If signs of dizziness or syncope occur, place patient in supine position and discontinue test. Auscultate blood pressure Assess pulse for rate, quality, and regularity Have patient stand for 1 full minute: Decrease of 10-20 points in either the systolic or diastolic pressure indicates positive orthostatic change. Auscultate blood pressure Assess pulse for rate, quality, and regularity Increase of 10-20 beats per minute in pulse rate indicates positive orthostatic change. REASSESSMENT (Ongoing Assessment) Skill Component Teaching Points Priority patients are patients who have abnormal vital signs, S/S of poor perfusion, if there is a suspicion that the patient’s condition may deteriorate, or when the patient’s condition changes. Repeat assessment at least every 5 minutes for priority patients and every 15 minutes for stable patients. Primary assessment Relevant portion of the secondary assessment Vital signs Patient Assessment – Vital Signs – Orthostatic BP © 2013, 2010, 2002 Page 1 of 3 Skill Component Teaching Points Evaluate results of reassessment and note any changes from patient’s previous condition and vital signs Evaluating and comparing results assists in recognizing if the patient is improving, responding to treatment or condition is deteriorating. **Manage patient condition as indicated. PATIENT REPORT AND DOCUMENTATION Skill Component Teaching Points Important to document patient’s blood pressure in lying, sitting, and standing positions (use stick figures). § Verbalize/Document: Blood pressure site used Blood pressure and pulse readings (lying, sitting, standing) Developed: 10/02 Documentation must be on either the Los Angeles County EMS Report form or departmental Patient Care Record form. Revised 1/10, 1/13 Patient Assessment – Vital Signs – Orthostatic BP © 2013, 2010, 2002 Page 2 of 3 PATIENT ASSESSMENT / VITAL SIGNS ORTHOSTATIC Supplemental Information PURPOSE: To assess potential for hidden blood loss or decrease in circulating blood volume. INDICATION: Suspicion of possible hypovolemia in patients who have a normal blood pressure and pulse rate. CONTRAINDICATIONS: Hemorrhage/hypovolemia Altered level of consciousness Possible spinal injury Signs of inadequate perfusion - weakness, dizziness, syncope Signs of decreased circulating volume Patients with irregular pulse or bradycardia NOTES: Orthostatic vital signs are also known as postural vital signs or tilt test. This is a diagnostic procedure and not pertinent for field assessment. Orthostatic vital signs are normally performed in 3 steps: lying sitting standing. A decrease of 10-20mm/Hg in either the systolic or diastolic pressure, or an increase of 10-20 beats/minute in the pulse rate represents positive orthostatic changes. Physicians and text sources vary as to what values are considered positive; therefore 10-20 range is given. Only one factor, a decrease of the systolic or diastolic blood pressure or an increase in the pulse, is required to determine a positive orthostatic change. Patients with positive orthostatic changes should be suspected of having hidden blood loss and transported to the hospital for further evaluation. Important to obtain a medical history as to medications because patients on calcium channel or beta blockers may not have the ability to raise their pulse rate. Patient Assessment – Vital Signs – Orthostatic BP © 2013, 2010, 2002 Page 3 of 3