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Vital Signs and History
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In the preceding chapters we've written a lot about what YOU can expect, what YOU need to be aware of, how YOU can protect yourself, and those things that YOU need to know about human bodies. In this chapter, and some others that follow, the focus is going to change.
This chapter will deal with the basic elements of patient assessment (Vital Signs and History Taking.) In those chapters that follow (dealing with patient assessment) the individual components will be expanded and explained.
The process called "Patient Assessment" is very possibly the most complex and important skill that you will learn. It, literally, makes no sense to learn how to apply a Kendrick's Extrication Device (KED,) how to secure a patient to a long back board, or how to assemble an oxygen delivery system, unless you know when these 'tools' are needed. The answer to "when" is found in the patient. The tool used to "find" the answer is discernment. Acute awareness of subtle (and sometimes not so subtle) "signs," and a heightened attentiveness to what the patient is saying ("symptoms") will help lead you to the answer.
During your initial contact with the patient, from the very onset, and all the way through transfer of your patient to the next level of patient care, the patient will be exhibiting signs that are related to the "problem." At times those "signs" will be verified by the "symptoms."
A patient who is pale, diaphoretic, and is using some accessory muscles to breath, and is complaining of radiating chest pain (rated at 7 of 10,) claiming respiratory difficulty, and stating that something terrible is going to happen, is exhibiting the classic signs and symptoms of a possible heart attack. The vital signs collected by the EMT reveal, respirations at 24 (slightly shallow and mildly labored,) pulse at 106 (irregular and bounding,) skin is pale, cool, and moist, cap refill less than 2 seconds, blood pressure 158/96, level of consciousness (LOC) is alert and oriented to person and place (X2 of 3), breath sounds include rales at the bases, bilaterally, and pupils are equal, round and reactive to light (PERRL.) This is a "complete" picture and all the "parts" seems to support each other.
But there will be times when that "support" just isn't there.
For example: A 62 year old male patient with a long standing history of emphysema appears with intercostal retractions, sits on the edge of a chair with outstretched hands supported by his knees, and when asked, "What's the problem, today," he responds, "Oh, not much, my wife overreacted again and called 911," using one- and two-word sentences. Respirations are 30 (shallow and labored) through pursed lips, pulse is 98 (thready,) skin is warm, moist, and cyanotic, capillary refill is delayed, blood pressure is 128/90, LOC is alert and oriented X3, breath sounds reveal course rhonchi, and pupils are PERRL. When asked if he's having any difficulty breathing, his answer is "Nah!" In this case the "signs" (physical signs and vital signs) indicate severe respiratory distress, but there are no such stated "symptoms."
In the event where there is conflict between "signs" and "symptoms" please keep in mind that "symptoms" are the patient's subjective interpretation of the events surrounding this "call for help." Embarrassment, advanced age, unpleasant previous experiences with medical providers, and simple stubbornness (to name just a few) can lead to an unrealistic interpretation. If YOUR findings lead you to believe that a patient needs immediate medical attention, do everything you can to convince the patient to allow, and accept, the needed care.
Nice little stories, huh?
Did they serve a purpose?
Sure!
If you read them with the same level of heightened attentiveness that you should employ when listening to a patient, you should have a fairly complete understanding of which signs are vital signs and how we further characterize each vital sign with additional descriptive language.
If you didn't, we'll go over them one more time.
Vital Signs include: (followed by some descriptive classifications)
Respirations (comfortable [eupnea], shallow, deep, labored [dyspnea], agonal, noisy, rapid [tachypnea], slow [bradypnea], absent [apnea], Cheyne-Stokes or Kussmaul patterned)
Pulse (regular, irregular, thready, bounding, absent [peripherally and/or centrally])
Skin Condition (normal color, pale, red, cyanotic, warm, cool, hot, cold, dry, moist, wet)
Capillary Refill (less than 2 seconds, more than 2 seconds)
Blood Pressure
Level of Consciousness (alert, responds to verbal or painful stimuli, unresponsive, oriented [to time/person and/or place], confused) **AVPU
Breath Sounds (equal, diminished [left/right/bilaterally], rales [location, course, fine], rhonchi [audible, course], wheezing, stridor, absent)
Pupils (equal, unequal, round, not round, reactive to light, non-reactive [fixed], sluggish [left, right, bilaterally], midrange, pinpoint, dilated, left or right fixed gaze)
**AVPU
A - Awake and Alert
V - Responsive to Verbal Stimuli
P - Responsive to Painful Stimuli
U - Unresponsive
During your career as an emergency care provider you may, at
times, hear other providers refer to a patient as "alert and oriented." It
is our experience that few, if any, new "providers" understand the concept of
"alert" and that most confuse the concept of "alert" with "oriented." For
that reason we offer the following little digression (as if you're not already
accustomed to our propensity for digression.)
It starts with a question. When is a patient alert? The answers we've received in the past lead us to believe, as stated above, that the EMT student is confusing this concept with orientation to time, person, and/or place.
Let's start at the beginning, the very beginning.
A child has just been born. Immediately, following the cord cutting, the infant, properly formed, breathing adequately, and apparently un-traumatized by the birth event, lays in the doctor's arms, looking around the room. No crying, just nice pink skin, and apparently comfortable. This is a brand new mind, a "blank slate." This newborn, first notices light and dark areas created by the overhead fixtures in the delivery suite, but doesn't even "know" what to "call" this new phenomenon. Is this patient "alert?" Obviously, the answer is "obviously." Is the patient oriented? No, but with a "slate" as clean as this one is, the rate of orientation is at a level that would make any adult dizzy.
So, just what is "it" that determines a patient's "alertness?"
If, when you enter the room, the patient is aware of your presence (without further interaction,) then the patient is categorized as alert (or awake.) If you need to announce your presence to make the patient aware, then the patient is responding to verbal stimuli, and if you have to touch the patient in order to make your presence known, then the patient is responding to "touch" (which constitutes the beginnings of "Painful Stimuli.") The accepted mental status "Responds to Painful Stimuli," however, is something that rarely includes any level of orientation. Where some painful stimulus is applied, and the patient responds. That "response" needs to be further categorized as "appropriate," where the patient takes some action to remove or discontinue the painful stimulus (as when a patient uses his/her hand to "brush" the hand causing the pain from his/her body,) or "inappropriate," where the patient may just moan, or move inappropriately. If the patient does not respond to painful stimuli, he/she is categorized as "Unresponsive."
As you can see, this AVPU tool is a very effective way of describing mental impairment, and the level of "response" (or a change in the level of "response") may just be the determining factor that helps the next level of care reach a definitive diagnosis. It's that important!
HISTORY TAKING is an art. In addition to collecting "objective" medical history the emergency medical provider must interpret that history and evaluate it's accuracy, appropriateness and any effect that the information might have on the seriousness and/or outcome of the present emergency. History taking also includes the evaluation of the patient's interpretation and/or denial of the symptoms being related to/hidden from the medical provider. For the purpose of simplifying the process and finishing a "complete," brief, useful history, the anachronism "SAMPLE" will guide the EMT.
S - Signs and Symptoms of the event. What signs were collected and what symptoms were reported? When were symptoms first noticed. If "obvious symptoms" are being ignored or denied, so state.
A - Allergies. Is the patient allergic to any medications, food, environmental conditions, or other substances? If so, what reactions resulted? How severe? How long ago? If the patient has no known allergies (nka,) include this information in the history.
M - Medications. What medication is the patient taking. How often and what dosage? Is the patient compliant with the prescribed dosage and frequency? Any over-the-counter drugs taken in the past 12 hours? Note: Some patients do not understand the concept of 'medication' and might deny taking any, but when questioned about what 'pills' they take, suddenly reveal information about their 'blue pill' for the heart, 'yellow pill' for the lungs, 'pink pill' for the ..... If the patient denies taking any medications, ask them if they take any pills....It might just keep you from looking foolish to the care providers next-in-line in the process.
P - Pertinent Past History. Has the patient had any recent surgeries, traumatic events, illnesses, or contacts that might contributed to this present event, or that might impact on the treatment of this present event?
L - Last Oral Intact. When did the patient last eat or drink ANYTHING? What? How much? Did whatever was ingested contribute to this event? If so, what happened the last time this substance/food/fluid was ingested?
E - Events Leading to the Injury or Illness. What happened just prior to the time when the patient first noticed the signs or symptoms. What happened just prior to the injury. Was there something that caused the accident? What has transpired just prior to the emergency care provider's arrival.
As mentioned above, taking a good patient history is an art. Just like any art it needs to be practiced until it's perfected. A patient's right to privacy always needs to be considered when asking 'sensitive' or personal questions. Conduct the history taking interview as if you were 'talking with the patient.' Don't shout across the room, it very unprofessional. If the patient is unable to answer questions for them self, seek the necessary information from a family member. Rarely will neighbors or onlookers have the kind of personal information that you are seeking. If you must seek information from ANYONE other than the patient, DO NOT discuss the patient's condition with the third party, without the permission of the patient. If there are no other sources of information, and you must look through belongings, wallets, handbags, or drawers for personal patient information, be absolutely certain that either a law enforcement officer or another member of your team is present to witness your actions.
Finally, when recording a long list of normal vital signs, in an effort to conserve time, some providers will utilize the phrase "Within Normal Limits." We feel that this practice is below the level of professionalism into which we would like to see every emergency medical provider grow. Some providers have attempted to save even more time by contracting the above phrase into "WNL." For us, this practice is completely unacceptable, because, for us, "WNL" is a contraction for "We Never Looked."
