1. Vitals and History Taking

2. Where are we going? What are vital signs? How do you take them?
So, what’s normal?
SAMPLE History

3. What are the vitals
They provide information about the status of a patient
Temperature
Breathing (Respirations)
Pulse
Skin and Pupils
Blood Pressure

4. Temperature One of the first assessments done.
Normal Adult temp. 98.6ºF or 37ºC
Variations range from 96.8ºF-100.4ºF
36.0ºC-38.0ºC
Changes within the body or exposure to the environment can cause variations
Time of day, allergic rxns, illness, stress
Exposure to heat/cold
Patient can “fake a respiration rate” May need to pretend to take a pulse and count respirations

5. Temperature Cont’d
When a temp. is above 100.4ºF (38.0ºC) you will document in the pt. chart, that the pt. is febrile.
If a temp. is w/in normal range, you will use the term afebrile.
Patient can “fake a respiration rate” May need to pretend to take a pulse and count respirations

6. Temperature Cont’d Temperature Sites: Types of Thermometers
Oral-within the mouth or under the tongue
Axillary - in the armpit
Tympanic - in the ear canal
Rectal - through the anus, in the rectum
Types of Thermometers
Glass (picture page 323)
Rounded tip- rectal
Long tip - oral (more surface area)
Security tip - can be used for both
Thermometer Handles:
Red:rectal
Blue: oral and axillary
Electronic

7. Pulse A wave of blood flow created by a contraction of the heart
How to take a pulse (P)
Palpate - feel by using 2 fingers
Auscultate - listening using a stethoscope or electronic vital signs machine
Provides information on how many pumps of the heart it takes to circulation all 5.2L of blood (in an adult)

8. Pulse Determined by counting for 30 sec and multiplying by 2.
Irregular pulse counted for 60 sec.
Provides information about heart, blood volume and perfusion.
Taken at a pulse point
Don’t use your thumb

9. Common Pulse Points Central Pulses Peripheral Pulses Carotid Femoral
Apical
Peripheral Pulses
Radial
Brachial (children under 1)
Posterior Tibial, Dorsalis Pedis
Temporal
Popliteal

10. Pulse Cont’d Apical Pulse Use table 9-1 as a reference pg. 326
Stethoscope
5-6 intercostal space, left of sternum
Must be taken before giving certain meds that may slow the HR
Digitalis
Use table 9-1 as a reference pg. 326

11. Normal Pulse Rate (BPM, bpm)
Adult
Adulthood 72-80
Late adulthood 60-80
Child
Newborn
1 mo.-1 yr
1-6 yrs
6-adolescence

12. Pulse Rate Tachycardia: Bradycardia: Rapid pulse rate Slow pulse rate
Stress, medications
Infection, pain, exercise
Lack of oxygen
Low BP
Bradycardia:
Slow pulse rate
Heart meds, physically fit
Severe low BP or oxygen levels

13. Pulse Quality Strength: scale of 0-3 Regular/Irregular pulse rhythm
0 -absent, unable to detect
1-thready, weak, diff. to palpate
2-strong, normal
3-bounding,
Regular/Irregular pulse rhythm
Arrhythmia or dysrhythmia
Bilateral Presence

14. Blood Pressure Taken with manual or automatic BP cuff
Taken by auscultation

15. Key Terms Systolic (SBP) Diastolic (DBP)
Pressure on arterial walls when heart is pumping
Diastolic (DBP)
Resting pressure on arterial walls when heart relaxes between contractions

16. BP by Auscultation Size using guides on cuff
Position on upper arm hoses pointing down
Inflate 30mmHg past pulse (no greater than 180mmHg)
Position stethoscope over brachial artery
Deflate
Note first sound and last sound
Record as systolic/diastolic (140/80)
Pay attention to SAFETY on pg. 331…read and record in your notes NOW

17. Normal Blood Pressure Male Female Systolic = 100+age until 50
Diastolic =60-90
Female
Systolic=90+age until 50
Diastolic = 50-80

18. Respirations
The act of breathing, or the exchange of oxygen and carbon dioxide
Includes: inhalation and exhalation
When you count respirations, you count one inhalation and one exhalation as one respiration or a complete breath
Patient can “fake a respiration rate” May need to pretend to take a pulse and count respirations

19. Counting Respirations
Methods to counting Respiration Rate (RR)
Observe a client’s chest movement upward and outward for a complete minute
Children <7yrs: use abdominal breathing, abnormal for adults (dyspnea)
Auscultation with stethoscope
A hand on the stomach/chest may help
Patient can “fake a respiration rate” May need to pretend to take a pulse and count respirations

20. Normal Respirations
Adult 12-20/min
Child 15-30/min
Infant 25-50/min

21. Respiration Quality Normal Shallow (low tidal volume) Labored
Use of accessory muscles
Flaring
Tripod Breating
Noisy breathing
Ventilation: hyper and hypo

22. Skin Color Temperature Condition Pink (Normal) Pale
Cyanotic (Oxygen problems)
Red (CO or heat problems)
Yellow (Jaundice)
Temperature
Warm (Normal)
Hot
Cool
Cold
Condition
Dry (Normal)
Moist
Abnormally dry skin can be heat or dehydration related

23. Practice Get pulse and respirations from at least two people
Try to get pulse from carotid, radial, and brachial pulse points

24. Assessing Skin
Color assessed using lips, nail beds, inside of mouth, membranes of the eye
Pull back glove to determine temp and condition
In children under 6 capillary refill is useful for determining perfusion
Refill should take less than 2 seconds
If you note color change, especially cyanosis, note where you see the color change. Cyanosis in the extremities is different from cyanosis at the core (mouth)
Cap refill is not a reliable indicator of perfusion for adults, or when temp is low. Can be used to determine perfusion to extremities if distal pulse can not be found (especially in the feet)

25. Pupils Size Reactivity to light
Constricted
Dilated
Equal/Unequal
Reactivity to light
Can check with pen light or by shielding eyes from light
Dialated – Cardiac Arrest, LSD, Amphetamines, darkness
Constricted – CNS disorder, Narcotics, bright light
Unequal – Head Trauma,stroke, artificial eye, normal condition
Unreactive – could be CNS problem, head trauma, drug use

26. One last note on Vitals
First set of vitals is the baseline, you are interested in changes
On not sick patients, repeat every 15 minutes
On sick patients, repeat every 5 minutes
Treat patient, not the vital signs or the equipment

27. Practice
Get BP from two people

28. History Taking

29. SAMPLE Organized technique to obtain pertinent medical informaiton
Can obtain information from patient, family or bystanders
SAMPLE is an acronym

30. SAMPLE Signs/Symptoms Allergies Medications
Past Pertinent Medical Conditions
Last Oral Intake
Events Leading to Injury or Illness

31. Signs/Symptoms Signs – things you can see or hear
Symptoms – things the patient reports
Nausea is a symptom, vomiting is a sign

32. Allergies Environmental and Medical allergies are important
Medic Alert tags are also useful

33. Medications Prescription and OTC Birth Control Pills Illicit Drugs
Including vitamins, herbal remedies
Birth Control Pills
Illicit Drugs
Always get a list of meds, or take them with
Home O2 rate is also important
What did you take, when, how much?
Had a patient brought in with chest pains (I believe) problem was an overdose of a vitamin suplement
If patient is unresponsive, where can you go to get the meds?

34. Past Pertinent Medical History
Underlying medical problems
Recent visits to hospitals/doctors
Recent medical procedures
Recent accidents/falls/trauma
Medic Alert tags may be useful
Look for signs of medical equipment in the house

35. Last Oral Intake What, how much, when
Important for trauma patients, diabetics

36. Events Leading to Call Get as much information as you can
What happened, what were you doing
Has anything unusual happened?
If this is a chronic problem, what’s different this time?

37. Final SAMPLE notes
Try to ask open ended questions (avoid yes/no questions)
Wait for the patient to respond
5-10 seconds is not out of line
Note pertinent negatives
Write everything down

38. Practice Let’s go through a couple of scenarios
Scenario 1: Called to scene of 86 M who has fallen and can’t get up. You are first on scene. After determining ABCs are Ok you are asked to do vitals. What do you check?
P: 78 regular
R: 18 normal
B/P 168/82
Skin:warm, pink, dry
Pupils: PERLA
(What do you think about vitals)
S: Pain in left hip (sign or symptom), leg is shortened and rotated outward (sign or symptom)
A: Penecilin
M: Glucagon, Asprin qday, vitamins
P: Hip replacement 8 years ago
L: Dinner last evening, glass of water while waiting for ambulance
E: Climbing on chair, slipped and fell about 9:00am
Scenario 2: 60M difficulty breathing. Upon arrival pt sitting on edge of bed. You are first on scene and once you determine that there are no ABC issues that you can address before additional assistance arrives, you obtain vitals and history
P: 50 weak, irregular
R: 26 a bit noisy
B/P: 50/80
PERLA
Cyanotic, clammy
S: Shortness of breath, posture, noisy breathing
A: NKA
M: Digoxin, Lasix and occasionally nitro sublingual
P: Heart attack 5 years ago,
L: bowl of soup for lunch, no dinner
E:shoveled snow earlier today. No chest pain, sob began following shoveling