Baseline Vital Signs & History Taking

CHAPTER 5

Gathering Patient Information

Some information readily available:

Some information involves detective work

Baseline Vital Signs“Signs of life”

The first set taken

Traditionally:BreathingPulseSkinPupilsBlood pressurePulse Oximetry (6th vital sign)

Baseline Vital SignsItems needed:

Sphygmomanometer (BP cuff)StethoscopeWristwatch (not your cell phone)PenlightPen and notebookBSI

Respiratory Rate# of breaths per minute

Normal Respiratory RatesAdult 12-20Adolescent (11-16) 12-20School aged (6-10) 15-30Preschool aged (3-5) 20-30Toddler (1-3) 20-30 Infant (older) 20-30 Infant (younger) 25-40Newborn (birth to 30 days) 30-60

Respiratory RateHow to count

Breathing QualityNormal breathing

Average chest wall motionOne inch of expansionNo accessory muscles Exhalation twice as long as inhalationNo abnormal lung sounds

Breathing QualityShallow breathing

Only slight chest or abdominal wall expansion

Breathing QualityLabored breathing

May include abnormal soundsGrunting stridor

Accessory muscle useNeckAbdominalNasal flaring

GaspingRetractions

Breathing QualityNoisy breathing

SnoringWheezingGurglingCrowing or stridorhttp://www.youtube.com/watch?v=VA9C_aCH7F0http://www.youtube.com/watch?v=jjf7LZxrwK8&fe

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Breathing RhythmRegularity

Irregularity

PulseLocation of pulses

CarotidFemoralRadialBrachialPoplitealPosterior tibialDorsalis pedis

PulseRate

Elderly 90Adult 60-80Adolescent 60-105Older child 60-120Younger child 80-150 Infant 120-150

PulseQuality and rhythm

Strong or weakRegular or irregular

Pulsus paradoxus- pulse becomes weaker during inhalation.

SkinColor

Paleness or pallorCyanosisFlushingMottling

Also, check the color of the mucosa

SkinTemperature

HotCoolCold

SkinCondition

DryMoistClammy = cool and moistDiaphoretic = profuse sweating

Capillary RefillTime it takes for compressed capillaries to fill.

< 2 seconds for infants, children, male adults< 3 seconds for females< 4 seconds for elderly

PupilsSize

Equality

Reactivity

PupilsDilated- cardiac arrest, drugs

Constricted- narcotics, central nervous system disorder

Unequal- stroke, head injury, artificial eye, eye drops, previous eye or head trauma

Nonreactive- cardiac arrest, brain injury, drugs

Blood PressureSystolic blood pressure

Ventricle of heart while contracted

Diastolic blood pressureVentricle of heart at rest

Measured in mmHg (millimeters mercury)

Always expressed as even numbers

Blood Pressure“Normal”

Adult male 100+ age… to age 40…. Diastolic 60-85

Adult female 90+ age… to age 40… Diastolic 60-85

Adolescent 90- mmHgChild 90 + 2 x age (upper limit)Child 70 + 2 x age (lower limit)

Taken byPalpationAuscultation

Orthostatic Vital SignsTilt test

Suspected volume loss

Heart rate increases more than 20 bpm

Blood pressure decreases more than 20 mmHg

Pulse Oximetry97-100%

Reading < 95 needs to be investigated

Pulse OximetryLimitations

ShockHypothermiaMovementNail polishCarbon monoxideCigarettesAnemia

SAMPLE HistoryS- Signs and Symptoms

O- OnsetP- ProvocationQ- QualityR- RadiationS- SeverityT- Time

SAMPLEA- Allergies

MedicationsFoodEnvironmental

SAMPLEMedications

PrescriptionOver-the-counterBirth control Illicit drugsHerbals

SAMPLEPertinent past history

Underlying medical problems Surgeries, procedures, or traumaHistory of current complaint

SAMPLELast oral intake

(Last menstrual cycle)

SAMPLEEvents

Leading up to injury