1. Vital Signs
MedLab

2. Objectives
Explore various medical science techniques to measure vital signs
Identify the different components of a medical patient chart
Diagnose a patient by analyzing vital signs and other symptoms

3. Things to know… Vital Signs are Baseline Vitals are
clinical measurements that indicate the state of a patient’s essential body functions. Vital signs are a quick and effective way to assess a patient’s condition.
Baseline Vitals are
a representation of a patient’s typical state of health. These are specific to the patient.

4. VITAL SIGNS Blood Pressure Heart Rate Respiratory Rate Temperature
Eye Function
Breathing Sounds

5. Average temperature: 98.6 °F (37.0 °C)
The measurement of internal heat created by normal body processes
Additional details to share if needed:
-Types of thermometers: disposable strips, electronic/digital, tympanic, temporal
- Common temperature measurement sites: oral, rectal, axillary, tympanic, temporal
Oral temperature reading from a digital thermometer
Average temperature: 98.6 °F (37.0 °C)

6. HEART RATE (PULSE) The number of heart beats per minute (bpm)
Highlights:
A pulse consists of two phases: contraction and relaxation. The combination of one contraction phase and one relaxation phase is equal to one heartbeat.
- The most common pulse sites include the wrist (radial), neck (carotid), inner elbow (brachial) and heart (apical).
Radial Artery
Additional pulse sites of the body
Standard Range: bpm

7. RESPIRATORY RATE The number of breaths taken per one minute
Highlights-
Respiration is the process of taking oxygen into the blood in exchange for carbon dioxide. This is done via the lungs when we inhale and exhale. One complete breath consists of two phases: inhalation (chest will rise) and exhalation (chest will fall).
A respiratory rate is measured when you are at rest, by simply counting the number of breaths in one minute.
Respiratory system response to inhalation and exhalation
Standard Range: breaths/min

8. BREATHING SOUNDS
The specific sounds identified in the lungs when a person takes a breath
Highlights:
-The five common breathing sounds include: clear, wheeze, stridor, stertor and crackle.
- A stethoscope is a medical instrument used to transmit internal body sounds to the ear of the listener. Using a stethoscope can assist a nurse or doctor with interpreting the difference between similar and faint breathing sounds.
Observation of breathing sounds with stethoscope
Standard: Clear

9. Standard Range: 90-120/60-80 mmHg
BLOOD PRESSURE
The force of blood pushing against the walls of the blood vessels
Recorded as Systolic/Diastolic
Systolic – the highest level the blood pressure reaches when the heart beats (contracts).
Diastolic - the lowest level the blood pressure reaches as the heart relaxes between the beats.
Highlights:
The medical device used to measure blood pressure is called a sphygmomanometer (pronounced sfig-mōh-ma-nom-ə-ter); it is composed of an inflatable cuff to restrict blood flow and a mercury manometer to measure the pressure. A sphygmomanometer can be manual or digital device, depending on the preference of the healthcare provider.
Digital Sphygmomanometers are often called “blood pressure monitors”
Additional details to share if needed:
-Types of sphygmomanometers: mercury, aneroid, digital
Parts of a aneroid (manual) sphygmomanometer
Standard Range: /60-80 mmHg

10. EYE FUNCTION (neuro-optometric response)
The essential elements of a neuro-optometric exam used to assess nerve and brain function associated with the eyes.
Optometrist using an optholmoscope
Standard: Baseline function and acuity

11. How does the medical staff record the vital signs during a patient’s visit?
Patient Chart
A patient chart is a confidential document that contains detailed and comprehensive information to serve as both a medical and legal record of an individual's clinical status, care, history, and treatment.

12. Care plans and Discharge
PATIENT CHART
Patient Information
Episodic Information
Patient History
· Patient information consists of the patient’s name, date of visit, contact info, occupation, employer, and insurance carrier.
· Episodic information includes the reason for the patient’s visit; including specific symptoms and concerns.
· The triage tag is a result of the process for sorting patients into groups based on their need for or likely benefit from immediate medical treatment. Most groups are separated into one of four categories: minor, delayed, immediate, morgue.
· Patient history provides a subjective description of the patient’s health and social history. It also contains information about the medical history of the patient’s family.
· The medical orders component contains orders written by healthcare providers. These can be orders for tests, administration of medication, or procedures.
· The lab/test results section identifies the laboratory tests that were performed and the results of those tests. The test results usually contain the numeric or graphical results and a narrative that describes the examiner’s findings.
· The notes section includes additional observations made by a healthcare provider, such as a physician or nurse, relating to the patient’s care.
· The care plans and discharge component documents the treatment goals and plans for future care, as well as contains final instructions for the patient before the chart is closed and stored in Medical Records.
Medical Orders
Lab/Test Results
Notes
Triage tag
Care plans and Discharge

13. Let’s explore our own vital signs!
Complete Warm-Up. Use the Explore Your Own Vital Sign Worksheet.

14. WELCOME TO THE EMERGENCY ROOM
The Emergency Room (ER) is a section of the hospital that is staffed and equipped to provide rapid and varied emergency care, especially for those who are stricken with sudden and acute illness or who are the victims of severe trauma.

15. What happens in the ER?
First stop: triage, prioritization of patient conditions
Immediate: life threatening injury
Delayed: serious, non-life threatening
Minor: walking wounded
Morgue: pulseless, non-breathing
Next stop: registration
A nurse takes vital statistics and collects identification and insurance information

16. What happens in the ER? Next up: examination room
Complete review of all patient body systems
Patient provides a more detailed medical history
Emergency Medicine Physician formulates a differential diagnosis
List of possible causes for symptoms
After a differential diagnosis, the physician recommends treatment
Patient is either released, referred to a specialist, or sent to the operating room (OR).

17. Common reasons for ER visits
Headaches
Abdominal pain
Chest pain / Heart attack
Cuts and contusions
Skin infections
Severe allergic reactions
Trauma / Broken bones / Sprains
Difficulty breathing / Asthma attack
Upper respiratory infections / Cold / Flu
Unconsciousness
Health conditions highlighted in pink will be addressed in today’s activity.

18. Are YOU ready to diagnose today’s patients?
Today, you will review the charts of six different patients
After reviewing the patient’s vitals, symptoms, and history, you and your medical team will make a diagnosis

19. How will you make your diagnosis?
A diagnosis is the medical decision determined after the healthcare team examines all the possible causes for a set of symptoms.
A differential diagnosis is based on listing as many diseases or conditions that can possibly cause the presented symptoms, followed by a process of elimination, aiming to reach the point where only one disease or condition remains likely.

20. Making a Differential Diagnosis
Reason for patient visit: sneezing, runny nose, stuffy nose, cough, sore throat and fever.
The aforementioned chief complaints for this patient are classic symptoms of which two conditions?
Cold
Allergies
How will you make your final conclusion?

21. Making a Differential Diagnosis
Remember, a differential diagnosis is a process of elimination, aiming to reach the point where only one disease or condition remains likely.
Symptom
Cold
Allergy
Cough
Usually
Sometimes
General aches and pains
Never
Fatigue
Itchy eyes
Rarely
Sneezing
Sore throat
Runny nose
Stuffy nose
Fever
Adapted from National Institute of Allergy and Infectious Diseases, MayoClinic

22. Making a Differential Diagnosis
What is your diagnosis?
The patient has a cold
How did you make your final conclusion?
Although most of the symptoms for colds and allergies are the same, we concluded that the patient has a cold due to the presence of a fever (never a symptom of allergies).

23. Are YOU ready to diagnose today’s patients?
Activity time