Copyright © 2004, Mosby Inc. All rights reserved.

Baseline Vital Signs and SAMPLE History Chapter 5 Slide 1 Copyright © 2004, Mosby 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 2 Copyright © 2004, Mosby Inc. All rights reserved.

Overview History and vitals signs are a standard part of every patient assessment.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.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.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 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, daysAge – years, months, days Sex – male or femaleSex – male or female Slide 4 Copyright © 2004, Mosby Inc. All rights reserved.

Baseline Vital Signs RespirationsRespirations PulsePulse Blood pressureBlood pressure TemperatureTemperature PupilsPupils Slide 5 Copyright © 2004, Mosby Inc. All rights reserved.

Respirations RateRate  Number of breaths in 30 seconds x 2 QualityQuality  Normal  Shallow  Labored  Noisy Slide 6 Copyright © 2004, Mosby Inc. All rights reserved.

Pulse Assess rate and qualityAssess rate and quality RateRate  Number of beats in 30 seconds x 2 QualityQuality  Strong, weak  Regular, irregular Assess carotid pulse, if peripheral pulse not presentAssess 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)Adults and children (> 1 y/o)  Radial pulse – anterior-lateral side of the wrist  Carotid when peripheral pulse is not palpable InfantsInfants  Brachial pulse Slide 8 Copyright © 2004, Mosby Inc. All rights reserved.

Assess Skin Assess skin, nail beds, oral mucosa, and conjunctivaAssess skin, nail beds, oral mucosa, and conjunctiva ColorColor  Normal, pale, cyanotic, flushed, jaundiced (yellow) TemperatureTemperature  Assess using back of hand on patient’s skin  Normal, cool, warm ConditionCondition  Normal, moist, dry Flushed Slide 9 Copyright © 2004, Mosby Inc. All rights reserved.

Assess Capillary Refill Used in infants and children to assess perfusionUsed in infants and children to assess perfusion Compress nail bed and releaseCompress nail bed and release Observe time to return of colorObserve 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/oMeasured in every patient > 3 y/o MeasurementsMeasurements  Systolic – First sound, reflects pressure generated by ventricular contraction  Diastolic – Sound disappears or diminishes, reflects pressure during relaxation phase of the ventricle TechniquesTechniques  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.Blood pressure cuffs come in several sizes, which affect the accuracy of the reading. Index lines are used to ensure correct sizing.Index lines are used to ensure correct sizing. Slide 12 Copyright © 2004, Mosby Inc. All rights reserved.

Pupils Briefly shine light in eyeBriefly shine light in eye ObserveObserve  Size, equality, and reactivity to light SizeSize  Dilated (wide)  Normal  Constricted (small) Slide 13 Copyright © 2004, Mosby Inc. All rights reserved.

Reassessment of Vital Signs Stable – every 15 minutesStable – every 15 minutes Unstable patient – every 5 minutesUnstable patient – every 5 minutes Should be assessed after all medical interventionsShould be assessed after all medical interventions Slide 14 Copyright © 2004, Mosby Inc. All rights reserved.

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

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

Allergies MedicationsMedications FoodFood Environmental allergiesEnvironmental allergies Medical identification tagMedical identification tag Slide 17 Copyright © 2004, Mosby Inc. All rights reserved.

Medications PrescriptionPrescription Birth control pillsBirth control pills NonprescriptionNonprescription Consider medical identification tagConsider medical identification tag Slide 18 Copyright © 2004, Mosby Inc. All rights reserved.

Pertinent Past History MedicalMedical SurgicalSurgical TraumaTrauma Consider medical identification tagConsider medical identification tag Slide 19 Copyright © 2004, Mosby Inc. All rights reserved.

Last Oral Intake Events Leading to Injury or Illness Last oral intakeLast oral intake  Time  Quantity EventsEvents  Examples »Chest pain on exertion »Chest pain while at rest »Fainted, then injured arm Slide 20 Copyright © 2004, Mosby Inc. All rights reserved.