Baseline Vitals ATHT 241

Objectives Signs and Symptoms RespirationsPulse The Skin Capillary Refill Blood Pressure Level of Consciousness Conclusions

Signs and Symptoms Symptom: Feelings that cannot be felt or observed by others Severity of symptom is subjective and is based off patients interpretation –“I feel dizzy” –“My leg hurts” Sign: conditions that can be seen, heard, felt, smelled or measured by others –Wounds –External bleeding –Marked deformities –Respirations –Pulses

Respirations Spontaneous respirations: a patient who is breathing independently may also be called spontaneous ventilations Assess breathing by watching the patients chest rise and fall Feel for air through the nose and mouth Listen for breathing with stethoscope in each lung Determine the rate, depth and quality of each breath

Respirations Rate: count the number of breaths in a 30 (x2) second period = number of breaths per minute Normal range for respirations –Adults: breaths per minute –Children: breaths per minute –Infants: breaths per miute

Respirations Quality: determine quality or character as you are counting –Normal: Breathing is neither shallow or deep; average chest wall motion; no use of accessory muscles –Shallow: Slight chest or abdominal wall motion –Labored: Increased breathing effort; grunting or stridor; use of accessory muscles; possible gasping –Noisy: Increase in sound of breathing including snoring, wheezing, gurgling and crowing

Respirations Rhythm: Notice the time from one chest peak rise to the next If rhythm is consistent then respirations are considered normal If rhythm varies and changes frequently respirations are considered to be abnormal

Respirations Depth: The amount of air that the patient is exchanging depends on the rate and tidal volume –The amount of air that is exchanged with each breath

Respirations Speech is a good indicator of whether breathing is difficult or not Sniffing Position: An unusually upright position in which the patients head and chin are thrust slightly forward –Also called the tripod position Stridor: Harsh high pitched inspiration –Sound heard with a laryngeal (upper airway) obstruction

Pulse Assess the strength, rate and regularity Rate: count number of pulses in 30 seconds and x 2 = pulses per minute –Irregular or slow pulses should be assessed for a full minute Strength: strong; bounding; weak and/or thready Regularity: determine if pulse has good rhythm or whether it does not have good rhythm

Pulse Tachycardia: rapid heart rhythm with more than 100 beats per minute Bradycardia: slow heart rate with less than 60 beats per minute –Normal: 72 beats per minute

Pulse Adults: beats/ min Children: beats/ min Toddlers: beats/ min Newborn: beats/ min

Skin Color: Perfusion: circulation of blood within an organ or tissue in adequate amounts to meet the cells current needs Cyanosis: a bluish gray skin color that is caused by reduced levels of oxygen in the blood

Skin Temperature: Skin is usually warm to the touch Observe any drastic changes in skin temperature –Hyperthermia, fever or sunburn Hot –Hypothermia, frostbite Cold

Skin Moisture Skin is usually dry Skin that is unusually wet (diaphoretic) will represent a problem Early stages of shock the skin will become moist

Capillary Refill Capillary refill is a test that evaluates the ability of the circulatory system to restore blood to the capillary system Capillary refill time is usually affected by patients body temperature, position and medications Test includes pressing on patients fingernail and observing the change in color –Capillary refill should take no more than 2 seconds

Blood Pressure Blood pressure is the pressure of the blood against the walls of the arteries A decrease in blood pressure can indicate –Loss of blood or its fluid components –Loss of vascular tone and sufficient arterial constriction –A cardiac pumping problem – Low blood pressure is a late sign of shock

Blood Pressure Diastolic Pressure –The residual pressure that remains in the arteries during the relaxing phase of the hearts cycle (diastole) when the left ventricle is at rest Systolic Pressure –Increased pressure that is caused along the artery with each contraction (systole) of the ventricle and the pulse wave it produces

Blood Pressure Adults: (systolic) Adults: (diastolic) Children: (systolic) Hypertension –Blood pressure is higher than normal range Hypotension –Blood pressure is lower than normal range

Blood Pressure Critically low levels of systolic blood pressure Male Adults/ Adolescents: 90 or less Female Adults/ Adolescents: 80 or less Children: 70 or less

Level of Consciousness A: Alert V: Responds to Verbal stimulus P: Responds to Painful stimulus U: Unresponsive P: Pupils E: Equal A: and R: Round R: Regular in size L: react to Light

Conclusions Signs and Symptoms RespirationsPulse The Skin Capillary Refill Blood Pressure Level of Consciousness