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Vitals and History Taking Where are we going? What are vital signs? How do you take them? So, what’s normal? SAMPLE History What are the vitals They provide information about the status of a patient Temperature Breathing (Respirations) Pulse Skin and Pupils Blood Pressure Temperature One of the first assessments done. Normal Adult temp. 98.6ºF or 37ºC Variations range from 96.8ºF-100.4ºF 36.0ºC-38.0ºC Changes within the body or exposure to the environment can cause variations Time of day, allergic rxns, illness, stress Exposure to heat/cold Temperature Cont’d When a temp. is above 100.4ºF (38.0ºC) you will document in the pt. chart, that the pt. is febrile. If a temp. is w/in normal range, you will use the term afebrile. Temperature Cont’d Temperature Sites: Oral-within the mouth or under the tongue Axillary - in the armpit Tympanic - in the ear canal Rectal - through the anus, in the rectum Types of Thermometers Glass (picture page 323) Thermometer Handles: Rounded tip- rectal Long tip - oral (more surface area) Security tip - can be used for both Red:rectal Blue: oral and axillary Electronic Pulse A wave of blood flow created by a contraction of the heart How to take a pulse (P) Palpate - feel by using 2 fingers Auscultate - listening using a stethoscope or electronic vital signs machine Provides information on how many pumps of the heart it takes to circulation all 5.2L of blood (in an adult) Pulse Determined by counting for 30 sec and multiplying by 2. Irregular pulse counted for 60 sec. Provides information about heart, blood volume and perfusion. Taken at a pulse point Don’t use your thumb Common Pulse Points Central Pulses Carotid Femoral Apical Peripheral Pulses Radial Brachial (children under 1) Posterior Tibial, Dorsalis Pedis Temporal Popliteal Pulse Cont’d Apical Pulse Stethoscope 5-6 intercostal space, left of sternum Must be taken before giving certain meds that may slow the HR Digitalis Use table 9-1 as a reference pg. 326 Normal Pulse Rate (BPM, bpm) Adult Adulthood 72-80 Late adulthood 60-80 Child Newborn 120-160 1 mo.-1 yr 80-140 1-6 yrs 80-120 6-adolescence 75-110 Pulse Rate Tachycardia: Rapid pulse rate Stress, medications Infection, pain, exercise Lack of oxygen Low BP Bradycardia: Slow pulse rate Heart meds, physically fit Severe low BP or oxygen levels Pulse Quality Strength: scale of 0-3 0 -absent, unable to detect 1-thready, weak, diff. to palpate 2-strong, normal 3-bounding, Regular/Irregular pulse rhythm Arrhythmia or dysrhythmia Bilateral Presence Blood Pressure Taken with manual or automatic BP cuff Taken by auscultation Key Terms Systolic (SBP) Pressure on arterial walls when heart is pumping Diastolic (DBP) Resting pressure on arterial walls when heart relaxes between contractions BP by Auscultation Size using guides on cuff Position on upper arm hoses pointing down Inflate 30mmHg past pulse (no greater than 180mmHg) Position stethoscope over brachial artery Deflate Note first sound and last sound Record as systolic/diastolic (140/80) Pay attention to SAFETY on pg. 331…read and record in your notes NOW Normal Blood Pressure Male Systolic = 100+age until 50 Diastolic =60-90 Female Systolic=90+age until 50 Diastolic = 50-80 Respirations The act of breathing, or the exchange of oxygen and carbon dioxide Includes: inhalation and exhalation When you count respirations, you count one inhalation and one exhalation as one respiration or a complete breath Counting Respirations Methods to counting Respiration Rate (RR) Observe a client’s chest movement upward and outward for a complete minute Children <7yrs: use abdominal breathing, abnormal for adults (dyspnea) Auscultation with stethoscope A hand on the stomach/chest may help Normal Respirations Adult 12-20/min Child 15-30/min Infant 25-50/min Respiration Quality Normal Shallow (low tidal volume) Labored Use of accessory muscles Flaring Tripod Breating Noisy breathing Ventilation: hyper and hypo Skin Color Pink (Normal) Pale Cyanotic (Oxygen problems) Red (CO or heat problems) Yellow (Jaundice) Temperature Warm (Normal) Hot Cool Cold Condition Dry (Normal) Moist Practice Get pulse and respirations from at least two people Try to get pulse from carotid, radial, and brachial pulse points Assessing Skin Color assessed using lips, nail beds, inside of mouth, membranes of the eye Pull back glove to determine temp and condition In children under 6 capillary refill is useful for determining perfusion Refill should take less than 2 seconds Pupils Size Constricted Dilated Equal/Unequal Reactivity to light Can check with pen light or by shielding eyes from light One last note on Vitals First set of vitals is the baseline, you are interested in changes On not sick patients, repeat every 15 minutes On sick patients, repeat every 5 minutes Treat patient, not the vital signs or the equipment Practice Get BP from two people History Taking SAMPLE Organized technique to obtain pertinent medical informaiton Can obtain information from patient, family or bystanders SAMPLE is an acronym SAMPLE Signs/Symptoms Allergies Medications Past Pertinent Medical Conditions Last Oral Intake Events Leading to Injury or Illness Signs/Symptoms Signs – things you can see or hear Symptoms – things the patient reports Allergies Environmental and Medical allergies are important Medic Alert tags are also useful Medications Prescription and OTC Including vitamins, herbal remedies Birth Control Pills Illicit Drugs Always get a list of meds, or take them with Home O2 rate is also important What did you take, when, how much? Past Pertinent Medical History Underlying medical problems Recent visits to hospitals/doctors Recent medical procedures Recent accidents/falls/trauma Medic Alert tags may be useful Look for signs of medical equipment in the house Last Oral Intake What, how much, when Important for trauma patients, diabetics Events Leading to Call Get as much information as you can What happened, what were you doing Has anything unusual happened? If this is a chronic problem, what’s different this time? Final SAMPLE notes Try to ask open ended questions (avoid yes/no questions) Wait for the patient to respond 5-10 seconds is not out of line Note pertinent negatives Write everything down Practice Let’s go through a couple of scenarios