Baseline Vitals and SAMPLE History Company Drill

Baseline Vitals and Sample History Company Drill Motivation The Baseline Vitals and SAMPLE History are part of the essential information necessary to obtain and document in order to give a patient the best possible care in the field. This...


  3. Systolic pressure usually parallels pulse rate

     (When pulse rate increases, systolic does also)

  4. Systolic reading is always an even number – if reading falls between two lines use the higher 

      reading

C. Diastolic – pressure remaining in the arteries when the left ventricle of the heart relaxes and refills

  1. Lower number read when taking a blood pressure

  2. Second number given when reporting a blood pressure

  3. Diastolic reading is always an even number – if reading falls between two lines use the higher

      number

D. High blood pressure causes

  1. Medical condition

  2. Exertion

  3. Fright

  4. Emotional distress or excitement

E. Low

  1. Athlete or other person with normally low blood pressure

  2. Blood loss

  3. Late sign of shock

F. Demonstrate obtaining a blood pressure

  1. Auscultation method

      a. Reading sphygmomanometer

      b. Placement of cuff

      c. Stethoscope placement

            i. Ear placement

            ii. Arm placement

  2. Palpation method

      a. Cuff placement

      b. Hand placement

      c. Inflate cuff 30 mm of mercury above point where you no longer feel a radial pulse

      d. Deflate cuff slowly

      e. Note reading at which the radial pulse returns

      f. This reading is the systolic reading

G. Demonstrate documenting a blood pressure

 

VII. SAMPLE History (2-1-1)

A. Signs/Symptoms

  1. Why did you call 911

  2. What is wrong

  3. Document

B. Allergies

  1. Medications

  2. Foods

  3. Environment

  4. Medical ID tag explaining allergies

  5. Document

C. Medications

  1. Medications currently taking

      a. Prescribed

      b. Over the counter

      c. Recreational

  2. If patient answers yes, ask:

      a. Name of medication

      b. Dosage and how often taken

      c. Why they are taking

      d. Was the medication taken today and when

      e. After taking was there any relief or change in symptoms

  3. Document

D. Pertinent past history

  1. Currently being treated for any illness

  2. Have you been feeling ill

  3. Any recent surgeries or injuries

  4. Have you been seeing a doctor

  5. What is your doctor’s name

  6. Document

E. Last oral intake

  1. When did you last eat or drink

  2. What did you eat or drink

  3. Document

F. Events leading to the injury or illness

  1. What were you doing before you began feeling this way

  2. Document

 

Summary

Review:

Properly obtaining and documenting Baseline Vitals and a SAMPLE History

   • Pulse: rate, type, quality

   • Respirations: rate, quality, method of obtaining

   • Skin Color: pink, pale, cyanotic, flushed, jaundiced, mottling

   • Skin temperature and condition: cool/clammy, cold/moist, cold/dry, hot/dry, hot/moist, goose

      pimples, shivering, chattering teeth, blue lips, pale skin

   • Pupil appearance: size, quality, reactivity

   • Blood pressure: systolic, diastolic, auscultation, palpation

   • Signs and symptoms

   • Allergies

   • Medications

   • Past pertinent history

   • Last oral intake

   • Events that lead to problem

Remotivation:

The Baseline Vitals and SAMPLE History are part of the essential information necessary to obtain and document in order to give a patient the best possible care in the field. This information can alert the provider to call for additional resources if necessary and can give those accepting care of the patient at the next level of patient care a good idea of what may be going on inside the patient’s body.