In this micro lecture, APC Hon. Snr. Lecturer Sam Willis discusses vital signs surveys. This video lesson forms part of the blended learning materials available to all enrolled students of the Australian Paramedical College. All students have unlimited access to a rich library of learning materials such as this.
My name’s Sam Willis. I’m the senior lecturer for the Australian Paramedical College, and in today’s lecture we’re going to talk a little bit about vital signs surveys. So you will hear a lot about this throughout your studies with the college, and today’s session really does touch on what we classify at the college as vital signs surveys where we’ll be talking about when to do them, how to do them. Although, this is not a practical demonstration of these, it really does allow you to put the vital signs surveys into context of what you’d be doing at the clinical face-to-face workshops.
So let’s start by talking about the aim of the session. So here we can see we’re going to help you guys recognise the importance of undertaking vital signs assessments in the context of being a paramedic, wherever that may be. Now, I say wherever that may be because today’s paramedics don’t just work on state ambulances. They work on mine sites. They work for medical companies, and in a whole range of complex places wherever there’s an emergency response required. So we’re going to look at the importance of undertaking a vital signs assessment because it really does underpin what you do as a paramedic and how you form your treatment plans.
We’re going to be looking at the different assessments that form a vital signs survey. We’re going to talk about when to do it because this can be just as complex as how to do it, particularly given that the patient is only one part of the system. Remembering you’ve got to try and fit in with what you’re seeing, what you’re hearing, as well as working together as a crew and being flexible as a crew. And of course, we’re going to recognise a range of vital signs considered to be within normal limits. So what this means is we’re going to take a look at some of the common vital sign values and discuss what are considered to be normal.
So exactly what constitutes a vital sign is subjective. So you’re going to be hearing the word vital sign, vital sign, vital sign over and over again, both in your readings and at the practical workshops. But what you will notice if you stop and take a look at what other ambulance services and other medical services do, you’ll notice that what one service considers to be a vital sign is not considered to be a vital sign by another service.
And you know what, it actually doesn’t matter that much because we tend to consider the vital sign as any type of assessment around the physiological output. So for example, respiratory rate, heart rate, blood sugar, those types of things. And we’re going to talk about that in a little bit more detail on the next slide.
I suppose this first point is just making you aware that vital signs is a subjective term. Broadly speaking, a vital sign is a measurement of a physiological function such as heart rate. So we’ve already said that. And undertaking a vital sign helps the paramedic identify any abnormal physiological responses due to illness or trauma.
So if we’re going to use heart rate as the example here, just to exemplify this third point, imagine somebody who was in a state of physical or clinical shock. Now, as you guys will know, the heart rate goes up as a way of compensating for whatever is occurring in the body at that moment in time.
So you can see that by monitoring the heart rate, something as simple as palpating a radio pulse or even a carotid pulse, and taking that vital sign recording will help you to work out, you know what? This is not normal. This is an abnormal vital sign.
Vital signs allow the paramedic to use a process of differential diagnosis. Now, for those of you who are unfamiliar with that term, differential diagnosis helps you to rule out what something is and isn’t working. So for example, if I’ve got a patient with chest pains and I’m trying to work out, is this caused by heart or respiratory?
So let’s say they describe it as tight, gripping, radiates down the side, left arm into the jaw. It doesn’t change when I breathe in or out or move. I can absolutely rule out respiratory problems. So that’s differential diagnosis. You are differentiating between the different conditions.
Exactly when to undertake a vital sign survey should be agreed upon by the ambulance crew and depends on the patient’s situation. Now what this means is yes, by all means, go running in and do your vital signs at the most appropriate time. Generally speaking, we introduce ourselves.
We go through the primary survey, danger response, airway, breathing, circulation, disability, and exposure. That’s primary survey. Then we do your secondary survey. So that’s your pain assessment, your vital signs surveys, your history taking, and your head to toe surveys if trauma is suspected. But you have to try and do them at the time that’s appropriate.
So there’s a lot of communication between you and your crew mate. There’s a lot of teamwork in here and there’s a lot of decision making as to what’s what’s the most appropriate. So for example, if your patient is laying on the floor looking cold and clammy and their partner tells you they’re diabetic, you’re going to go and do a blood sugar test pretty quickly rather than doing a thermometer test to check the body temperature. So you have to apply a little bit of decision making here.
Okay. Common vital signs, then. This is what we have decided to be common vital signs here at the college. Cardiac characteristics, respiratory characteristics, body temperatures. So we’re talking about the core body temperature, not the peripheral. There’s a difference between the two, which we’ll discuss in a moment. Blood glucometry, and blood pressure. So these are the skills that you will be taught, as well as other skills when you arrive at the face-to-face clinical workshops.
Okay, so cardiac characteristics. Now notice we haven’t just put heart rate, because it’s not as simple as just palpating the radial pulse or putting a probe on the finger and doing the heart rate. You have to actually palpate the radial pulse. You have to feel for the absence or presence of the radial pulse.
So when we’re talking radial, we’re talking roundabout here at the wrist. So we look into seeing if it’s present or absent. If the radial pulse is not present, you feel for the carotid pulse, which is on the neck. We tend to avoid going straight for the neck because it’s very delicate in that area.
So if the radial pulse is absent, but your patient’s conscious and talking, do say to your patient, “I need to feel your neck to feel your heart rate. Is that okay with you?” And then go and feel for the carotid pulse. It’s as simple as that.
What you’re feeling for, apart from the absence and the presence, is the rate, in other words how fast it is and how slow it is; the regularity. So for example, what’s the distance between each contraction? Is it equal or is it not equal? And of course, you’re feeling for the strength as well.
Sometimes the strength can be determined just by palpating. So for example, a full bound impulse is not always a good thing because it means your heart’s having to squeeze and compress harder.
So typical types of things that will affect your heart rate include infection, shock, drugs, stimulant drugs. So drugs that will speed your heart rate up as well as slowing your heart rate down. Typical stimulant drugs that speed your heart rate up include cocaine and ecstasy, and typical drugs that slow your heart rate down include heroin.
And of course, there are some prescribed medication that will slow your heart rate down and speed it up as well, and a typical medication that will slow your heart rate down that’s prescribed are beta blockers, which is what the elderly use or anybody uses to control blood pressure. So if you do have somebody who’s taking a beta blocker type medication and they’ve got a slow heart rate, it’s probably normal because that actually is a side effect of the drug itself.
Now, we haven’t mentioned a lot about saturations yet, but absolutely oxygen saturations are in that list as well. Now oxygen saturations, I think it’s timely to talk about this here, is a little probe that you place onto the patient’s finger and not only does it give you a reading in a percentage, but it also calculates the heart rate.
Now, typically speaking, a normal oxygen saturation reading is anywhere between 92% and 96%, according to the Australia and New Zealand Thoracic Society. So what that means is any time a patient presents with an oxygen saturation below 92%, then they are considered as being hypoxic, and they require oxygenation through the use of oxygen masks.
Now let’s talk about respiratory characteristics. So very similar to the cardiac characteristics. We’re looking to see if breathing is absent or present, and again, if somebody is unconscious but breathing, you really do need to do a thorough and systematic respiratory system assessment. Remembering that the breathing pattern. There’s an inspiration and an expiration. So there’s always two phases to the respiratory cycle.
When you’re checking the respiratory system characteristic, you’re looking at absence or presence. You’re looking at the rate. A normal respiratory rate should be between 12 and 20 breaths per minute. You’re looking to see if there’s any use of accessory muscles. In other words, in normal quiet breathing, breathing is controlled by a number of processes which includes pressure on the outside in the atmosphere and the low pressure on the inside, and there’s a change in those atmospheric pressures inside and outside as you breathe. It’s also controlled by the muscular system, and at no point should there be any accessory muscle uses that are really pulling your rib cage upwards and outwards to allow breathing to occur. It should all be nice and relaxed and in a controlled manner.
You are also taking a look at the chest and looking at the respiratory pattern. In other words, does one side go up in a different matter to the other side, or are they coming up simultaneously? Nicely like that together at the same time. As well as falling. So inspiratory and expiratory.
And then finally, we are considering added sounds. Now, later on you’ll be taught how to check. In other words, putting the stethoscope onto the patient’s chest and listening for the added sounds. But it goes outside this lecture to be covering those. But you do need to consider added sounds when you’re doing a respiratory system assessment, and by added sounds all we mean is any type of sound that is not air.
One of the other really useful vital signs is temperature. Now we consider normal temperature to be between 36.5 and 37.5 degrees Celsius. Now this is really, really important because let’s say for example, you’re called to somebody with chest pains. You’re going to get a lot of that in the state ambulance services. You’ll also get a lot of that where ever else you’re working, because it’s a common presentation.
Now let’s say the person describes their chest pain as sharp and stabbing, and … It’s sharp and stabbing and it’s worse when I breathe in. Now, using a thermometer to be able to take the core body temperature is crucial because for me as an experienced paramedic, if somebody tells me their chest pain is sharp and stabbing, I’m going to immediately think some kind of chest infection, maybe pleurisy, maybe pneumonia, maybe some other type of chest infection where there’s an inflammation of the lung somewhere. But the temperature really is the piece of equipment that’s going to help me to really determine that’s really the cause.
Now, on the workshop you’ll be able to learn how to use this, and all you really do is put a probe over the cover. Sometimes you have to turn it on, do a bit of tragus to pull the ear upwards, place it into the ear canal, press the button, and it gives you a nice core body temperature.
Now, when I touch my forehead like this, or touch my peripheries, that’s what we call the peripheral temperature. But the good thing about this thermomix temperature is that it’s recording the core temperature. So it’s a really good piece of kit to measure the body’s internal temperature.
Now, blood glucometry is also a really, really important assessment task that you will use. Now, a normal blood sugar level should be on or above 4 Mmol/liter. Now, you do have to use this in a really careful and considered way. So for example, using the previous case study I gave, if your patient is laying in a semi-comatose state and they’re pale and sweaty and clammy, once I’ve done my primary survey, which will involve airway, breathing, circulation, I may need to give them some oxygen first.
I may need to put and oropharyngeal layaway in their mouth if they’re unconscious. One of the next things I will do is to do a blood glucometry assessment because in my experiences and through the texts that I’ve read and all the learning that I’ve done, I know that patients with low blood sugar do present in a cold, clammy aggravated state.
So once you’ve determined that the blood sugar is below 4, then you can actually treat it. Now, some texts will tell you that a sugar above 10. A blood glucose level or blood sugar level above 10 should also be treated, but pre-hospital, the typical treatment for hyperglycemia is really sodium chloride, which will allow you to dilute the sugar if your service allows you to do it and it’s in your scope of practice. Now, treating with sodium chloride, as I’ve said, does dilute the sugar, but it also allows the replacement of fluid as well because these patients are usually dehydrated because they’re excreting a lot of sugar.
And then blood pressure. Blood pressure is a really, really important skill to have. And like all the other skills we’re talking about here, it’s a skill that you will develop over time. Now typically, a blood pressure is 120/80. 120 is what we call the systolic blood pressure, systolic just meaning contractions. And diastole, which is your 80 or your diastolic blood pressure, meaning relaxation. Now these guidelines are up for changing at the moment. So it could be that this changes into the future.
Now, a low blood pressure is considered to be 90 mmHg. That’s what mmHg stands for, millimeters of mercury, and that’s the pressure rating. But it’s not as simple as just saying, “Yep. 90 is a low blood pressure,” because, of course, it depends if the patient presents with symptoms. Many of us do automatically have low blood pressures, but our bodies tolerate it.
You just have to remember here that every single organ you have needs a certain amount of pressure to push the blood into it, and that’s called the mean arterial pressure. So if your patient’s got a blood pressure of 90 mmHg and they’re fine and they’re living their life, then that’s not really low for them. So you have to not just treat the numbers but treat the whole patient.
Now, a high blood pressure, according to the Royal Australian Colleges of GPs is considered to be 140/90. So anything over 139/89 is considered high. And again, there’s different types of high. So in the context of patient assessment, you wouldn’t go rushing this patient under blue lights to hospital. But instead you’d ask them lots of different things in their history.
So what we’ve done in this session is recognize the importance of undertaking vital signs assessments, help you to identify the different types of assessment that form the vital sign surveys, know when to do it.
That’s a work in progress with your crew mate and your patient. Recognise a range of vital signs considered to be within normal limits. Now, of course, with all of this, there is an expectation that you do undertake your own readings and you get lots of practice in the skills labs when you arrive at the college and try not to be a passive participant. I’d be an active participant when you get to the college.