1. Vital Signs, Lung and Heart Examination Matthew L. Picone MD, MSEd St. Joseph’s Hospital

2. Vital Signs Heart Rate or Pulse Respiratory Rate Temperature Blood Pressure Oxygen Saturation-O2 sat

3. Vital Signs Areas of important interest to take the Pulse Rate: Neck-Carotids, Wrist:Radial, Groin-Femoral, Ankle-Posterior Tibialis All of these VS are influenced upon each other and react to the change-normally. Example: When your temperature goes up it’s a normal physiologic response to have your RR and HR go up as well.

4. Vital Sign Changes When BP goes down it is normal for the HR go up to in an attempt to compensate. Sleep State: All go down to low normal or even abnormal during Deep Sleep State- Stage 4 Exception-REM state or Dream state- where almost anything can happen with VS

5. Heart Rate or Pulse Normal Ranges Abnormal Ranges Abnormal findings that can be normal and non-concerning

6. Children’s Normal HR Age Heart Rate Birth 140 6 mo 130 1 yr 115 2 yr 110 6 yr 103 8 yr 100 10 yr 95

7. Adult Heart Rates By Definition: 60-100 beats/min Below 60 can be normal for many athletes- runners especially can have HR 40-60. Some adults have normal HR over 100, usually 100-110. If an individual is anxious, just finishing skiing(exercising) or on certain medications then HR can vary out of the normal range either high or low.

8. Abnormal HR HR >> 125-150b/min Assess for regularity of rhythm Patients will sometimes feel nothing, palpitations. Assess for lightheaded, dizziness and syncope. Maneuvers that can slow the HR down Oxygen is always helpful in this setting

9. Fight or Flight Response When our fight or flight response is activated, sequences of nerve cell firing occur and chemicals like adrenaline, noradrenaline and cortisol are released into our bloodstream. These patterns of nerve cell firing and chemical release cause our body to undergo a series of very dramatic changes. Our respiratory rate increases. Blood is shunted away from our digestive tract and directed into our muscles and limbs, which require extra energy and fuel for running and fighting. Our pupils dilate. Our awareness intensifies. Our sight sharpens. Our impulses quicken. Our perception of pain diminishes. Our immune system mobilizes with increased activation. We become prepared—physically and psychologically—for fight or flight. We scan and search our environment, "looking for the enemy."

10. Fight or Flight

12. Stethoscope Positioning

13. Stethoscope

14. Heart Sounds Positioning Before You Begin a) Try to create a quiet environment as much as possible. This may be difficult in a busy emergency room or in a room with other patients and their visitors. Eliminate noise by closing the door and turning off any radios or televisions in the room. b) The patient should be in the proper position for auscultation, i.e. sitting up in bed leaning forward, lying on his/her left side, or supine or at 30 degree elevation on the examining table.

15. Positioning for Heart Sounds c) Your stethoscope should be touching the patient's bare skin whenever possible or you may hear rubbing of the patient's clothes against the stethoscope and misinterpret them as abnormal sounds. You may wish to wet the patient's chest hair with a little warm water to decrease the sounds caused by friction of hair against the stethoscope. d) Always ensure patient comfort. Be considerate and warm the diaphragm of your stethoscope with your hand before auscultation.

16. Audio Heart Sounds http://www.easyauscultation.com/heart- sounds.aspxhttp://www.easyauscultation.com/heart- sounds.aspx Listening to the heart in the Right and Left Intercostal space in the Anterior midclavicular line. Followed by left lateral sternal border in the remaining spots

17. Groups of childrenTheir agesNormal respiratory rates Newborns and infantsUp to 6 months old30-60 breaths/min Infants6 to 12 months old24-30 breaths/min Toddlers and children1 to 5 years old20-30 breaths/min Children6 to 12 years12-20 breaths/min Normal pediatric respiratory rate for infants, newborn, toddlers, and children

18. Adult Respiratory Rates Normal: 12-18 breaths/min Abnormal called Tachypnea >20 br/min If RR > 24 br/min then look for signs of distress. Check O2 Saturation-pulse oxygenation Normal O2 saturation: > 92-100%

19. Abnormally fast RR Hyperventilation Syndrome: or rapid RR Mental Health Causes: Anxiety or Panic Medical Causes: Diabetes out of control(DKA) Physiologic Causes: Taking too many deep breaths and increasing rate. Sometimes seen in laboring woman

20. Hyperventilation Syndrome Metabolic Results: Loss of CO2 Physiologic results: Compensatory in uncontrolled diabetes to blow-off CO2 Physical Symptoms you may see: Numbness and tingling in face, hands or feet. Chest Pains, dizzy, sweaty, confused and sometimes fainting occurs

21. Auscultation of Lung Sounds

22. Respiration http://www.easyauscultation.com/heart- sounds.aspx http://www.easyauscultation.com/heart- sounds.aspx