bp assessment

Flow Chart

1. Walk in

2. Hi there my name is Mary Francis, and Im the pharmacy intern (put on hand sanitizer!!!)

3. Can I please get your full name and date of birth (patient speaks)

4. And your gender identity please (patient speaks)

5. So I understand you have some concerns going on, do you have 10 mins so we can go over it and find the best option for you? (patient speaks)

6. Perfect! 

7. So what’s going on (CC) (patient speaks)

8. Do you have any allergies (and reaction) (patient speaks)

9. Before we get more into it, do you mind if I can take some vitals from you? (patient speaks)

10. Perfect! 

11. Before we get started on that: (1) Did you have any caffeine, alcohol, or nicotine in the last 30 mins (2) Do you take any blood pressure medications (if yes, write it down) (3) what is your typical blood pressure you would say

12. Take Blood pressure → MAKE SURE TO TELL THEM 

13. Take Pulse → MAKE SURE TO TELL THEM 

14. Take Respiratory Rate →  MAKE SURE TO TELL THEM 

15. Take Temperature → MAKE SURE TO TELL THEM 

16. Thank you so much for that, now let’s go back to what brang you here (say the CC) 

17. Ask PPQRSSTA questions (try to write down) (patient speaks)

18. Ask ROS questions (minimum 3) (patient speaks)

19. Past Medical History (patient speaks)

20. Family History (patient speaks)

21. Social History (patient speaks)

22. Medication History (patient speaks) (MAKE SURE TO INCLUDE OTC, HERBALS, EYE, EAR, INJECTIONS, WHAT TO TAKE WHEN IN PAIN)

23. Triangle Recommendations (OTC or Provider)

24. What questions do you have for me (patient speaks)

25. Well, thank you for your time, if you need more help or are confused about something, please stop by any time and we would love to help you, wish you all the best and have a great day!

PQRSTA

1. What caused it?

2. Have you tried anything to help?

3. What does it feel like?

4. Does it spread? Or just in a specific area?

5. Where exactly is it?

6. How bad is it? (does it affect your daily activities? scale on 1-10)

7. When did you first notice the issue?

General

• Tired

• Weakness

• Fever

• Night sweats

• Weight loss

• Weight gain

Skin, Hair, Nails

• Sores

• Dryness

• Itching

• Rashes

• Bumps

• Hair loss

• Change in nail texture

Head/Neurological 

• Headache

• Head injury

• Fainting

• Blackouts

• Seizures

• Weakness

• Paralysis

• Numbness

• Tingling

• Shaky

Mental Status/Psychiatric

• Anxiety 

• Memory problems

• Depression

• Hallucinations

• Mood changes

• Disorientation/Confusion

Respiratory

• Cough

• Wheezing

• Pain

• Asthma

• Bronchitis

• COPD

• Pneumonia

• Shortness of breath

• Coughing up blood

• Difficulty breathing     

• Tuberculosis (including exposure)

• Mucus production (colour, how much)

Cardiac

• Heart trouble

• Chest pain/discomfort

• Fast heart beat

• High cholesterol

• Trouble breathing when: working/lying down/at night

• Swelling in feet, ankles or legs

Gastrointestinal

• Nausea

• Vomiting

• Abdominal pain

• Vomiting blood

• Heartburn

• Indigestion

• Excessive burping 

• Poor appetite

• Constipation

• Diarrhea

• Rectal bleeding

• Change in stool color

• Black stools   

• Hemorrhoids

• Excessive passing of gas

• Jaundice

• Hepatitis

• Liver disease

Peripheral Vascular

• Leg cramps    

• Varicose veins

• Blood clots

• Pain in legs with walking

Musculoskeletal

• Cramping

• Pain

• Stiffness

• Swelling

• Limitation of movement         

• Arthritis

• Gout

• Back problems

Endocrine 

• Thyroid trouble

•  Heat or cold intolerance

• Diabetes

• Excessive thirst or rash

• Increased sweating

• Hormone therapy

Pulse

• 60-100 

• bpm 

• Watch timer for 15 seconds than x 4

Respiratory Rate

• 12-20 

• bpm 

• Try to watch how much times the patient takes breath in 15 seconds 

Temperature

• 97-98.5 

• °F

Blood Pressure

• mmHg

Blood Pressure Information

1. Right or Left Arm 

2. Sitting or Lying Down 

3. Cuff Size: Standard/ Regular