Alexander ch18 lecture

Copyright © 2017, 2012 Pearson Education, Inc. All Rights Reserved.
Advanced EMT
A Clinical-Reasoning Approach, 2nd Edition
Chapter 18
Vital Signs and
Monitoring Devices

• Applies scene information and patient assessment
findings (scene size-up, primary and secondary
assessments, patient history, and reassessment)
to guide emergency management.
Advanced EMT
Education Standard

1. Define key terms introduced in this chapter.
2. Discuss the importance of accurate assessment and
documentation of vital signs over the course of contact
with the patient to identify problems and changes in the
patient’s condition.
3. Perform the steps required to assess the patient’s
respiration, pulse, skin, pupils, blood pressure, and
oxygen saturation.
4. Consider a patient’s overall presentation when
interpreting the meaning of vital sign findings.
Objectives (1 of 9)

5. Differentiate between normal and abnormal findings
when assessing a patient’s respiration to include the
rate, depth, effort, and rhythm of breathing.
6. Differentiate among normal breathing rates for adults,
children, infants, and newborns.
7. Evaluate the need to administer treatment based on
assessment of a patient’s respiration.
8. Auscultate breath sounds to determine the presence
and equality of breath sounds and to detect abnormal
breath sounds.
Objectives (2 of 9)

9. Associate abnormal breath sounds with their likely
underlying causes.
10.Assess the pulse at each of the following pulse points:
carotid, femoral, radial, brachial, popliteal, posterior tibial,
and dorsalis pedis.
11.Consider the patient’s age and level of responsiveness
when selecting a site to palpate the pulse.
12.Differentiate between normal and abnormal findings
when assessing a patient’s pulse to include the pulse
rate, quality of the pulse, and rhythm of the pulse.
Objectives (3 of 9)

13.Differentiate among normal heart rates for adults,
children, infants, and newborns.
14.Associate abnormalities in the assessment of pulses with
possible underlying causes.
15.Describe pulsus alternans and pulsus paradoxus.
16.Recognize normal and abnormal findings in the
assessment of skin and mucous membrane color, skin
temperature and condition, and capillary refill time.
17.Associate abnormal findings in skin color, temperature,
and condition with potential underlying causes.
18.Explain factors that can affect capillary refill time.
Objectives (4 of 9)

19.Differentiate among normal, dilated, and constricted
pupils.
20.Recognize anisocoria (inequality of pupils) greater
than 2 mm.
21.Assess the pupils for size, equality, and reactivity to light.
22.Associate abnormal pupil findings with potential
underlying causes.
23.Explain the underlying physiological processes being
evaluated by measuring systolic and diastolic blood
pressure.
Objectives (5 of 9)

24.Demonstrate the proper techniques of obtaining blood
pressure by auscultation, palpation, and noninvasive
blood pressure monitoring.
25.Relate the methods, techniques, and equipment for
obtaining a blood pressure measurement to differences
in findings and potential errors in blood pressure
measurement.
26.Determine whether a blood pressure value is consistent
with expected values for the patient’s age and gender.
Objectives (6 of 9)

27.Use the blood pressure value to find the patient’s pulse
pressure and mean arterial pressure (MAP).
28.List potential causes of abnormal findings or changes
in blood pressure and pulse pressure.
29.Explain the concept of orthostatic (postural) hypotension.
30.Given a patient scenario, determine the frequency with
which vital signs should be reassessed.
31.Explain what is being measured when pulse oximetry
is used.
Objectives (7 of 9)

32.Describe factors and limitations that should be
considered when interpreting the meaning of pulse
oximetry findings.
33.Explain what is being measured when capnography
is used.
considered when interpreting the meaning of
capnography findings.
35.Explain what is being measured when a glucometer
is used.
Objectives (8 of 9)

36.Use glucometry values as an adjunct in determining the
need for supplemental glucose/dextrose administration.
considered when interpreting the meaning of glucometry
findings.
38.Describe the value of continuous ECG monitoring.
39.Obtain a Lead II ECG recording.
Objectives (9 of 9)

• Vital signs, assessment of skin and pupils,
information from monitoring devices obtained
during secondary assessment.
– Information to assist with further patient assessment
and decision making.
• What do vital signs include?
Introduction (1 of 2)

• Monitoring devices:
– Electronic vital sign monitoring
– Pulse oximetry
– Capnography
– Electrocardiogram (ECG) monitoring
– Blood glucose level determination
• Integrate vital signs and monitoring results into
overall impression of patient.
Introduction (2 of 2)

• How should Marcie and Matt go about getting
vital signs for this patient while considering the
patient’s priority for transport?
• How will they know if the patient’s vital signs are
normal or abnormal?
• What other types of information should they obtain
from special monitoring devices?
Think About It

Prioritizing Information Collection
(1 of 2)
• Integration of vital signs and use of monitoring
devices require teamwork.
• Prioritize tasks in relation to condition, anticipated
treatment, other tasks.
– Assess critical patients’ vital signs every 5 minutes.
– Assess noncritical patients’ vital signs every
15 minutes.

• Reassess vital signs
– After giving medications
– Additional complaints
– Increased distress
– Worsening condition
Prioritizing Information Collection
(2 of 2)

Vital Signs (1 of 2)
• Four vital signs
– Pulse, respirations, blood pressure, temperature
 Obtain pulse and respirations on all patients.
 Blood pressure measured on all patients over three
years of age.
 Temperature not routinely obtained.

Vital Signs (2 of 2)
• Equipment to obtain vital signs
– Watch or clock with second hand (digital watch
with stopwatch feature)
– Stethoscope
– Sphygmomanometer (blood pressure cuff)
– Thermometer
– Penlight (assessment of pupils)

Figure 18-1
Pulse locations.

Assessing the Pulse (1 of 7)
• Pulse
– Intermittent wave of pressure felt in arteries as
result of left ventricular systole
• Gives information about cardiac function and
tissue perfusion

• Peripheral pulses
– Responsive patients
– Radial pulse
• Central pulses
– Unresponsive patients
– Carotid pulse

Figure 18-2
(A)
The brachial pulse is palpated (A) in the antecubital fossa in adults.
(Bottom photo: © Daniel Limmer)

• Rate, rhythm, volume, strength
• Press lightly with tips of index and middle fingers
over location of artery to find pulse
• Count number of pulsations in 15 seconds
and multiply by 4
• Normal heart rate for adult is 60–100 BPM

Table 18-1
Normal Pediatric Vital Signs
Age Group
Respiratory
Rate Heart Rate
Systolic Blood
Pressure
Newborn 30–60 100–180 70–90
Infant 25–40 100–160 70–90
Toddler 24–30 80–130 72–100
Preschooler 22–34 80–120 78–104
School age 18–30 70–110 80–115
Adolescent 12–20 60–105 88–120

• Tachycardia
– Heart rate faster than normal
• Can be caused by anxiety/ fear but may be a
potentially life-threatening cause
• Consequences of tachycardia

• Bradycardia
– Slower-than-normal heart rate
– Problem with cardiac conduction system,
excessive stimulation of vagus nerve, reflex
response to hypertension
– Cushing’s reflex
 Combination of hypertension and bradycardia in
patient with brain injury

• Regular pulse
– Same amount of time between all heartbeats
• Irregular pulse
– Beats come earlier or later than expected
• Atrial fibrillation

• Volume
– reflection of arterial diameter
• Pulse strength
– indication of blood pressure
• Significant vasoconstriction
– pulse may feel “thready”
• Under normal conditions
– pulse is strong

Assessing Blood Pressure (1 of 7)
• Amount of force exerted against walls of arteries
by blood flow
– Measured in millimeters of mercury (mmHg).
• Adequate blood pressure
– Required for tissue perfusion.
• Chronic high blood pressure
– Tissue and organ damage occur.

• Blood pressure depends on
– Volume of blood available, effectiveness of heart as
pump, capacity of vascular system at any moment
• Mean arterial pressure (MAP)
• Cardiac output (CO)
– Volume of blood that leaves left ventricle every minute,
measured in liters per minute

• Stroke volume and heart rate
– Decrease in one maintained by an increase in the other
• Systemic vascular resistance
– Vasoconstriction = increase in SVR
– Vasodilation = decrease in SVR

• Systolic blood pressure
– ventricular contraction (systole)
– 100 to 140 mmHg normal range
• Diastolic blood pressure
– ventricular relaxation (diastole)
– 60 to 90 mmHg normal range

• Hypertension
– High blood pressure
• Hypotension
– Low blood pressure
• Pulse pressure
– Difference between systolic and diastolic
• Pulsus paradoxus
– Drop in systolic blood pressure greater than
10 mmHg during inspiration

Figure 18-5
A blood pressure cuff and stethoscope are used to auscultate the blood pressure.

• Stethoscope and sphygmomanometer
– used to measure blood pressure
• Korotkoff sounds
– firce of first pulsations of blood that exceed pressure in
cuff with stethoscope (auscultation)
• Systolic
– number on gauge at the first sound heard
• Diastolic
– number on gauge at the last sound heard

Vital Signs
• When palpating blood pressure
– Pulse in radial artery is palpated as cuff is deflated
– First pulsation felt is systolic pressure
– No diastolic

Scan 18-1 (1 of 4)
Taking a Blood Pressure by Auscultation
1. Tell the patient what you are going to do. Position the blood pressure cuff around the
patient’s arm, with its bottom edge one inch above the crease of the elbow. The cuff should
be snug, and the marker on the cuff should be in line with the brachial artery.

Scan 18-1 (2 of 4)
2. Locate the radial pulse and keep your fingers on it. Close the valve on the inflation
bulb. Inflate the cuff by squeezing the bulb several times quickly and firmly while
watching the needle on the gauge. Inflate the cuff 20 mmHg past the point where the
radial pulse disappears.

Scan 18-1 (3 of 4)
3. With the earpieces of the stethoscope in your ears, place the diaphragm of the
stethoscope over the patient’s brachial artery.

Scan 18-1 (4 of 4)
4. Listen and watch the gauge while slowly opening the valve on the inflation valve to
deflate the cuff at a rate of 5 to 10 mmHg per second. Listen for the Korotkoff sounds. The
position of the gauge when you hear the first sound is the systolic blood pressure. The
position of the gauge when you hear the last sound is the diastolic blood pressure. Quickly
release the remaining air from the cuff.

• Orthostatic vital signs
– Useful when suspect dehydration or blood loss
in medical patient
– Procedure
 Supine for 3 minutes, take blood pressure and pulse
 Stand for 3 minutes, retake blood pressure and pulse
– Drop in systolic of 20 mmHg or increase in heart rate
by 20 bpm is positive

Assessing Respirations (2 of 9)
• Ventilation, external respiration, internal
respiration
• Ventilation requires
– Functioning brainstem
– Functioning nerve pathways
– Integrity of chest wall and diaphragm
– Contact between visceral and parietal pleura
– Open airway

• Stimulus to breathe is increased carbon dioxide
in blood
• Inhalation based on inverse relationship between
volume and pressure of a gas
– Active process
• Movement of air out of lungs is exhalation
– Passive process

• Ventilations
– assessed for rate, depth, effort, regularity
• Normal adult respiratory rate
– 12 to 20 breaths per minute at rest
• Tidal volume
– 5 to 10 mL/kg (about 500 mL)
• Minute volume
– Tidal volume × respiratory rate

• Primary assessment
– Note signs of distress
– Accessory muscle use
– Tripoding
– Abnormal noises with ventilation
– Other signs (cyanosis or altered mental status)

Figure 18-7
Signs and symptoms of difficulty breathing. (© Ray Kemp/Science Source)

• Respiratory rate
– Count ventilations for 15 seconds and multiply by 4
– Observe depth
• Rhythm
• Document findings

Table 18-2
Breathing Patterns
Condition Description Causes
Eupnea Normal breathing rate and pattern
Tachypnea Increased respiratory rate Fever, anxiety, exercise, shock
Bradypnea Decreased respiratory rate Sleep, drugs, metabolic disorder,
head injury, stroke
Apnea Absence of breathing Deceased patient, head injury, stroke
Hyperpnea Normal rate but deep respirations Emotional stress, diabetic
ketoacidosis
Cheyne-Stokes respirations Gradual increases and decreases in
respirations with periods of apnea
Increasing intracranial pressure,
brainstem injury
Biot’s respirations Rapid, deep respirations (gasps)
with short pauses between sets
Spinal meningitis, many central
nervous system causes, head injury
Kussmaul respirations Tachypnea and hyperpnea Renal failure, metabolic acidosis,
diabetic ketoacidosis
Apneustic Prolonged inspiratory phase with
shortened expiratory phase
Lesion in brainstem

• Abnormal upper airway sounds
• Snoring
– Caused by partial occlusion of upper airway by tongue
– Position airway and insert OPA or NPA
• Gurgling
– Indication of fluid in airway
– Suction and recovery position
• Stridor
– high-pitched sound indication of partial obstruction

• Lung sounds auscultated using stethoscope
– Normal air movement and abnormal sounds
• Abnormal breath sounds
– Crackles (rales)
 Fine, popping, cracking sound
– Rhonchi
 Lower-pitched, coarse rumbling sound
– Wheezes
 High-pitched, whistling sound

• Feeling patient’s skin gives general indication
of body temperature.
• Orally
– Average normal body temperature 37 degrees
Celsius (C); 98.6 degrees Fahrenheit (F).
• Fever (pyrexia)
– Infection, blood transfusion reactions, medication
reactions, hyperthyroidism

Figure 18-8
Taking an oral temperature.

Assessing Body Temperature
• Older thermometers
– Closed glass tube containing mercury
• Digital thermometers
– Reading of temperature in degrees Celsius,
Fahrenheit, both.
• Oral or tympanic (ear); rectal or axillary
temperature; forehead thermometer strips

Table 18-3
Celsius–Fahrenheit Conversion Table
Degrees Celsius Degrees Fahrenheit
35 95
36 96.8
37 98.6
38 100.4
38.6 101.4
39 102.2
39.6 103.2
40 104
To convert Celsius to Fahrenheit, multiply by 9/5 and add 32. To convert Fahrenheit to Celsius, subtract 32
and multiply by 5/9.

Think About It
• What other signs should Matt check for at
the scene?
• Why do you think Matt chose to delay blood
glucose testing until he and the patient were
in the ambulance?

Assessing the Skin
• Color
– Pallor
– Cyanosis
– Jaundice
– Redness
• Condition
– Dryness or sweating
– Diaphoresis
– Turgor

Table 18-4
Skin Assessment Findings and Possible
Significance
Skin Finding Possible Significance
Pink Normal skin color in lighter-skinned individuals; normal color of mucous
membranes in all Individuals
Pale Peripheral blood vessel constriction; may indicate shock or fright
Cyanosis Hypoxia resulting from inadequate ventilation, oxygenation, circulation
Flushed Fever, exertion, hyperthermia, excitement, embarrassment
Jaundice Liver disease
Mottled Exposure to cold, shock
Cold Hypothermia, poor circulation
Cool Shock, fright, anxiety
Warm Normal
Hot Fever, hyperthermia
Dry Normal
Excessive dryness Dehydration, hypothyroidism
Moist/wet Fever, exertion, hyperthermia, shock, fear, anxiety
Poor mobility (skin is “tight”) Edema
Poor turgor (skin lacks elasticity) Dehydration

Figure 18-10
Check for pupil size, equality, and reaction to light.

Assessing the Pupils (1 of 4)
• Pupil
– Opening in center of ring-shaped muscle of eye called
the iris
• Iris adjusts size of pupil
– Dilating to let more light reach inside of eye
– Constricting it to limit amount of light that enters
• Size of pupil controlled by oculomotor nerve and
sympathetic nerve fibers

• Pupils
– Size determined by balance of sympathetic and
parasympathetic input.
– Larger (more dilated) in dim light.
– Smaller (more constricted) in bright light.
– Round and equal in size.
 Size ranges from 2 to 8 mm in diameter.

• Anisocoria (slightly unequal pupils) of 2 mm or
more is concern
– Can be result of injury to one eye
– Sign of increased ICP
• Dim bright ambient light
– Note size of pupils and whether they are equal
– Briefly shine penlight into one eye; repeat procedure
for other eye

• Pupil dilation
– Fear, anxiety, shock, dim light, and drugs that
stimulate the sympathetic nervous system
• Pupils dilated and nonreactive to light (fixed)
– Cerebral hypoxia and death
• Pupil constriction
– Bright light, some narcotic drugs, and substances
that stimulate the parasympathetic nervous system

Figure 18-12
Pulse oximetry uses different wavelengths of light to measure the saturation of hemoglobin
with oxygen.

Monitoring Devices (1 of 7)
• Pulse oximetry
– Uses light to measure the saturation hemoglobin.
 Light sources placed on one side of capillary bed (finger
or earlobe); sensors placed on other side.
– Gives saturation percentage of oxygen (SpO2);
displays pulse rate.
– Maintain SpO2 of 95 percent or higher by administering
and assisting with ventilations.

• Pulse oximetry (continued)
– Readings affected by
 high-intensity ambient lighting
 poor circulation in capillary bed
 anything that interferes with light source passing
through tissue to sensor.

Figure 18-15
End-tidal carbon dioxide detection in a spontaneously breathing patient.

• End-tidal carbon dioxide monitoring
– Exhaled carbon dioxide monitoring (capnometry)
measures amount of carbon dioxide in exhaled air.
– Capnography
 Display of measurements of exhaled carbon dioxide monitoring
– Capnogram
 Display of waveform that represents amount of exhaled
carbon dioxide

• End-tidal carbon dioxide monitoring (continued)
– Normal range of end-tidal carbon dioxide (EtCO2) in
exhaled air is 35 to 45 mmHg.
– Correlates to pCO2 in arterial blood of 38 to 45 mmHg.

• End-tidal carbon dioxide monitoring (continued)
– Useful for
 Respiratory complaints
 Critically ill patients
 Confirming/monitoring endotracheal tube placement
– Colorimetric devices less sophisticated way to measure
exhaled carbon dioxide; placed over end of airway
device

• Blood glucose level
– Glucose essential source of energy for cellular
metabolism.
 Very little glucose can enter cells without help of insulin.
– For brain to function, constant adequate supply of
glucose required.
 Brain cells do not require insulin to use glucose.

Figure 18-17
A glucometer uses a drop of blood on a test strip to measure the blood glucose level.

• Blood glucose level (continued)
– Measure in all diabetic patients.
 Especially when signs and symptoms suggest hypoglycemia
or hyperglycemia.
– Drop of blood placed on test strip in device for analysis,
giving digital readout of BGL.
– Normal BGL 70 to 110 mg/dL.

Scan 18-2 (1 of 5)
Checking the Blood Glucose Level
1. Prepare the blood glucose meter, including a test strip and a lancet.

Scan 18-2 (2 of 5)
2. Cleanse the skin with an alcohol preparation. Allow the alcohol to dry before performing
the finger stick.

Scan 18-2 (3 of 5)
3. Use the lancet to perform a finger stick. Wipe away the first drop of blood that appears.
You will test the second drop of blood.

Scan 18-2 (4 of 5)
4. Apply the blood to the test strip. You may do this by holding the strip to the finger to draw
the blood into the strip.

Scan 18-2 (5 of 5)
5. Read the blood glucose level displayed on the glucose meter. (It may take 15 to
60 seconds for the device to provide a reading.) Assess the puncture site and apply
direct pressure or a bandage to the site if bleeding continues.

Figure 18-18
A portable cardiac monitor–defibrillator.

• Cardiac monitoring
– Electrical activity of heart assessed by obtaining
electrocardiogram (ECG).
– Use electrodes placed on skin to detect electricity from
cardiac impulses that travel to skin.
– Detects and displays representation of electrical
activity as it flows between positive and negative
electrodes.

Figure 18-20
The waveforms of an ECG.

• Cardiac monitoring (continued)
– Waveforms of ECG show amount and direction of
electricity being conducted through heart as waves of
different sizes, durations, directions.
– Graph paper moves through ECG machine.
– Normal sinus rhythm (NSR):
 When heart rate and measurements are within normal limits

– P wave
 Electricity moving through atria
– PR interval (PRI)
 Length of time for cardiac impulse to travel through atria and
atrioventricular (AV) node

– QRS complex
 Movement of electricity through ventricles
– T wave
 Flow of electricity as cells in ventricles resume their
electrical charge

Chapter Summary (1 of 5)
• Vital signs are essential information about
patient’s baseline condition and how condition
changes over time.
• Pulse and blood pressure provide information
about function of cardiovascular system and
adequacy of perfusion.
• Pulse assessed for rate, rhythm, strength, volume.

• Blood pressure:
– Information about cardiac output and peripheral
vascular resistance
• Depth, rate, volume of ventilations, presence of
abnormal upper airway or lung sounds,
information about adequacy of ventilation.
• Thermometer measures body temperature; fever,
hyperthermia, hypothermia suspected.

• Color, temperature, moisture, mobility, turgor of
skin gives wealth of information about perfusion,
hydration, underlying disease.
• Skin can reveal signs of shock, hypoxia, fever,
liver disease.
• Examining pupils provides information
about central nervous system, and also clues
about drugs or toxins patients may have been
exposed to.

• Pulse oximetry measures degree to which
hemoglobin saturated with oxygen.
• Capnometry measures amount of carbon dioxide
being exhaled; information about perfusion and
ventilation.
• Blood glucose measurement important in
diabetics and patients with altered mental status
or neurologic deficit.

• ECG monitoring provides real-time information
about electrical function of heart.
• Analyze all information obtained by measuring
vital signs, examining skin and pupils, monitoring
devices in context of whole patient.

Alexander ch18 lecture

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Alexander ch18 lecture

Similar to Alexander ch18 lecture (20)

More from corynava00

More from corynava00 (10)

Recently uploaded

Recently uploaded (20)

Alexander ch18 lecture