Slide 1 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Baseline Vital Signs and SAMPLE History Chapter 5

Slide 2 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Case History You respond to a call and find a 52-year-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. You respond to a call and find a 52-year-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 3 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier 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 4 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier 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 pressure-like feeling in my chest” “I have a pain in my wrist” “I have a pain in my wrist” “I feel like I am going to faint” “I feel like I am going to faint”  Age – years, months, days  Sex – male or female

Slide 5 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Baseline Vital Signs  Respirations  Pulse  Blood pressure  Temperature  Pupils

Slide 6 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Respirations  Rate  Number of breaths in 30 seconds x 2  Quality  Normal  Shallow  Labored  Noisy

Slide 7 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier 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 8 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier 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 9 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier 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  Normal, cool, warm  Condition  Normal, moist, dry Flushed

Slide 10 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier 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 11 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier 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 120/80 120/80  Palpation 80/palp 80/palp

Slide 12 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier 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 13 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Pupils  Briefly shine light in eye  Observe  Size, equality, and reactivity to light  Size  Dilated (wide)  Normal  Constricted (small)

Slide 14 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier 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 15 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. SAMPLE History  S igns and symptoms  A llergies  M edications  P ertinent past medical history  L ast oral intake  E vents

Slide 16 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Signs/Symptoms  Signs (Observations)  Examples Hear – respiratory distress Hear – respiratory distress See – bleeding See – bleeding Feel – cool, clammy skin Feel – cool, clammy skin  Symptoms (Complaints)  Examples Shortness of breath Shortness of breath Chest pain Chest pain Dizziness Dizziness Nausea Nausea

Slide 17 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Allergies  Medications  Food  Environmental allergies  Medical identification tag

Slide 18 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Medications  Prescription  Birth control pills  Nonprescription  Consider medical identification tag

Slide 19 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Pertinent Past History  Medical  Surgical  Trauma  Consider medical identification tag

Slide 20 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier 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 on exertion Chest pain while at rest Chest pain while at rest Fainted, then injured arm Fainted, then injured arm