Chapter 11

vital signs

- respirations

- pulse

- skin

- pupils

- blood pressure

- pulse oximetry

respirations

- 12-20/min (

- rate, quality, rhythm

- ventilate adult patient > 40 / min or infant/young child > 60 / min

- interpret based on overall presentation

- too fast = fatigue and does not allow adequate tidal volume

- Cheyne Stokes, Biot, apneutic, ataxic, agonal, Kussman (in DKA do not fix), central neurogenic hyperventilation

- normal, shallow, labored, noisy

pulse

- number and feel

- carotid and femoral are central

- brachial, popliteal, posterior tibial, dorsalis pedis are peripheral

- older than 1 = radial

- older than 1 without peripheral = carotid

- less than 1 = brachial

- pressure waves generated by left ventricle contractions

- directly reflects heart function

- adults avg 60-80 bpm

- >100 = tachy

-

skin

- temp, wet, color

- capillary refill: more reliable in children, 2 sec max children/men, 3 sec max women, 4 sec max elderly (squeeze finger)

- pink = normal

- paleness/palor = blue gray/cyanosis

- red color = flushing

- yellow = jaundice

- clammy = cool + moist

- diaphoresis = extremely sweaty

- Hot = fever / heat exposure

- Cool = inadequate circulation, shock, cold exposure

- Cold - extreme cold exposure

- Moist = shock, poisoning, heat related, cardiac, diabetic emergency

- Abnormally Dry = spinal injury, severe dehydration

pupils

- size, equality, reactivity to light

- dilated: cardiac arrest, drugs (LSD, amphetamines, cocaine)

- constrictedL CNS disorder or narcotics

- unequal: stroke, head injury, artificial eye, eye drops, eye trauma

- nonreactive: cardiac arrest, brain injury, eye drops, drug intox/OD

blood pressure

- systolic = contraction

- diastolic = relaxation (SVR/blood volume)

- take in all patients > 3 years

- auscultation (systolic + diastolic)

- palpation (systolic)

- pulse pressure: 25-50% systolic

- Low BP = hypoperfusion

- high BP = can damage heart, brain, kidneys vessels

- adult: 120/80

- infant 72-104/37-56

- hypo: less than 90 in adults, less than 70+2xage in children, less than 60 in infants

- sphyngomanometer

pulse oximetry

- normal 97-100%

- hypoxia

baseline

- first set of vital signs that later findings are compared to

- repeat every 15 mins if stable

- repeat ever 5 mins if unstable

orthostatic vital signs

- suspected volume los

- supine take vitals, stand for 2 mins take again

- if HR increases more than 10-20 born and systolic decreases more than 10-20 mmHg indicates volume loss

abnormal breathing findings

-

- looks like distress

- altered mental status

- >40 adult or >60 kid = needs assistance

- shallow (inadequate tidal volume)

- labored (stridor)

- noisy

cheyne stokes

- RR and tidal volume gradually increase than gradually decrease followed by apnea for up to 10 seconds and repeat

biot

- RR interrupted by period of apnea (like cheyne stokes but tidal volume does not change)

apneustic

- prolonged periods of inhalation

ataxic

- irregularly irregular RR and tidal volume

agonal

- long periods of apnea with gasping breaths

kussmaul

- rapid Rr with deep and labored tidal volume

central neurogenic hyperventilation

- sustained deep + rapid RR of at least 25 breaths per minute with regular pattern

normal respiratory rates

- adults: 12-20

- adolescents: 12-20

- 6-11 years: 18-25

- preschoolers: 20-28

- toddler: 22-37

- infant: 30-53

- neonate: 40-60

assessing breath sounds

- upper: audible

- lower: with stethoscope

snoring

- tongue partially blocking pharynx

gurgling

- fluid in upper airway

stridor or crowing

- partial obstruction of larynx

wheezing

- constriction and inflammation reducing internal diameter of bronchioles

crackles (rales)

- fluid surrounding + filling alveoli

rhonchi

- mucus blocking larger bronchioles

carotid pulse

- don't check both at same time

pulse paradoxus

- decrease in pulse strength during inspiration, could be significant cardiac or respiratory injury or significant blood loss

bounding pulse

- abnormally strong

thready pulse

- weak and rapid

normal findings pulse

- adult: 60-100

- 12-15 years: 60-100

- 6-11 years: 75-118

- 3-5 years: 80-120

- 1-2 years: 98-140

- infant: 100-180

- neonate: 100-205

causes of abnormal pulse

- irregular rhythm: cardiac disease

- rapid, regular, full: exertion, fright, fever, high BP, early stage blood loss

- rapid, regular, thready: shock, early stage blood loss

- slow: head injury, barbituate/narcotic use, some poisons, possible cardiac problems / other medical conditions (ex: hypothyroidism)

- no pulse: cardiac arrest, profound hypotension

abnormal skin findings color

- paleness / pallor (extreme vasoconstriction or blood loss)

- cyanosis (bad oxygenation/perfusion)

- red (heat, peripheral vasodilation, late CO poisoning)

- jaundice (liver disease)

- mottling (blotchy cyanosis, shock of blood pooling)

abnormal skin findings temperature

- hot (fever / heat exposure)

- cool (inadequate circulation / shock / cold exposure)

- cold (extreme cold exposure)

- hot spot (infection)

- cold spot (circulation problem)

abnormal skin findings condition

- wet/moist (shock, poisoning, heat/cardiac/diabetic emergency)

- diaphoresis (profuse sweating)

- abnormally dry (spinal injury, severe dehydration, heat stroke, poisoning, hypothyroidism)

abnormal findings pupils

- dilated: drugs (LSD, amphetamines, atropine, cocaine), cardiac arrest

- constricted: CNS disorder, narcotics, glaucoma meds, bright light

- unequal: stroke, head injury, artificial eye, eye disease, eye drops, injury to eye or nerve

- sluggish reactivity: hypoxia, drug OD, bad perfusion

- fixed: cardiac arrest, head injury, severe hypoxia, extremely poor brain perfusion

anisocoria

- pupils remain reactive to light with a size difference less than 2mm

consensual reflex

- same response in both eyes reactive to light even when light only in one eye

causes of abnormal BP findings

- decreased: late sign of shock

- widened pulse pressure: could be head injury

- narrow pulse pressure: shock, cardiac tamponade, tension pneumothorax

- systolic < 90: shock

- low = blood / fluid loss, cardiac pump failure, blood vessel dilation, severe bleeding, heart attack, heart failure, spinal injury)

- high BP leads to heart and blood vessel damage --> failure + ruptured vessels + kidney disease

capnometry

- measurement of expired CO2

- used to monitor correct endotracheal tube placement and effectiveness in chest compressions

- at end of exhaled breath

- sudden increase may indicate cardiac arrest patient regained pulse

- decreases during hyperventilation, increases during hypoventilation

- decreases with decreased cardiac output, blood flow, pulmonary capillary perfusion, or metabolic activity

- increases with improvement in alveolar ventilation and with seizure

- changes with breathing, metabolic, and perfusion disturbances

capnogram

- visual recording of CO2 waveform throughout the process of breathing

glucometer

- 70-140 mg/dL normal

- 120-140 mg/dL after meal

- 80-80 mg/dL after 8-12 hour fast

- diabetic number may be higher

- waste first drop of blood before testing second

- take in heel of foot in kids

controlling the scene

- competence, confidence, compassion

smooth transition of care

- from EMR/police/other person providing aid, quickly gain info before making actual patient contact

reducing the patients anxiety

- bring order to the environment, introduce yourself, gain patient consent, position yourself at their level, use communication skills, courteous, touch when appropriate

maintain control

- recognize when scene cannot be controlled, remove yourself and patient if possible

SAMPLE

- signs and symptoms

- allergies

- medications

- pertinent past history

- last oral intake

- events leading up to illness or injury

- gives more details on past medical history

OPQRST

- onset

- provocation/palliation/position

- quality

- radiation

- severity

- time

- gives more info on chief complaint

chief complaint

- in patients own words

- get history from patient if possible

open ended questions

- yield more info

closed questions

- useful for quick details

active listening

- facilitation

- reflection

- clarification

- empathetic response

- confrontation

- interpretation

base core temperature

- heat produced by cellular metabolism

- 97.7-99.5 degrees F

- peripheral temp: 1-2 degrees cooler

- rectal or tympanic

pediatrics

- limited role in overall status because decompensate quickly

- focus on sickness or wellness instead

- children seek out parent/caregiver for reassurance

- gain trust first

- reassuring and calm voice

- at eye level

- no rapid fire yes/no questions

- avoid anxiety provoking words

- let handle equipment

- feet to head secondary exam

- do not explain too far in advance

when approaching sensitive topics

- nonjudgemental

- questions pertain to care

- respect privacy

- ask at appropriate time and location

- remain within your scope of practice

special challenges

- silence

- overly talkative patients

- patients with multiple symptoms

- anxious patients

- angry patients

- intoxication

- crying patient

- depressed patient

- confusing behavior or history

- patients with limited intelligence

- language barriers

- hearing impairment

- visual impairment

- talking with family or friends