Emergency situations/vital signs
emergency medical care
What are vital signs?
Why do we measure vital signs?
To assist with physical assessment
What do vital signs measure?
Changes in patient’s status
what do we look for?
Changes from previous readings…...
Variations from “normal”
Is a vital sign in a normal range always “OK”?
normal B/P range is 100/60-140/90
example: patient’s normal B/P is 130/70...
Next reading is 100/60
is still in normal range but not normal for that patient.
So we need to assess...
Not only if in normal range but is it normal for that patient!
When are vital signs taken?
As ordered by MD and…
when patient condition changes,,,,,
After surgery, transfusions, procedures.
How often are vital signs usually ordered?
Every shift for stable patients,,, every 4 hours or less when status requires
more frequent assessment
Where are vital signs recorded?
What should you do if an abnormal reading is obtained?
measurement of the balance between heat produced and lost
heat regulating center?
Depends on where taken
ways to take temp?
Types of thermometer?
Glass (mercury, alcohol)
4-5 minutes if glass,
if electronic or digital,,
When the thermometer “beeps”
use protective sheath
normal oral temp?
98.6F, 37 C
If patient has had something to eat or drink or has just smoked….
Wait 15 minutes
When do we not take oral temp?
O2, unconscious, NGT,
Child under 4,
stroke, mouth surgery
Red, stubby tip with glass,,
Red probe for electronic.
Never use red tip for any other route!!!
Use protective sheath,,
Lubricate, insert one inch, 1/2 for infants
3 minutes for glass
always hold in place!!!
When do we take a rectal temp?
infants, young children, when we need most accuracy
Rectal temp is the
most accurate way to take a temp but…
when do we not take a rectal temp?
Patient with a heart condition..
Axillary region must be dry
7-9 min. glass
measure of how many times the heart beats in one minute
How do we measure?
Feel the wave of blood as it pushes out of the heart
felt over arteries...
Nearer to the skin surface.
Most common site?
Age, activity, illness
how do we measure?
Which is measured with stethoscope?
actually listening to heart
counted for full minute
2 sounds, “Lubb/Dupp”
counts as one beat.
Palpating a pulse?
Radial for adults most common,,,,
Brachial for infants
Never use thumb
gently press over pulse point,,,,
Count each throb for 30 seconds,,,, multiply by 2
then count for full min.
Need to assess
depth/volume (bounding/full, thready/weak)
If irregular,, check apical pulse
Measures differences between apical/radial
Requires 2 people
terms: pulse deficit
Measure one inhalation and expiration
detects breathing problems
Taken after pulse for 30 seconds, multiplied by 2
Pressure against artery walls with each heart beat
types of B/P cuffs?
One or two step method
Ensures cuff not over-inflated
conditions when not to use an arm?
IV, vascular surgery
compromised circulation, cast
good Samaritan Law?
types of emergencies?
call for help
consent to treat
treat for shock
signs of shock?
Assume person will go into shock
never move unless absolutely necessary
Keep warm, lying down
apply pressure over bleeding
types of fractures?
Foreign object in eye?
never attempt to remove object
degrees of burns?
1st? 2nd?, 3rd?
what are they?
Alternating muscle contractions/relaxation
try to determine what was taken
Heat stroke? Hyperthermia
S&S of hypoglycemia?