P2 Fall OSCE

vital signs

physical signs which indicate that a person is alive

-temperature

-respiratory rate

-pulse

-BP

-pain

What are the 5 primary vital signs?

assess

Vital signs are used to _________ level of function.

palpatation

The act of touching or feeling; using pressure of the hand or fingers on the surface of the body to complete a physical examination

auscultation

The act of listing to sounds arising within organs as an aid to diagnosis and treatment

percussion

Use of tapping motion of finger to determine whether a a compartment is filled with air, fluid or solid material

-Age

-Gender

-Weight

-Exercise

-Stress/Anxiety

-Medical conditions (e.g., pain)

What are some factors that influence vital signs?

about 5 mins

How long should pts be seated prior to assessing BP?

pain

-Subjective measurement

-Often called the "5th vital sign"

-Can use standardized pain assessment tools or pain-rating scales

-Measurement should include severity of pain and location of pain

fever

-hyperthermia

- > 38 degrees C (100.4 degrees F)

hypothermia

< 95 degrees F

cooler

Women usually feel _________ more quickly than men.

-oral

-axillary and temporal

-rectal and tympanic

what are the ways to measure temp?

NO

Should you ever recommend mercury-in-glass thermometers?

electronic probe thermometers

-Oral, rectal, axillary

-Provide reading in 10-60 seconds

infrared thermometers

-Tympanic and temporal artery measurements

-Must be placed directly over the line of a blood supply

-Provide reading in 5 seconds

-Only accurate if used correctly

rectal

What is the most reliable device used for taking temp?

axillary

What is the least reliable device used for taking temp?

Rectal > Tympanic/Temporal > Oral > Axillary

List the reliability of the different ways to measure temp:

measuring oral temp

-digital

-no drinks in previous 30 mins

-not ideal for children < 4/5 yrs

4-5 mins

How long does it take to do an axillary temp (under the arm)?

0.5-1 degree

Axillary temp usually measures _________ lower than oral.

higher

rectal temp usually measures 0.5-1 degrees F ______ than oral.

rectal temp

what is the preferred method of taking temp in children < 3 months?

measuring rectal temp

-Hold child still

-Before inserting, put some water- based lubricating jelly on the end of the thermometer and on the opening of the bottom (anus)

-Insert carefully; never force past any resistance

infrared heat waves

are released by temporal artery (runs across forehead)

measuring temporal temp

-Place sensor at center of forehead midway between eyebrow and hairline

-Depress and hold scan button

-Slowly slide thermometer straight across forehead toward top of ear, keeping in contact with skin

-Stop and release scan button when you reach hairline

-Remove thermometer from skin and read temperature

lower

Temporal temp also measures 0.5-1 degree F _________ than oral.

temporal temp

What is the most expensive option to take temperature?

no

Can you use the tympanic temp for children <6 months old?

measuring tympanic temp

1. Place lens cover on ear probe.

2. Turn thermometer on

3. For children < 1 yr old, pull ear backwards to straighten ear canal. Place probe into canal until the ear canal is sealed and aim the tip towards the patient's eye

4. For patients > 1 year old, pull ear backwards and up to straighten ear canal. Place probe into canal until the ear canal is sealed and aim tip towards the patient's eye.

5. Press button to obtain temperature

6. Record temperature and discard lens cover

oral temp

Not ideal way to measure temp for children < 3 yrs old

pulse

is wave of blood created by the contraction of the left ventricle

radial pulse

the pulse felt at the wrist

apical pulse

auscultation at apex of heart

apical pusle

should be considered in pts with irregular heart rthymns

steps for checking radial pulse

1. Make sure patient is in a sitting or laying position.

2. Locate the radial artery inside pt's wrist with index and middle finger

3. Gently press on artery to detect the pulse

4. Count the beats for 30 seconds then multiple by 2

5. Assess rhythm while counting- if irregular, continue to count beats for a full 60 seconds

6. Record results

- Wrist* (radial)

- Side of the lower neck (carotid)

- Inside of the elbow (brachial)

- Femoral

- Pedal

What are the pulse locations?

checking pulse

-Place tips of your index and middle fingers just proximal to the patients wrist on the thumb side, orienting them so that they are both over the length of the vessel

-Push lightly at first, adding pressure if there is a lot of subcutaneous fat or you are unable to detect a pulse

-If you push too hard, you might occlude the vessel and mistake your own pulse for that of the patient

you may mistake your pulse for the pts

Why can you not use your thumb to check pulse?

quantitiy

-Measure the rate: (recorded in beats/min)

- Count (start with "0") for 30 seconds & multiply by 2

- If rate is slow or fast: count for a full 60 seconds to minimize chance of error

regularity

time between beats constant (irregular rhythms are common)

60-100 beats per min

What is the normal pulse rate for a healthy adult?

low

Athletes may have ______ pulse rates (40s-50s) and experience no problems.

bradycardia

Slower than normal pulse

< 60 beats/min

tachycardia

Faster than normal pulse

> 100 beats/min

respiratory rate

-Number of breaths per minute

-Measured by observing the rise and fall of the patient's chest while taking their pulse

-Count at least 30 seconds

-Described based on rate, rhythm, depth and sound

respiratory rate

-Keep your fingertips on the radial artery and don't tell the patient you are counting respirations

-doesnt always correlate with respiratory impairment (use in conjunction with oxygen saturation)

12-20 breaths/min

What is the normal respiration rate at rest?

tachypnea

> 20 breaths/min

bradypnea

< 12 breaths/min

apnea

lack of breathing

age

affects respiration rates more in pediatric than adutls

increases

Fever/illness _________ respiratory rate.

dyspnea

difficulty breathing

systolic blood pressure

-is the pressure at which you can first hear the pulse

-Arterial pressure during heart contraction (systole)

-1st Korotkoff sound

-TOP number

diastolic blood pressure

-is the last pressure at which you can still hear the pulse

-Arterial pressure while heart is at rest (diastole)

-5th Korotkoff sound

-BOTTOM number

30 mins

When measuring BP, no eating/drinking/smoking or taking drugs that affect BP ________ before measurement.

full

A ______ bladder also affects BP, so it should be empty.

60 mins

Painful procedures and exercise should not have occurred within _________ before measuring BP.

about 5 mins

How long should a pt be sitting quietly before taking their BP?

pt prep for BP monitoring

-Sitting position

-Arm and back supported

-Arm at heart level

-Both feet resting firmly on the floor (e.g., not dangling, legs not crossed)

-Have you had any caffeine or nicotine in the last 30 min?

-What BP meds do you take? Have you taken them in the last 30 min?

-Have you exercised in the last 30 minutes?

-What is your BP normally?

What questions do you ask before taking a pts BP?

bladder length

80% arm circumference

bladder width

40% circumference of arm

overestimation

A too small cuff may result in ____________ of BP.

underestimation

A too large cuff may result in _____________ of BP.

1 in

The position of a BP cuff should be _________ above the site of pulsation (antecubital area and wrap snugly).

brachial artery

The artery marker on a BP cuff should be positioned on the ____________

out

Ear pieces of stethoscope should be pointing ________ (toward the pt).

diaphragm or bell

You should place the stethoscope on the ___________ on artery when using it to take BP.

right

turn the valve of the BP cuff to the ______ to tighten

left

turn the valve of the BP cuff to the _____ to loosen

about 20 mmHg

you should inflate the BP cuff _________ above a pts suspected SBP

additional 20 mmHg

If you immediately hear sound, pump up an additional 20mmHg and repeat

2-3 mmHg

Deflate BP cuff slowly at a rate of ________ per second until you can again detect a radial pulse

korotkoff sounds

auditory vibrations from artery

DBP

last sound detected when listening for BP

2-5 mins later

If the BP is surprisingly high or low then repeat the measurement __________

yes

Can repeated BP measurements be uncomfortable?

hypotension

BP <90/<60

normal BP

BP <120/<80

elevated BP

BP 120-129/< 80

stage 1 HTN

BP 130-139/80-89

stage 2 HTN

BP ≥ 140/ ≥ 90

Hypertensive crisis

BP > 180/>120

oxygen staturation

-Measured using pulse oximeter

-Indirectly measures how much oxygen is carried in the blood

-Readings are recorded as oxygen saturation level (O2sat or SaO2)

-% of how much oxygen your blood is carrying compared to the maximum it is capable of carrying

95-100%

What is the normal oxygen saturation?

<88%

What level of O2 saturation requires O2 therapy?

-Ensure pt does not have any fingernail polish on- if so, place probe at the base of the nail or use toe

-Ensure pt's hand is warm and relaxed

prior to measuring O2 sat:

higher

Smokers may have _________ than actual pulse ox readings due to high carbon monoxide levels.

less

Poor circulation or cold extremities may result in ________ accurate O2 sat readings

underweight BMI

< 18.5 BMI

normal BMI

18.5-24.9 BMI

overweight BMI

25-29.9 BMI

obese BMI

≥ 30 BMI

Class 1 obese

30-34.9 BMI

class 2 obese

35-39.9 BMI

class 3 obese

40 + BMI

1) anti-platelet therapy

2) BB

3) ACE or ARB

4) statin therapy

5) mineralcorticoid receptor antagonist

6) SGLT2 inhibitor

7) pneumococcal vaccine

What is the checklist for STEMI pt discharge?