Baseline Vital Signs, Monitoring Devices, And

Detailed Lesson Plan

Chapter 11

Baseline Vital Signs, Monitoring Devices, and

History Taking

170–180 minutes

Chapter 11 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines. /
Minutes / Content Outline / Master Teaching Notes /
5 / I.  Introduction
A.  During this lesson, students will learn about taking vital signs, monitoring devices, and gathering patient history.
B.  Case Study
1.  Present The Dispatch and Upon Arrival information from the chapter.
2.  Discuss with students how they would proceed. / Case Study Discussion
·  How will the patient’s vital signs help you determine what is wrong with the patient?
·  What aspects of the patient’s medical history are important in determining the problem?
·  At what point is it appropriate to obtain the history and vital signs?
5 / II.  Gathering Patient Information
A.  Assessment is the process of finding out about a patient’s condition.
B.  Some information gained during assessment is obvious—items at the scene, bruises, difficulty breathing.
C.  Some indications of a patient’s condition are less obvious—vital signs and medical history.
D.  Be aware of a patient’s feelings.
E.  Respect a patient’s dignity. / Teaching Tip
Ask how students feel when asked medical questions by a health care provider
Critical Thinking Discussion
What are actions that show a health care provider respects a patient’s dignity?
5 / III.  Baseline Vital Signs—Breathing (Respiration)
A.  Breathing (respiratory) rate
1.  Observe the patient’s chest rise and fall.
2.  Determine if the patient is in respiratory distress.
3.  Assess the patient’s mental status.
4.  Pay attention to speech patterns.
5.  Count the number of breaths in a three-second period and multiply by two.
B.  Breathing (respiratory) ruality
1.  Normal breathing
2.  Shallow breathing
3.  Labored breathing
4.  Noisy breathing
C.  Breathing (respiratory) rhythm
1.  The breathing rhythm is the regularity of respirations.
2.  An abnormal respiratory rhythm in a patient with altered mental status may indicate medical illness, chemical imbalance, or brainy injury. / Video Clip
Go to www.bradybooks.com
and click on the mykit link for Prehospital Emergency Care, 9th edition to access a video clip providing an overview of vital sign assessment.
10 / IV.  Baseline Vital Signs—Pulse
A.  Location of pulses
1.  Carotid artery
2.  Femoral artery
3.  Radial artery
4.  Brachial artery
5.  Popliteal artery
6.  Posterior tibial artery
7.  Dorsalis pedis artery
B.  Pulse rate
1.  60–80 bpm in adults
2.  60–105 bpm in adolescents
3.  60–120 bpm for school aged-children
4.  80–150 bpm for preschoolers
5.  120–150 bpm for infants
6.  100–180 bpm for newborns
C.  Irregular pulses
1.  Tachycardia is a heart rate greater than 100 bpm in adults.
2.  Bradycardia is a heart rate less than 60 bpm in adults.
D.  Taking a pulse
1.  Position the patient.
2.  Use the tips of two or three fingers to palpate the artery.
3.  Count the number of beats in a 30-second period, and then multiply by two.
4.  If pulse is irregular, take it for a full minute.
E.  Pulse quality and rhythm
1.  Strong pulse
2.  Weak pulse
3.  Regular pulse
4.  Irregular pulse / Teaching Tip
Have students locate their radial, brachial, carotid, and dorsalis pedis pulses.
Discussion Question
When should the carotid pulse be assessed?
Weblink
Go to www.bradybooks.com
and click on the mykit link for Prehospital Emergency Care, 9th edition to access a web resource showing how to take a pulse.
10 / V.  Baseline Vital Signs—Skin
A.  Skin color
1.  Paleness, or pallor
2.  Blue-gray color, or cyanosis
3.  Red color, or flushing
4.  Yellow color, or jaundice
5.  Mottling
B.  Skin temperature
1.  Relative skin temperature is common measurement.
2.  Place back of your hand against the patient’s skin.
3.  Normal skin feels warm to the touch.
4.  Abnormal skin temperatures
a.  Hot
b.  Cool
c.  Cold
5.  Changes in skin temperature over a period of time, or different temperatures in various parts of the body can be significant.
C.  Skin condition
1.  Normal skin is dry.
2.  Wet or moist skin
a.  Hypoperfusion
b.  Poisoning
c.  A heat-related, cardiac, or diabetic emergency
3.  Cool and moist skin is described as clammy.
4.  Diaphoreses describes profuse sweating.
5.  Abnormally dry skin may be a sign of spine injury or dehydration.
D.  Capillary refill
1.  Capillary refill time is the time is takes for compressed capillaries to fill up again with blood.
2.  Reliable in infants and younger children
3.  Affected by a cold environment, preexisting conditions of poor circulation, and certain medications
4.  Count the time it takes a location on the skin to turn from white to color after pressing.
5.  A longer than normal time may indicate hypoperfusion.
6.  Capillary refill time alone cannot be used to determine shock but can be combined with other signs and symptoms.
10 / VI.  Baseline Vital Signs—Pupils
A.  Size
1.  Pupils that are dilated may indicate cardiac arrest or use of certain drugs.
2.  Pupils that are constricted may indicate a central nervous system disorder, the use of narcotics, glaucoma medications, or a brightly lit environment.
B.  Equality
1.  Pupils of unequal size
a.  Stroke
b.  Head injury
c.  Artificial eye
d.  Disease of the eye
e.  Use of certain eye drops
f.  Injury to the eye or nerve that controls the pupil
2.  Anisocoria is a condition in which the pupils are slightly unequal but remain reactive to light.
C.  Reactivity
a.  Pupils will constrict when light is shined on them.
b.  Pupils will dilate when shaded.
c.  Consensual reflex indicates that both pupils will respond in the same way even if only one is exposed to a stimulus.
d.  Fixed and dilated pupils
i.  Pupils do not change when exposed to light.
ii.  Can result from cardiac arrest, severe head injury, severe hypoxia, or extremely poor perfusion to the brain / Discussion Question
What is consensual pupil response?
10 / VII.  Baseline Vital Signs—Blood Pressure
A.  Blood pressure is the pressure exerted on the walls of the arteries by the blood flowing through them.
1.  Systolic blood pressure is the amount of pressure exerted on the walls of the arteries during the contraction of the left ventricle.
a.  Pulse is an assessment of the systolic blood pressure.
b.  The systolic blood pressure is identified by the first distinct sound (Korotkoff sound) heard when measuring the blood pressure by auscultation.
2.  Diastolic blood pressure is the amount of pressure exerted on the walls of the arteries while the ventricle is at rest.
a.  Diastolic blood pressure depends on the amount of blood in the artery and the diameter of the artery.
b.  The diastolic blood pressure is recorded when the systolic sound disappears or changes drastically.
B.  Normal range of systolic blood pressure
1.  Adult male: Add the patient’s age to 100 mmHg.
2.  Adult female: Add the patient’s age to 90 mmHg.
3.  Child age one to ten years: Multiply age by two and then add 80 mmHg.
4.  Child or adolescent greater than ten years: Minimum of 90 mmHg
C.  Blood pressure alone cannot be used to determine shock but can be combined with other signs and symptoms.
D.  Blood pressure should not be measured in children less than three years of age.
E.  Pulse pressure is the difference between systolic blood pressure and diastolic blood pressure.
1.  Increases or decreases in the pulse pressure can indicate possible conditions or injuries.
2.  EMT should record any abnormalities in the pulse pressure.
F.  Low blood pressure
1.  Can cause an inadequate delivery of oxygen to cells and organs, known as shock or hypoperfusion
2.  Can decrease as a result of blood or fluid loss, or blood vessel dilation
3.  Conditions that may cause shock or hypoperfusion include severe bleeding, heart attack, heart failure, or spine injury.
G.  High blood pressure (hypertension)
1.  Can result from a variety of causes
2.  Can cause damage to heart and blood vessels leading to heart failure, stroke, ruptured blood vessels, and kidney disease
H.  Methods of measuring blood pressure
1.  Auscultation—Listening for the systolic and diastolic sounds through a stethoscope
2.  Palpation—Feeling for the return of the pulse as the cuff is deflated / Discussion Question
What do systolic and diastolic pressures each represent?
Discussion Question
What are the expected vital signs for adults?
Weblink
Go to www.bradybooks.com
and click on the mykit link for Prehospital Emergency Care, 9th edition to access the AHA blood pressure site.
Class Activity
Have pairs of students assess each others’ pulse, breathing, blood pressure, and pupils and record the values on a piece of paper.
10 / VIII. Baseline Vital Signs—Testing Orthostatic Vital Signs
A.  Obtaining orthostatic vital signs
1.  Place the patient in a supine position.
2.  Measure blood pressure and heart rate.
3.  Then stand the patient up and reassess blood pressure and heart rate.
4.  Orthostatic test is positive if heart rate increases by greater than 10–20 bpm and the systolic blood pressure decreases by 10–20 mmHg.
5.  Orthostatic vital signs test is commonly known as tilt test.
B.  Be aware of false positive results, as in the case of elderly patients who experience a normal drop in systolic blood pressure when rising.
C.  If a patient cannot be placed in a standing position, move him to a seated position.
D.  Do not perform this test on patients with possible spine injuries. / Knowledge Application
Give several sets of vital signs and have students determine if they are within expected ranges for the patient’s age. For abnormal values, ask students what the findings might indicate.
Discussion Question
How do breathing, pulse, and blood pressure change with age?
5 / IX. Baseline Vital Signs—Vital Sign Reassessment
A.  Vital signs should be taken and recorded at least every 15 minutes.
B.  Take and record vital signs every five minutes if the patient is unstable.
C.  Reassess vital signs immediately following every medical intervention. / Critical Thinking Discussion
What changes would you expect in the vital signs of a patient with on-going bleeding?
15 / X.  Monitoring Equipment—Pulse Oximeter: Oxygen Saturation Assessment
A.  Pulse oximetry is a method of detecting hypoxia by measuring oxygen saturation levels in the blood.
B.  A pulse oximeter is used to measure the level of hemoglobin saturated with oxygen.
1.  Device is clipped onto or attached to a patient’s finger, toe, earlobe, or across the bridge of the nose.
2.  A red light or infrared light shines through the tissue to a photosensor, detecting the amount of hemoglobin saturated with oxygen.
3.  The read is provided as a percent of hemoglobin saturated with oxygen, as percent SpO2.
C.  Indications for pulse oximetry
1.  The pulse oximeter should be applied in any situation where the patient’s oxygen status is a concern or when hypoxia may be suspected.
2.  This reading is commonly described as the “sixth vital sign.”
D.  Limitations of the pulse oximeter
1.  Any conditions that interfere with the blood flowing to the area where the probe is attached may produce an erroneous reading.
2.  The device does not provide a direct measurement of the blood oxygen content.
3.  The reading does not indicate the amount of oxygen being off-loaded to the cells, the oxygenation status of the cells, or the ability of the cells to use the oxygen.
E.  Procedure for determining the SpO2 reading
1.  Connect the sensor to the SpO2 monitor device.
2.  Attach the probe to the fingertip.
3.  Turn on the device and wait for a reading.
4.  Match the pulse reading on the monitor with the patient’s.
5.  If a poor signal is detected, check that the probe is on properly.
6.  Once an accurate reading is achieved, reassess every five minutes in an unstable patient or every 15 minutes in a stable patient. / Discussion Questions
·  How does pulse oximetry work?
·  What are some reasons pulse oximetry readings may be inaccurate?
Weblink
Go to www.bradybooks.com
and click on the mykit link for Prehospital Emergency Care, 9th edition to access a web resource about pulse oximetry.
15 / XI.  Monitoring Equipment—Noninvasive Blood Pressure Monitor
A.  A noninvasive blood pressure monitor is a device that automatically measures a blood pressure.
1.  Can be set to reassess at selected intervals
2.  Can be activated manually
3.  Alarms can be set to signal upper and lower limits.
B.  Procedure for noninvasive blood pressure monitoring
1.  Obtain blood pressure reading by the auscultation method first.
2.  Position the cuff.
3.  Activate the device.
4.  Obtain the reading. / Class Activity
Give students the opportunity for guided practice using pulse oximetry and noninvasive blood pressure monitors.
Critical Thinking Discussion
Why should you first obtain a blood pressure by auscultation before relying on noninvasive blood pressure monitor values?
5 / XII.  Preparing to Take the History—Gain Control of the Scene
A.  Display competence, confidence, and compassion through appearance and professional manner.
B.  Obtain the history or parts of the history from Emergency Medical Responders, relatives, or other care givers at the scene.
C.  Gain cooperation from the patient and others at the scene. / Teaching Tip
Give examples from your experience of how you have gained control of scenes.
5 / XIII. Preparing to Take the History—Achieve a Smooth Transition of Care
A.  Announce your arrival at the scene.
B.  Gain information from Emergency Medical Responders before making patient contact.
C.  Give immediate attention to an unresponsive or obviously injured patient. / Class Activity
Provide students with opportunities to establish control of scenes and establish rapport with patients during lab scenarios.
5 / XIV.  Preparing to Take the History—Reduce the Patient’s Anxiety
A.  Bring order to the environment.
1.  Have televisions and radios turned down.
2.  Ask that dogs be removed from the area.
3.  Make sure that children are supervised.