EMR ch12

Copyright ©2012 by Pearson Education, Inc.
All rights reserved.
Emergency Care, Twelfth Edition
Daniel J. Limmer • O’Keefe • Grant • Murray • Bergeron • Dickinson
Emergency Medical Responder: First on Scene, Ninth Edition
Le Baudour • Bergeron • Wesley
CHAPTER
Obtaining a Medical History
and Vital Signs
12

Topics
• Obtaining a Medical History
• Vital Signs

OBTAINING A MEDICAL HISTORY

• Medical history: previous medical
conditions and events for patient.
• Signs: something you can see and
observe about patient.
– Can be pale skin; rapid pulse; open wound
to chest.
– All are obvious.

• Symptom: something patient feels;
may complain about.
– Can be obvious or very subtle.
– Pain, nausea common symptoms.

Common Signs and Symptoms

• Interviewing Your Patient
– An alert patient is the best source of
information.
– Chief complaint: main medical complaint
described by patient.
– Family members, bystanders, first
responders should all be questioned.
(continued)

Get down at eye level with your patient and make good eye contact
as you begin your medical history.

• Interviewing Your Patient:
– Ask questions slowly and clearly.
– Allow time for patient to process and
respond.
– Listen carefully.
– Document important details.
(continued)

– Establish a good rapport
 Introduction
 Consent
 Patient's name
 Patient's age
 Chief complaint
(continued)

– SAMPLE history tool:
 S — Signs/symptoms
 A — Allergies
 M — Medications
 P — Past pertinent medical history
 L — Last oral intake
 E — Events leading to the illness or injury
(continued)

– OPQRST: most commonly used for
assessment of pain or discomfort.
 O — Onset
 P — Provocation
 Q — Quality
 R — Region/Radiate
 S — Severity
 T — Time

• Additional Sources of Information
– Family members, bystanders, first
responders; patient unresponsive or unable
to provide medical history.
– Medical identification jewelry.

Consider using bystanders or family members when your patient is
unresponsive or unable to provide a medical history on his own.

VITAL SIGNS

Vital Signs
• Respiration
• Pulse
• Blood pressure
• Skin signs
• Pupils
• Perfusion: adequate supply of well-
oxygenated blood to all parts of body

Vital Signs
• Mental status (Level Of Consciousness
[LOC]) or level of responsiveness
evaluated using AVPU scale.
– A — Alert
– V — Verbal, responsive to verbal stimuli
– P — Pain, responsive only to painful stimuli
– U — Unresponsive, unconscious, or
completely unresponsive

Vital Signs
• Baseline vital signs: first set of vital
signs obtained.
• Trending: comparing multiple sets of
vital signs from same patient over time.
• Careful analysis of vital signs can alert
you to current or developing problems.
• Do not rush to a conclusion too soon.

Vital Signs
• Respiration
– Act or process of breathing in (inhaling)
and out (exhaling).
• Evaluate
– Rate, depth, sound, ease.
• Work of breathing
– Effort that patient must exert to breathe.

Assessment Signs—Respirations

Vital Signs
• To assess respirations:
– Grasp patient's wrist as if you were going
to count pulse rate. Hold his arm firmly
against his upper abdomen.
– Observe abdomen and chest move in and
out. Listen for abnormal sounds.
– Count number of breaths patient takes in
15 or 30 seconds.
(continued)

Vital Signs
• To assess respirations:
– While counting respirations, note depth and
ease of breathing.
– Document rate, depth, ease.

Normal Respiration Rates

Emergency Medical Responder assessing respirations on a supine
patient.

EMT assessing respirations on a seated patient.

Vital Signs
• Pulse: remote heartbeat.
– Gives insight into circulatory status of
patient.
– Good pulse indicates blood is moving well
throughout body.
– Carotid; femoral: central pulses.
– Brachial; radial; pedal: peripheral pulses.
(continued)

Locating the carotid pulse point in the neck.

Locating the radial pulse point in the wrist.

Vital Signs
• Pulse
– Assess for rate, strength, rhythm.
• Responsive patient
– Check radial pulse.
• Unresponsive patient
– Check carotid pulse.
• Radial pulse may not be detectable if
blood pressure is too low or if there is
extremity injury.
(continued)

Vital Signs
• Pulse rate for adults is between 60 and
100 beats per minute (see Table 11.4).
– Rate above 100 considered rapid
(tachycardia)
– Rate below 60 considered slow
(bradycardia)
• Pulse point for infants under the age of
one year is brachial pulse in upper arm.

Vital Signs
• Capillary refill: time it takes for
capillaries to refill after being blanched.
– Select appropriate finger or toe.
– Using thumb and index finger, squeeze pad
of finger or toe from both sides. Observe
pad as it blanches.
– Quickly release pressure; observe color
return to pad; document findings.

Checking capillary refill time in the fingers.

Vital Signs
• Blood pressure: measurement of
pressure of blood against walls of
arteries, both when heart beats and
when it is at rest.
– Systolic: pressure within arteries when
heart beats; contraction phase of heart.
– Diastolic: pressure that remains in arteries
when heart is at rest; resting phase of
heart.
(continued)

Vital Signs
• Reading of 120/80 considered normal
blood pressure.
• Take several readings to identify
changes in status.
• Systolic reading above 140 considered
high blood pressure (hypertension).

Normal Blood Pressures

Vital Signs
• Palpation: using one's hands to touch
or feel the body.
• Auscultation: listening to internal
sounds of the body (stethoscope).
– Adjust earpieces.
– Have patient sit or lie down.
– Remove clothing on arm.
– Support arm at level of heart.

Adjust the earpieces of the stethoscope so they point forward into
the ear canal.

Proper position for taking a blood pressure while seated.

Obtaining a blood pressure on a supine patient.

Vital Signs
• Auscultation
– Select correct-size blood pressure cuff.
– Wrap cuff around upper arm.
– Apply cuff securely but not too tightly.
– Place ends of stethoscope in your ears.
– Use fingertips to locate brachial artery.
– Position diaphragm of stethoscope over
brachial artery pulse site.
(continued)

Location of the brachial artery.

Proper placement of the blood pressure cuff.

Vital Signs
• Auscultation
– Close valve and inflate cuff (180 mmHg
adult; 120 mmHg child).
– Open valve slowly to release pressure from
cuff.
– Listen carefully as you watch needle move.
– Let cuff continue to deflate.

Vital Signs
• Auscultation
– Let rest of air out of cuff quickly.
– Record time, arm used, position of person,
pressure readings.

Place the cuff snugly around the upper arm.

Palpate the brachial pulse point and place the diaphragm of the
stethoscope over the pulse point.

Quickly inflate the cuff then release the pressure to obtain the blood
pressure readings.

Document your readings.

Vital Signs
• Palpation
– Not very accurate method.
– One reading: approximate systolic
pressure.
– Used when too much noise, making it
difficult to hear with stethoscope.
(continued)

Place the cuff and locate the radial pulse.

Inflate the cuff until you feel the radial pulse go away.

Continue inflating cuff to approximately 30 mmHg beyond where the
pulse went away.

Release the pressure in the cuff and note the pressure on the gauge
when the radial pulse returns.

Vital Signs
• Palpation
– Place cuff and locate radial pulse.
– Inflate cuff until you feel radial pulse go
away.
– Continue inflating cuff to 30 mmHg beyond
where pulse went away.
– Release pressure in cuff; note pressure on
gauge when radial pulse returns.

Vital Signs
• Skin signs: evaluate color, temperature,
and moisture.
– Not perfused well: pale or cyanotic
(bluish).
– Receiving abnormal amount of blood flow:
flushed (red).
– Yellow: jaundiced.
(continued)

Vital Signs
• Skin signs
– Examples of skin signs:
 Pink, warm, dry (PWD)
 Pale, cool, moist
 Flushed, hot, moist
 Flushed, hot, dry

Skin Signs

Use the back of an ungloved hand to assess skin temperature and
moisture.

Vital Signs
• Evaluate skin color in dark-skinned
patients:
– Oral mucosa
– Conjunctiva
– Nail beds
– Palms

Vital Signs
• Pupils
– Note general condition; identify any
obvious injury or deformity.
– Ensure both pupils are round and same
size.
– Respond to sudden introduction of light by
constricting; dilate when light to pupil is
blocked.
(continued)

Vital Signs
• Pupils
– PERL stands for:
 P — Pupils
 E — Equal
 R — Reactive
 L — Light
– See Table 11.7: Pupils.

Pupils

Constricted pupils

Dilated pupils

Unequal pupils

SUMMARY

Summary
• Good patient assessment: gathering
information (history) about patient and
chief complaint and obtaining complete
and accurate vital signs.
• Properly introduce yourself and get
patient's name right away.
• Whenever possible, direct your
questions to patient.

Summary
• Speak clearly and confirm that patient
hears, understands, and answers each
question before asking another.
• Utilize SAMPLE tool to help guide
questions, and always document
patient's answers.
• Obtain set of vital signs to establish
good baseline.

Summary
• Repeat vital signs and compare to
previous readings to establish trends in
patient's condition.
• Most vital signs have multiple
characteristics; document
characteristics for each vital sign.

EMR ch12

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