Module 3: Patient Intake and Vitals

Patient screening

usually chief complaint and medication review, but can vary based on the type of visit

Cheif complaint

subjective information documented in medical record in the paitent’s own words (usually the first piece of information)

Medication reconciliation

formal process at each visit

compare patient’s list of medications to the medical record - saftey measure that reduces risk of improper medications prescriptions.

white coat syndrome

anxiety related to seeing a health care provider for an evaluation - might be mild to severe

Blood pressure

force of the blood circulating through the arteries

measured using a sphygmomanometer (blood pressure cuff) and stethoscope

Systolic pressure

recoreded when the first tapping sound is heard

when blood surges into artery

Diastolic pressure

when last sound disappears out of blood cuff

wrong cuff size

errors for systolic/diastolic pressures up to 6.9 mm Hg

patinet has legs crossed

systolic pressure raised by 2-8 mm Hg

if arm is above heart level

BP reading is lowered

if arm is lower than RA (dangling by side) of if arm is raised up (muscle tension)

BP reading is artificially elevated

Palpatory method

systolic pressure measured at radial pulse through palpating/feeling when pulse returns after BP cuff

Expected BP: older than 12 y/o

Systolic: 110-130

Diastolic: 65-80

Expected BP: 6-12 y/o

Systolic: 100-120

diastolic: 60-75

Expected BP: 3-6 y/o

Systolic: 95-110

Diastolic: 60-75

Expected BP: 1-3 y/o

Systolic: 90-105

Diastolic: 55-70

Normal BP

Systolic: <120 AND

Diastolic: <80

Elevated BP

Systolic: 120-129 AND

Diastolic: less than 80

High Blood Pressure (Hypertension stage 1)

Systolic: 130-139 OR

Diastolic: 80-89

Hypertension stage 2

Systolic: 140 or higher OR

diastolic: 90 or higher

Hypertension crisis (emergency care)

Systolic: higher than 180 AND/OR

Diastolic: higher than 120

BP Cuff size: Small adult

8.7-10.2 inch

BP Cuff size: adult

10.6-13.4 inch

BP Cuff size: large adult

13.8-17.3 inch

BP Cuff size: XL adult

17.7 - 20 inch

orthostatic hypotension

significant drop in blood pressure when changing position (when standing up or laying to sitting)

caused by dehydration, heart disease, diabetes, or medications)

greater than 10/min increase in HR and greater than 20 mm Hg drop in BP

Pulse

number of times the heart beats per minute

Radial pulse

on thumb side of wrist, most common for taking adult pulse

Brachial pulse

inside upper arm, most common when measuring children

carotid pulse

located in the neck below jawbone (used for emergency procedures)

temporal artery

located on the side of the forehead

femoral artery

located on the inner groin area

popliteal artery

located behind the knee

posterior tibial artery

located behind the ankle

dorsalis pedis artery

located on top of the foot

Normal Pulse: Adolescent and older

60-100 bpm

Normal Pulse: school age (6-15y/o)

75-118 bpm

Normal Pulse: Preschooler (3-5 y/o)

80-120 bpm

Normal Pulse: Toddler (1-2 y/o)

98-140 bpm

Normal Pulse: Infant

100-180 bpm

tachypnea

fast respiratory rate

bradypnea

slow respiratory rate

hyperventilation

fast/rapid breathing could be caused by intense pain, anxiety, panic attacks

hyperpnea

excessively deep breathing could be caused by excessive pain or anxiety

Dyspnea

difficult or painful breathing, COPD, pneumonia, asthma, high altitudes, physical exertion

orthopnea

difficulty breathing unless in upright position

could be caused by congestive heart failure, COPD

Wheezing

whistling sounds during breathing, caused by asthma

Rales

small clicking, bubbling, or rattling sounds

Fluid in air sacks, pnemonia

Ronchi

large airway sounds

COPD, chronic bronchitis, pnemonia

Respiratory rate

breathing with each count being one complete inhalation and exhalation

since patients can control their breathing, don’t tell patients you are checking for breathing, rather do it when looking for heartrate (count for 30 secs)

Normal respiratory rate: Adolescent and older

12-20 breaths per min

Normal respiratory rate: School age (6-15 y/o)

18-25 breaths per min

Normal respiratory rate: preschooler (3-5 y/o)

20-28 breaths per min

Normal respiratory rate: Toddler (1-2 y/o)

22-37 breaths per min

Normal respiratory rate: Infant

30-53 breaths per min

Pulse oximetry

Percentage of oxygen in blood and heartrate, infrared light of oximeter can be blocked by nailpolish and artificial nails, so they shouldnot be used when reading the finger

earlobe is an option if finger isn’t available

Tympanic Temperature

(T) or (AU) - measuring in the ear

popular because of the speed and comfort

doesnt work if patient is complaining of ear pain or cerumen in ears

Axillary temperature

Ax - armpit

Rectal temperature

R - rectum

Temporal artery

TA - moved across the forehead and behind ear

preferred by pediatritions bc. it is more accurate

Axillary temp

usually 1 F or 0.6 C lower than oral reading since it isn’t in body cavity

Expected temp: Newborn

use Axillary - 98.2 F/ 36.8C

Expected temp: 1 year old

Tympanic: 99.7 F/37.6 C

Expected temp: 6 years - adult

oral - 98.6F/37C

tympanic, rectal and temporal artery temperatures are 1F or 0.6 C higher than oral readings

Expected temp: Older adults (over 70)

Oral - 96.8F/ 36C

Convert Temp: F→C

(F-32) / 1.8

Convert Temp: C → F

(C*1.8) + 32

what affects temp reading

drinking hot or cold liquids, smoking, cold weather, hot weather, age, menstrual cycle

Documenting pain

must document: location, duration, characteristics, onset

convert lb - kg

1 kg = 2.2 lb

BMI

weight in kg/(height in m)²