vital signs and sample history

REFERENCES: Clayton L. T., M.D., M.P.H., Taber’s Cyclopedic Medical Dictionary 17^th ed. Philadelphia: F.A. Davis Company, 1993.

Grant, H.D., Murray, R.H., Bergeron, J.D., O’Keefe, M.F., and Limmer, D. Emergency Care 9th ed. Upper Saddle River, NJ: Brady, Prentice Hall, Inc. 2001.

A. Opening Statement: Vital Signs are a major component of patient care. Evaluating a patient’s breathing, assessing the heart rate, taking a temperature, determining the blood pressure, and obtaining a SAMPLE history. This information is obtained from every patient the medic encounters. Without this information, you may remain unaware of life threatening conditions that require you to provide specific treatment at the scene along with prompt transport to the appropriate treatment facility. As a medical specialist, you must become skilled in determining normal and abnormal vital signs and obtaining a (SAMPLE History) so that the patient's condition can be assessed correctly.

Given a simulated patient and the necessary equipment, measure and record a patient's temperature, pulse, respiration, and blood pressure within the limits allowed and obtain a SAMPLE History.

a. Given a list of terms related to measurement of vital signs and a list of definitions, match each term with its definition IAW cited references.

b. Given a list of equipment, select the equipment necessary to measure and record a patient's oral, rectal, or axillary temperature and disinfect and store the thermometer IAW cited references.

c. Given a glass thermometer or diagram and a list of routes and normal temperature ranges, read the temperature within 0.2 (two tenths) of a degree and match each route with its normal temperature range IAW cited references.

d. Given a scenario, select the indications, contraindications, and appropriate route and procedure to obtain and record a temperature IAW cited references.

e. Given a list of body areas or a diagram of the body, and a list of pulse sites, match each pulse site with the corresponding body area or location IAW cited references.

f. Given a list of pulse characteristics and the procedures to take a pulse, select the normal and abnormal pulse characteristics and procedures to take a pulse IAW cited references.

g. Given a description of heart activity and a list of systolic and diastolic blood pressure ranges, select those activities responsible for producing a blood pressure and blood pressure ranges considered to be normal for adult, child, or infant IAW cited references.

h. Given a list of factors, select those factors which affect blood pressure IAW cited references.

i. Given a list of equipment and a list of steps to obtain a blood pressure, select the equipment and steps in sequence to measure and obtain a blood pressure IAW cited references.

j. Given a patient scenario, select the indication for using an alternate method and steps required to obtain a blood pressure on the thigh or by palpation IAW cited references.

k. Given a list of respiratory characteristics, select those necessary to assess respirations and the normal and abnormal characteristics of respiration IAW cited references.

l. Given a series of steps, select the steps for measuring and recording a patient's respirations IAW cited references.

m. Given a list of acronyms and a list of components, select the acronym and components that define SAMPLE history IAW cited references.

n. Given a list of statements, select the statements which identify additional medical identification on a patient IAW cited references.

C. Class Procedure and Lesson Tie-in: This lecture followed by hands-on training on obtaining vital signs are directly related to all other assessments of ill and injured patients.

Objective a. Given a list of terms related to measurement of vital signs and a list of definitions, match each term with its definition IAW cited references.

2. Core body temperature--the body's temperature in deep structures such as the liver or heart.

4. Hypothermia--a deviation in temperature which persists below the normal average.

7. Pulse--the expansion and contraction of an artery, felt or heard when the ventricles contract.

8. Pulse point--the site where the pulse can be palpated by holding a superficial artery against firm tissue and/or a bony prominence.

9. Pulse rate--the rate at which the heart is contracting, measured in beats per minute.

12. Blood pressure--refers to the pressure exerted by the blood on the walls of the arteries as the heart beats.

13. Systolic pressure--force of blood exerted against the artery walls when the heart contracts. Recorded in milligrams of mercury (mmHg) as the top number of the blood pressure.

14. Diastolic pressure–force of blood exerted against the artery walls when the heart is relaxing. Recorded in milligrams of mercury (mmHg) as the bottom number of the blood pressure.

15. Sphygmomanometer--an instrument used to measure the arterial blood pressure. It consists of an arm or leg cuff with an air bladder connected to a tube and bulb for pumping air into the bladder, and a gauge to indicate the amount of pressure being exerted against the artery.

16. Stethoscope--an instrument used to auscultate sounds produced in the body. Consists of two earpieces connected by flexible tubing to a diaphragm, which is placed against the patient’s skin.

17. Respiration--one complete cycle of breathing; comprised of one inhalation and one exhalation.

19. Bradypnea--respiratory rate that is below the range determined to be normal for a person's age group.

20. Tachypnea--a respiratory rate that is above the range determined to be normal for a person's age group.

Objective b. Given a list of equipment, select the equipment necessary to measure and record a patient's oral, rectal, or axillary temperature and disinfect and store the thermometer IAW cited references.

B. Equipment Necessary to Measure and Record a Patient's Oral, Rectal, or Axillary Temperature.

(2) Uses a thermoscan tympanic probe with cover or other commercially designed digital tympanic thermometer.

6. Disinfectant, (i.e., alcohol, betadine solution). Soak time determined by the type of disinfectant solution used and local SOP.

a. Clean, dry container for each type, clearly marked "clean oral" and "clean rectal".

b. Dirty container with disinfectant solution for each type, clearly marked "dirty oral" and "dirty rectal".

Objective c. Given a glass thermometer or diagram and a list of routes and normal temperature ranges, read the temperature within 0.2 (two tenths) of a degree and match each route with its normal temperature range IAW cited references.

NOTE: The stem of the mercury-in-glass thermometer contains a temperature measuring scale. The scale has an arrow marking the normal temperature of 98.6°F. Long lines on the scale represent each degree, with only the even numbered degrees written (for example, 94, 96, 98, 100). Short lines between degree lines represent 0.2 (two tenths) of a degree.

a. Observe the side with numbers below and lines indicating number of degrees above (long lines = one degree; short lines = 0.2 of a degree).

c. Identify the number corresponding to the line at the end of the mercury column (i.e.,98.6, 97.8). This is the patient's temperature you will record.

NOTE: The following are approximate ranges and may vary slightly from one reference to another.

Objective d. Given a scenario, select the indications, contraindications, and appropriate route and procedure to obtain and record a temperature IAW cited references.

(5) Patient is old/alert enough to assure he/she will not bite down on thermometer.

NOTE: These activities produce temporary change in the temperature of the oral cavity.

(3) Ask if patient has ingested hot/cold food or drink, smoked, or chewed gum within last 20 minutes.

(a) If yes--instruct patient not to drink hot or cold fluids, eat any foods or chew gum before temperature is taken. Wait twenty minutes, take temperature.

(5) Grasp the glass thermometer tightly with thumb and forefinger, and, using a sharp, snapping motion of your wrist, shake down mercury below 96.0°F or turn on IVAC.

(9) Wipe off glass thermometer using gauze pad with one downward motion toward bulb end.

(12) Record temperature. Local SOP may require annotation of “P.O.” to indicate oral temperature.

(8) Position thermometer or probe next to rectum. Ask patient to take deep breath as this will relax rectal sphincter muscle.

(12) Wipe off thermometer using gauze pad with one downward motion toward bulb end.

NOTE: Axillary temperature is the least accurate and least preferred method.

ANSWER: Perspiration/moisture cools the skin which would cause an inaccurate reading.

NOTE: Discuss the need for the monitor mode due to longer time required to achieve the actual body temperature using the axilla route.

(12) Wipe off thermometer using gauze pad with one downward motion toward bulb end.

(15) Record findings followed by "A" or "AX" with a circle around it IAW local SOP.

Objective e. Given a list of body areas or a diagram of body, and a list of pulse sites, match each pulse site with the corresponding body area or location IAW cited references.

2. Brachial artery--located in the depression proximately ½ inch from the crease on the inside of the elbow (Figure 2).

3. Carotid artery--located in the groove on either side of the windpipe (Figure 2).

a. Located approximately 2 inches from the end of the sternum (breast bone) towards the patient's left side (5th intercostal space). The apical pulse can be heard with a stethoscope.

b. Usually taken on infants, and on cardiac patients in hospital and clinic settings.

NOTE: The following pulse sites are used less frequently, for a very specific purpose.

7. Femoral artery--In the middle of the groin where the femoral artery crosses the pelvic bone.

Objective f. Given a list of pulse characteristics and the procedures to take a pulse, select the normal and abnormal pulse characteristics and procedures to take a pulse IAW cited references.

a. Rate--the number of times the pulse is palpated or auscultated in one minute.

NOTE: The following are approximate ranges, and may vary slightly from one reference to another.

(4) Normal range for infants (full-term newborn to one year old) is 120-140 bpm.

NOTE: As with other vital signs, the body can adapt to an individual's condition and health status and create its own "normal" range. Always evaluate "abnormal" findings with this in mind. EXAMPLE: The athlete may have a "normal" heart rate of 45 bpm and be perfectly healthy.

(2) Irregular--differing interval between beats. May have a repetitive pattern, or be “irregularly irregular".

c. Quality--the strength or forcefulness of the heartbeat as felt or heard when palpating or auscultating the pulse.

NOTE: When a distal pulse is abnormal or can not be palpated, take a second pulse at the apical or carotid site. Peripheral and distal pulses are more likely to be difficult to find or absent due to occlusion or vasoconstriction as a result of trauma, medication, disease process, decreased blood pressure, shock etc.

e. Locate the pulse point that is easiest to reach. Normally, this is the radial, brachial or carotid site (Figure 3).

f. Palpate the pulse site by lightly placing your index and middle fingertips on pulse point. Never use your thumb because your thumb has its own pulse which you may feel pulsating, and mistake for the patient's pulse.

g. Count the pulse rate for one full minute. A minimum of 60 seconds is required to get an accurate reading and/or detect irregularities or abnormalities. Note rate, rhythm and quality as discussed above.

Objective g. Given a description of heart activity and a list of systolic and diastolic blood pressure ranges, select those activities responsible for producing a blood pressure and blood pressure ranges considered to be normal for adult, child, or infant IAW cited references.

G. Activities Responsible for Producing a Blood Pressure and Blood Pressure Ranges Considered to be Normal for an Adult, Child, or Infant.

1. Description of heart activity.

a. When the heart contracts, blood is forced out into the arteries. The pressure exerted against the walls of the arteries is measured to determine the systolic reading.

b. When the heart relaxes, blood in the arteries is at its lowest pressure. This pressure is measured to determine the diastolic pressure.

c. Normal elasticity of arteries allows them to expand with and relax after each heartbeat.

d. Elasticity of arteries maintains a certain amount of systolic and diastolic pressure.

2. Normal range of blood pressure in mmHg.

NOTE: The following are approximate ranges, and may vary slightly from one reference to another.

a. Adults.

(1) Male--100-150 (Systolic)/65-90 (Diastolic).

(2) Female--90-140 (Systolic)/55-80 (Diastolic).

b. Children--3-12 years old--80-135 (Systolic)/ 60-80 (Diastolic)

NOTE: Blood pressure should be measured in all patients older than 3 years of age. When evaluating children under the age of 3, a general assessment such as sick appearance, respiratory distress or unresponsiveness, is more valuable than a blood pressure.

Objective h. Given a list of factors, select those factors which affect blood pressure IAW cited references.

H. Factors Affecting Blood Pressure.

1. Force of the heart's pumping action.

2. Amount of resistance in blood vessels.

3. Amount of blood in the blood vessels.

4. Diet.

5. Gender (sex) and pregnancy.

6. Physical fitness.

7. Obesity.

8. Race/heredity.

9. Pain.

10. Emotion.

11. Age.

12. Disease.

13. Drugs/medications.

14. Trauma.

Objective i. Given a list of equipment and a list of steps to obtain a blood pressure, select the equipment and steps in sequence to measure and obtain a blood pressure IAW cited references.

I. Equipment and Steps in Sequence to Measure and Obtain a Blood Pressure.

1. Equipment to measure blood pressure.

a. Sphygmomanometer (aneroid or mercury column). The cuff should cover two-thirds of the upper arm, elbow to shoulder (Figure 4).

b. Stethoscope (Figure 5).

2. Steps for taking a patient's blood pressure.

a. Prepare stethoscope.

b. Decontaminate stethoscope diaphragm with 70% alcohol solution/pad.

c. Clean ear piece with clean cotton swab.

d. Explain procedure of taking a blood pressure to the patient.

(1) Time required.

(2) Method used.

(3) Pressure felt, tingling sensation.

(4) Request that he not talk during procedure as this may affect reading.

e. Position patient

(1) Support patient comfortably standing, seated, or lying down.

(2) Arm extended palm up at approximately heart level.

CAUTION: Make sure you use the correct size blood pressure cuff. Cuffs which are too large will give a falsely low reading, cuffs too small will give a falsely high reading.

f. Place blood pressure cuff on the patient.

(1) Locate brachial pulse by palpation.

(2) Place cuff 1 to 2 inches above elbow.

(3) Wrap cuff to prevent slippage (locate gauge in alignment with palm), and arrow on the cuff over artery.

g. Place diaphragm/bell on patient's artery.

NOTE: Place ear piece of stethoscope facing forward in ears. This is the only correct placement any time a stethoscope is used.

NOTE: Do not use thumb to stabilize diaphragm on arm, as your pulse may be heard instead of the patient's blood pressure.

h. Position gauge where you will have full view to observe the column or dial.

i. Inflate cuff until the pulse is no longer heard and then for another 30 millimeters of mercury on the blood pressure gauge.

CAUTION: The inflated cuff is not to stay in place any longer than 2 minutes.

j. Deflate cuff slowly while:

(1) Taking systolic pressure reading--the location of the level of mercury or pointer on the dial (aneroid) of the sphygmomanometer when the first beat is heard.

(2) Taking diastolic pressure reading--the location of the level of mercury or pointer on the dial when the sound changes significantly or disappears.

k. Release remaining air.

l. Determine pressure and record results.

(1) Compare to previous reading.

(2) Immediately report abnormal range or significant change from previous readings.

(3) Record in even numbers only.

NOTE: SF 511 Vital Signs Record, is graduated in even numbers.

Objective j. Given a patient scenario, select the indication for using an alternate method and steps required to obtain a blood pressure on the thigh or by palpation IAW cited references.

J. Alternate Methods for Taking the Blood Pressure.

1. Thigh--use when the arm is unavailable due to injury, IV placement or amputation.

a. Explain procedure.

b. Position patient.

(1) Supine.

(2) Flex knee if necessary.

c. Place and wrap cuff midthigh.

d. Locate popliteal artery by palpation.

e. Place stethoscope on artery.

f. Determine pressure.

g. Record results in even numbers (document if taken at thigh).

2. BP cuff/no stethoscope.

NOTE: Explain that this method may be used when noise prohibits hearing through the stethoscope.

a. Palpate appropriate artery (radial or popliteal) and leave finger in place.

b. Inflate cuff approximately 30 mmHg above the point where the pulse is no longer felt.

c. Gradually deflate cuff, and note the reading on the sphygmomanometer when the pulse returns. This is the palpable systolic blood pressure.

d. Record this number. Example: "76 palpable."

NOTE: Only systolic blood pressure can be read this way.

3. Field expedient method (no BP cuff or stethoscope available).

NOTE: Explain the lack of accuracy with this method.

a. Palpate radial pulse--if present, systolic BP is at least 80 mmHg.

b. If radial and pulse is not present (absent), check femoral pulse--if femoral pulse is present, systolic BP is at least 70 mmHg.

c. If radial and femoral pulses are not present, check carotid pulse; if present, systolic BP is at least 60 mmHg.

Objective k. Given a list of respiratory characteristics, select those necessary to assess respirations and the normal and abnormal characteristics of respiration IAW cited references.

K. Characteristics to Assess and Determine Normal and Abnormal Respirations.

1. Assessing respirations.

a. Rate--the number of complete cycles of breathing that occurs within one minute.

b. Rhythm--the regularity of inhalations and exhalations.

c. Depth--refers to the degree of expansion and relaxation of the chest wall during inhalation and exhalation.

2. Normal and abnormal respiratory characteristics.

a. Normal respiratory characteristics.

(1) General.

(a) Effortless.

(b) Automatic.

(d) Free from discomfort.

(2) Rate.

NOTE: The following are approximate rates, and may vary slightly from one reference to another.

(a) Adult--12-20 respirations per minute.

(b) Child (ages 1 to 12)--15-30 respirations per minute.

(3) Rhythm.

(a) Consistent pattern of respirations and of intervals between respiratory cycles.

(b) Smooth movement of the chest wall.

QUESTION: What is a respiration?

ANSWER: One complete cycle of one inhalation and one exhalation.

(4) Depth--equal expansion and relaxation of the chest wall during inhalation and exhalation.

NOTE: The assessment of normal respiratory depth is based on judgment while watching people breathe when at rest. With experience you will be able to differentiate between deep and shallow respirations.

QUESTION: What must be assessed while taking a patient's respirations?

ANSWER: The rate, rhythm, and depth.

b. Abnormal Respiratory Characteristics.

(1) Causes.

(a) Emotions, e.g., anxiety, fear.

(b) Pain.

(d) Smoking.

(e) Environment, e.g., temperature, altitude.

(f) Medications.

NOTE: Narcotics decrease respirations while amphetamines increase respirations.

(g) Medical conditions, e.g., fever, trauma, asthma.

(2) Abnormal findings.

(a) Effort--labored, difficult breathing(dyspnea); requiring excessive work to regulate breathing.

(b) Automaticity–requiring conscious effort or mechanical assistance to breathe.

(d) Pain with breathing--may be demonstrated by changes in posture, facial expression, and behavior.

(e) Rate--either above or below the range determined as normal for the individual's age e.g. tachypnea, bradypnea.

NOTE: A respiratory rate of 8 or less per minute and signs of respiratory distress should be treated immediately.

(f) Rhythm--irregular variations in the amount of time between respiratory cycles.

(g) Depth--over or under-expansion of the chest wall during inhalation.

NOTE: Shallow respirations are difficult to see, you may only be able to determine the rate by using your hand to actually feel for chest movement.

Objective l. Given a series of steps, select the steps for measuring and recording a patient's respirations IAW cited references.

L. Procedure for Measuring a Patient's Respirations.

1. Identify the patient.

2. Have patient remove bulky clothing (if possible) that might interfere with observation of chest movement.

3. Position patient sitting or supine.

4. Place your fingers on patient's wrist as if you are taking his pulse. Also, if there is difficulty in seeing chest movement, you may fold the patient's arm diagonally across their chest, allowing you to feel the movement instead.

NOTE: Respiratory rates may be more easily obtained if combined with taking of pulse or temperature.

5. Count the number of respirations for 1 minute.

6. Observe the respiration rate, rhythm, and depth.

7. Record the respiration rate on a scratch pad and transfer to either a SF 511 (TPR graph sheet) or other document IAW local SOP.

8. Report all abnormal findings to the supervisor.

QUESTION: How long should you count respirations?

ANSWER: One minute.

Objective m. Given a list of acronyms and a list of components, select the acronym and components that define SAMPLE history IAW cited references.

M. Acronym and Components That Define SAMPLE History.

1. Acronym utilized to obtain important information relating to the patient’s medical history.

2. Components of the SAMPLE history.

a. S=signs, symptoms.

(1) Sign-what you see-bleeding, vomiting, etc.

(2) Symptom-what the patient tells you: “My head hurts”, “I feel weak”.

b. A=allergies. Is the patient allergic to any food or medications?

c. M=medications. Is the patient taking any medications, either prescribed or over the counter?

d. P=pertinent medical history. Does the patient have heart problems, breathing problems, etc?

e. L=last oral intake (what, when, how much).

f. E=events leading to the problem. What happened? What was the patient doing?

Objective n. Given a list of statements, select the statements which identify additional medical identification on a patient IAW cited references.

N. Identify Additional Medical Identification on a Patient.

1. Medic alert necklace or bracelet (Figure 7).

a. Identifies medical problems, heart problems, diabetic, allergies, etc.

b. Identifies patient as an organ donor.

2. Driver’s license.

a. Identifies medical problems, heart problems, diabetes, allergies, etc.

b. Identifies patient as organ donor.

3. Vial of Life.

a. Sticker with red background and white lettering Vial of Life placed on front of door.

b. Plastic bottle with sticker Vial of Life found in patient’s refrigerator, on the door shelf or shelf of refrigerator.

c. Paper found in bottle identifying the following:

(1) Patient’s name, age, date of birth.

(2) Patient’s medical history, medications and dosage, and allergies.

(3) Patient’s physician, next of kin, hospital of preference.

(4) Patient’s insurance number and Medicare or Medicaid number.

4. Microfiche card identifies medical history, medications, allergies, insurance number, next of kin, date of birth.

a. Generally found in patient’s wallet.

b. Need a microfiche reader which may be found in most hospitals.

O. Questions from Students.

III. SUMMARY (2 min).

A. Review of Main Points.

1. Terms and definitions.

2. Equipment to record oral, rectal, and axillary temperature.

3. Routes and normal temperature ranges.

4. Indications, contraindications and procedures to obtain temperature.

5. Location of pulse sites.

6. Normal and abnormal pulse characteristics.

7. Heart activities that produce blood pressure.

8. Factors that affect blood pressure.

9. Equipment and steps to obtain a blood pressure.

10. Alternate methods to obtain blood pressures.

11. Normal and abnormal characteristics of respirations.

12. Steps for measuring and recording respirations.

13. Components of SAMPLE history.

14. Identify additional medical identification on a patient.

B. Closing Statement: It is very important to measure a patient's vital signs accurately, along with the SAMPLE history they will alert the medic and physician to abnormalities, thus allowing him/her to properly assess and treat the patient's condition. The procedures studied in this lesson must be mastered in order to accurately measure and record them. It is equally as important to disinfect the equipment properly so that pathogens are not transmitted to other patients.

4. Saturate gauze pad with disinfecting solution or germicide, such as betadine.

6. Wipe each thermometer using a twisting motion from tip towards bulb end one time only.

7. Use cool water to rinse thermometers. Do not use hot water or very cold water.

9. Use one covered basin for oral thermometers. Use another covered basin for rectal thermometers.

10. Make sure solution completely covers thermometers. Bulb ends of the thermometers point in the same direction.

11. Keep thermometers in covered basin for a minimum of 30 minutes. Change solution and disinfect, thermometer holders, and trays daily or IAW local SOP, as standing solution may develop bacterial growth.