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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 Copyright © 2004, Mosby Inc. All rights reserved. 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 Copyright © 2004, Mosby Inc. All rights reserved. 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 Copyright © 2004, Mosby Inc. All rights reserved. Baseline Vital Signs • • • • • Respirations Pulse Blood pressure Temperature Pupils Slide 5 Copyright © 2004, Mosby Inc. All rights reserved. Respirations • Rate Number of breaths in 30 seconds x 2 • Quality Normal Shallow Labored Noisy Slide 6 Copyright © 2004, Mosby Inc. All rights reserved. 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 Copyright © 2004, Mosby Inc. All rights reserved. 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 Copyright © 2004, Mosby Inc. All rights reserved. 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 Copyright © 2004, Mosby Inc. All rights reserved. Pupils • Briefly shine light in eye • Observe Size, equality, and reactivity to light • Size Dilated (wide) Normal Constricted (small) Slide 13 Copyright © 2004, Mosby Inc. All rights reserved. Reassessment of Vital Signs • Stable – every 15 minutes • Unstable patient – every 5 minutes • Should be assessed after all medical interventions Slide 14 Copyright © 2004, Mosby Inc. All rights reserved. SAMPLE History • • • • • • Signs and symptoms Allergies Medications Pertinent past medical history Last oral intake Events Slide 15 Copyright © 2004, Mosby Inc. All rights reserved. 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 Copyright © 2004, Mosby Inc. All rights reserved. Allergies • Medications • Food • Environmental allergies • Medical identification tag Slide 17 Copyright © 2004, Mosby Inc. All rights reserved. Medications • • • • Prescription Birth control pills Nonprescription Consider medical identification tag Slide 18 Copyright © 2004, Mosby Inc. All rights reserved. Pertinent Past History • • • • Medical Surgical Trauma Consider medical identification tag Slide 19 Copyright © 2004, Mosby Inc. All rights reserved. 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.