ch13 vital signs monitoring devices

Emergency Care

CHAPTER

Copyright © 2016, 2012, 2009 by Pearson Education, Inc.All Rights Reserved

Emergency Care, 13eDaniel Limmer | Michael F. O'Keefe

THIRTEENTH EDITION

Vital Signs and Monitoring Devices

13



Multimedia Directory

Slide 66 Health and Physical Assessment: Vital Signs Video

Slide 67 Patient Assessment Skills: Blood Pressure Video



Topics

• Gathering the Vital Signs• Vital Signs



Gathering the Vital Signs



Gathering the Vital Signs

• Importance of vital signs Outward signs of what is going on inside

the body Identify important conditions or trends

in patient conditions Gathered on virtually every EMS patient

• Patient severity and treatment priorities may prevent acquisition.



Vital Signs



What Are Vital Signs?

• Pulse• Respiration• Skin color, temperature, and condition

(plus capillary refill in infants and children)

• Pupils• Blood pressure

continued on next slide



What Are Vital Signs?

• Baseline vital signs First vital signs obtained

• Repeat vital signs Gain further information by establishing

trends



Pulse

• Palpable pressure of heart beating, causing blood to move through arteries in waves




Pulse

• Can be felt by placing fingertip over artery where it lies close to body's surface and crosses over bone



Pulse

Assess pulse rate and quality. Count for 30 seconds and multiply by 2.



Pulse Rate

• Number of beats per minute• Normal rate for adult at rest is between

60 and 100 beats per minute.




Pulse Rate

• Tachycardia Rate above 100 beats per minute is

rapid.• Bradycardia Rate below 60 beats per minute is

considered slow.




Pulse Rate

• Above 120 beats or below 50 beats per minute is considered a serious finding.

• During an emergency, it is not unusual for pulse rate to temporarily be between 100 and 140 beats.



Think About It

• What normal situations might account for a heart rate outside the normal range?



Pulse Quality

• Two factors determine pulse quality. Rhythm

• Reflects regularity• Regular when intervals between beats are

constant• Irregular when intervals are not constant




Pulse Quality

• Two factors determine pulse quality. Force

• Pressure of pulse wave as it expands artery

• Pulse should feel strong.• Thready

• When pulse feels weak and thin




Pulse Quality

• Common pulse locations Radial

• Used in patients one year and older• Wrist pulse• Found by placing first three fingers on thumb side of patient's wrist just above the crease



Radial Pulse

Assess respiration rate and quality. Count for 30 seconds and multiply by 2.



Pulse Quality

• Common pulse locations Brachial

• Used in patients one year old or younger• Upper arm pulse



Brachial Pulse

Palpating a brachial pulse in an infant.



Pulse Quality

• Common pulse locations Carotid

• Felt along large carotid artery on either side of the neck




Pulse Quality

• Assessing pulse Count pulsations for 30 seconds and

multiply by 2. If rate, rhythm, or force is not normal,

continue with count for full 60 seconds. Judge rhythm and force.



Respiration

• With regard to vital signs, respiration means the act of breathing in and out.

• Measurement includes both rate and quality.



Respiratory Rate

• Number of breaths the patient takes in one minute

• Rate of respiration is classified as normal, rapid, or slow.




Respiratory Rate

• Normal rate for adult at rest is between 12 and 20 breaths per minute.

• Age, sex, size, physical conditioning, and emotional state influence breathing rates.

• Rates above 24 breaths per minute (rapid) or below 8 breaths per minute (slow) are potentially serious findings.



Respiratory Quality

• Four categories Normal Shallow Labored Noisy



Respiratory Rhythm

• Count respirations after assessing pulse rate.

• Count number of breaths taken over 30 seconds and multiply by 2.

• Note rate, quality, and rhythm of respiration.



Skin

• Color, temperature, and condition of skin can provide valuable information regarding circulation




Skin

• Color Best places to assess skin color

• Nail beds• Inside of cheek• Inside of lower eyelids




Skin

• Color Abnormal skin colors

• Pale• Cyanotic (blue-gray)• Flushed (red)• Jaundiced (yellow)




Skin

• Temperature Feel patient's skin with back of hand. Note if skin feels normal (warm), hot,

cool, or cold.



Skin Temperature

Determining skin temperature.



Pediatric Note

• For children under six years, also evaluate capillary refill. Press on nail bed or top of hand or foot

and release. Observe how long it takes normal pink

color to return. Normal

• Less than 2 seconds



Pupils

• Black center of eye• Dim environment Pupil will dilate.

• Bright environment Pupil will constrict.




Pupils

• Assessing Note baseline size. Cover one eye and shine a light into

other eye. Repeat with other eye.



Assessing Pupils

Examining the pupils.



Pupils

• Assessing Look for:

• Size• Equality• Reactivity



Assessing Pupils

(A) Constricted, (B) dilated, and (C) unequal pupils.



Assessing Pupils

Unequal pupils can be a sign of the influence of a topical drug (one placed directly on the eye, such as an eye drop) or of head or eye injury.

© Edward T. Dickinson, MD



Blood Pressure

• Force of blood against the walls of the blood vessels

• Normal pressure Systolic no greater than 120 mm Hg Diastolic no greater than 80 mm Hg

• Change can indicate something very significant.




Blood Pressure

• Measured with a sphygmomanometer and stethoscope Cuff should cover two-thirds of upper

arm, elbow to shoulder.



Measuring Blood Pressure

Positioning blood pressure cuff.



Blood Pressure

• Measured with a sphygmomanometer and stethoscope Wrap cuff around patient's upper arm. Lower edge of cuff placed about one

inch above crease of elbow Center of bladder placed over brachial

artery



Determining Blood Pressure by Auscultation

• Prepare patient.• Position cuff and stethoscope. Palpate brachial artery at crease of

elbow. Position stethoscope. Position diaphragm of stethoscope

directly over brachial pulse or medial anterior elbow.




When measuring blood pressure by auscultation, locate the brachial artery by palpation before placing the stethoscope.




• Inflate cuff. Listen and inflate until gauge reads 30

mm higher than the point the pulse sound disappeared.

• Obtain systolic pressure. Slowly release air from cuff. When you hear the first of these

sounds, note the reading on gauge.





• Obtain diastolic pressure. Continue to deflate cuff. When sounds turn to dull, muffled

thuds, the reading on the gauge is diastolic pressure.

• Record measurements.




Determining Blood Pressure by Palpation

• Position cuff and find radial pulse.• Inflate cuff.• Obtain and record systolic pressure. Slowly deflate cuff. Note reading when radial pulse returns

(systolic pressure).



Pediatric Note

• Difficult to obtain on infants and children younger than three years

• More useful information about the condition of an infant or very young child comes from observing for conditions such as sick appearance, respiratory distress, or unconsciousness



Determining Blood Pressure by Blood Pressure Monitor

• Position the cuff.• Inflate the cuff.• Obtain and record the systolic pressure. Slowly deflate the cuff.



Temperature

• Narrow range of temperature allows chemical reactions and other activities to take place inside the body.

• Core temperature reflects level of heat inside trunk.




Temperature

• Normal temperature depends on: Time of day Activity level Age Where measured



Temperature

An electronic thermometer is safer, more hygienic, and quicker to produce a reading than a glass thermometer.



Oxygen Saturation

• Measurement of proportion of oxygen attached to hemoglobin

• Measured with pulse oximeter



When to Use a Pulse Oximeter

• Protocol depends on institution.• Generally includes all patients

complaining of respiratory problems or otherwise at risk for hypoxia



Oxygen Saturation

A pulse oximeter with sensor applied to the patient's finger.



Interpreting Pulse Oximeter Readings

• Normal 96 to 100 percent

• Mild hypoxia 91 to 95 percent

• Significant or moderate hypoxia 86 to 90 percent

• Severe hypoxia 85 percent or less




Interpreting Pulse Oximeter Readings

• Accuracy of reading can be affected by: Shock, hypothermia Carbon monoxide Certain other uncommon types of

poisoning Excessive movement Nail polish Anemia



Blood Glucose Meters

• Measures quantity of glucose in the bloodstream

• Can help identify some diabetic emergencies



Blood Glucose Monitor

Many EMS systems allow EMTs to use blood glucose meters that are carried on the ambulance.



Using a Blood Glucose Meter

• Permission from medical direction or by local protocol is required to perform blood glucose monitoring using a blood glucose meter

• Monitors must be calibrated and stored according to manufacturer's recommendations





1. Prepare device, test strip, and lancet2. Cleanse patient's finger with alcohol3. Perform finger stick with lancet4. Apply blood to test strip5. Use glucose meter to analyze sample

and provide reading





• Normal levels Usually at least 60 to 80 mg/dL No more than 120 or 140 mg/dL



Pediatric Note

• Age is one of the most important factors determining normal range.

• Infants and children have faster pulse and respiratory rates, and lower blood pressures than adults.



Health and Physical Assessment: Vital Signs Video

Click on the screenshot to view a video on the subject of assessing vital signs.

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Well, before you see the doctor, I just need to perform a couple of tests. First, you're gonna step in here so I can weigh you. Can I take off my shoes? Absolutely. I always do. And remember, your chart is not a public document. And I'm thankful for that. But I don't wanna know either so don't tell me, okay? No problem. Okay, let's go back into the exam room now.

I need to take your blood pressure and do a couple more things before you see the doctor. Okay. I'm going to take your temperature. Do you smoke? No, why?

Well smoking can affect your temperature, so can drinking fluids,

but only if we were an old fashioned glass thermometer which are fine. Open up. Wow, that's fast. Technology. Isn't it great? Looks like you do have a slight fever. Well, up next, I'm going to take your blood pressure. So would you mind rolling up your sleeve? No, but take a little of the mystery out of this for me

because the doctor just told my husband to take his blood pressure everyday. What is it that you're measuring and how do you find it?

Well, right now, I'm looking for your artery to be able to hear your heart beating. This screw allows some air to escape from the valve.

As the cuff deflates, we're listening to hear the first sound of your heart beating and note the pressure which this occurs,

that will be your systolic pressure then I'll wait till I hear no sound at all, that's your diastolic pressure. [ Noise ] So what's the story on my blood pressure? Up or down? [ Background Noise ]

Well, your systolic pressure is up to 160 while the diastolic is the same at 82. So what does that mean?

Well, your systolic measures the pressure when your heart pumps.

The diastolic is the opposite, the pressure between beats.

Okay, so when you're listening to my heart, it's the first sound and then basically no sound that matters? Basically that's right. What if you don't get a good reading? Well, Ill check it again in a minute

or two which probably is what the doctor is going to tell me to do with you. Your blood pressure is never been high like that.

Yeah, I've been under a lot of pressure lately both at home and work. Two more easy tests to go. I'm just going to check your pulse and respiration rates and then we'll have you meet the doctor. Okay, well what will I have to do?

Well, I'll check your pulse first, that will take just a minute. So just seat comfortably and we'll be all set.



Patient Assessment Skills:Blood Pressure Video

Click on the screenshot to view a video on the topic of assessing blood pressure.

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Following your initial patient assessment and control of any immediate life threats you should obtain baseline set of

vital signs which include: pulse, respirations, skin color, temperature, and condition, pupil

size and reactivity, and blood pressure. The baseline set of vitals gives you a beginning place from which

to make treatment decisions. As you retake vital signs you will compare the readings to your

previous findings. This is called serial vital signs. Serial vital sign assessment allows you to note trends in the

patient condition, such as a declining blood pressure or increasing respiratory rate. When measuring blood pressure, you will use a blood pressure

cuff and gauge called a sphygmomanometer. You can collect readings by auscultating or listening to the

characteristic clicking or thumping sounds with a stethoscope. Or when the environment is too loud or the Kortokoff's sounds

too soft, you can palate the blood pressure which means to feel the radial

or brachial pulse, with your fingertips while using the BP cuff. To report BP readings, use a blood pressure fraction. The top or first number reported is the systolic blood pressure. This is the pressure created when the heart contracts and forces

blood into the arteries. The bottom or second number is the diastolic blood pressure. It measures the pressure remaining in the arteries when the left

ventricle releases and refills, or the residual pressure in the system. A normal blood pressure for the average adult is around 120/80. Hypertension is defined as consistent readings with a systolic

over 140. Low blood pressure, or hypotension, is usually considered a systolic below 90 millimeters of mercury. Begin the blood pressure measurement by removing or rolling

clothing to expose the bare skin of the arm. Be sure that sleeves, when rolled, do not occlude the arteries of the arm preventing blood flow. If the shirt is that tight, remove the arm from the sleeve. Select the appropriate size BP Cuff. The cuff should measure two‐thirds of the length of the upper

arm, from elbow to shoulder. Additionally, it should be long enough to fasten the Velcro

securely when the cuff is placed circumferentially around the arm. Place the cuff on the bare arm, following the illustration on the cuff for placement over the artery. With your fingertips, locate the brachial pulse on the medial upper arm near the antecubital fossa, or the

crease of the elbow. Place the diaphragm or bell of the stethoscope over this pulse

point. With the bulb valve closed, inflate the cuff until the pulse is no

longer heard or felt. Using the stethoscope, listen for the sound of the pulse returning as the pressure is the cuff is slowly released. Note the number on the cuff's gauge as soon as you hear the first

pulse beat. This is the systolic pressure‐the top number of the BP fraction. Continue to deflate the cuff, this time listening for the point at

which the beats fade. Again, note the number indicated on the gauge. This is the diastolic blood pressure‐the BP fraction's bottom

number. Since you now have both your diastolic and systolic measurements, let the BP cuff deflate rapidly. Record the measurements and the time. Blood pressure is recorded in even numbers. As already mentioned, you may find yourself in a situation where

it is impossible to hear an auscultated blood pressure... ...due to external noises on scene or in the back of a moving

ambulance. In such cases, an estimated systolic blood pressure can be

obtained by palpation. Since the palpated blood pressures are usually lower than actual

blood pressures, an auscultated blood pressure should be taken as soon as

possible. The steps for palpating blood pressure are basically the same

used for auscultation. The obvious difference is that you do not rely on a stethoscope to

hear the presence or absence of Korotkoff's sounds. Begin by palpating for the radial pulse. Inflate the cuff until the radial pulse disappears. Then slowly release air from the cuff until the pulse reappears. At that point check the gauge for the systolic blood pressure. Report your finding as the systolic blood pressure over "P" for

palpation, as well as the time of the reading.



Chapter Review



Chapter Review

• You can gain a great deal of information about a patient's condition by taking a complete set of baseline vital signs, including pulse, respirations, skin, pupils, and blood pressure.




Chapter Review

• The EMT must become familiar with normal ranges for pulse, respirations, and blood pressure in adults and children.

• Trends in patient's condition will become apparent only when vital signs are repeated, an important step in continuing assessment.




Chapter Review

• How often you repeat vital signs will depend on patient's condition: at least every 15 minutes for stable patients and at least every 5 minutes for unstable patients.



Remember

• Consider if there is time to obtain vital signs or if you must wait to obtain them en route to the hospital.

• Consider when to apply a pulse oximeter. Should you apply it to a patient with difficulty breathing? Without difficulty breathing?




Remember

• Consider whether abnormal vital signs are a result of an illness or injury or the result of some other factor.



Questions to Consider

• Name the vital signs. • Explain why vital signs should be taken

more than once.• How much time should the EMT spend

looking for a pulse when the radial pulse is absent or extremely weak?




Questions to Consider

• How should you react when the blood pressure monitor gives a reading that is extremely different from previous readings?

• How can you get an accurate pulse oximeter reading on a patient with thick artificial nails?



Critical Thinking

• Sometimes a patient's heart will have an electrical problem and beat more than 200 times a minute. Why is the pulse so weak in such a patient?

ch13 vital signs monitoring devices

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