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Transcript
Copyright © 2004, Mosby Inc. All rights reserved.
Chapter 5
Baseline Vital Signs
and SAMPLE History
Slide 1
Copyright © 2004, Mosby Inc. All rights reserved.
Case History
You respond to a call and find a 52year-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.
Slide 2
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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.
Slide 3
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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
Slide 4
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Baseline Vital Signs
•
•
•
•
•
Respirations
Pulse
Blood pressure
Temperature
Pupils
Slide 5
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Respirations
• Rate
 Number of breaths in
30 seconds x 2
• Quality
 Normal
 Shallow
 Labored
 Noisy
Slide 6
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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
Slide 7
Copyright © 2004, Mosby Inc. All rights reserved.
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
Slide 8
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Assess Skin
• Assess skin, nail beds, oral mucosa,
and conjunctiva
• Color
 Normal, pale, cyanotic, flushed, jaundiced
(yellow)
• Temperature
 Assess using back of hand on patient’s skin
Flushed
 Normal, cool, warm
• Condition
 Normal, moist, dry
Slide 9
Copyright © 2004, Mosby Inc. All rights reserved.
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
Slide 10
Copyright © 2004, Mosby Inc. All rights reserved.
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
Slide 11
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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.
Slide 12
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Pupils
• Briefly shine light in
eye
• Observe
 Size, equality, and
reactivity to light
• Size
 Dilated (wide)
 Normal
 Constricted (small)
Slide 13
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Reassessment of
Vital Signs
• Stable – every 15
minutes
• Unstable patient –
every 5 minutes
• Should be assessed
after all medical
interventions
Slide 14
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SAMPLE History
•
•
•
•
•
•
Signs and symptoms
Allergies
Medications
Pertinent past medical history
Last oral intake
Events
Slide 15
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Signs/Symptoms
• Signs (Observations)
 Examples
» Hear – respiratory distress
» See – bleeding
» Feel – cool, clammy skin
• Symptoms (Complaints)
 Examples
»
»
»
»
Shortness of breath
Chest pain
Dizziness
Nausea
Slide 16
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Allergies
• Medications
• Food
• Environmental allergies
• Medical identification tag
Slide 17
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Medications
•
•
•
•
Prescription
Birth control pills
Nonprescription
Consider medical identification tag
Slide 18
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Pertinent Past History
•
•
•
•
Medical
Surgical
Trauma
Consider medical identification tag
Slide 19
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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
Slide 20
Copyright © 2004, Mosby Inc. All rights reserved.