TAKING VITAL SIGNS
Lesson 1: Initial Assessment
1-5. ASSESSING LEVEL OF CONSCIOUSNESS
Level of consciousness should also be assessed upon initial contact with your patient and continuously monitored for changes throughout your contact with the patient.
a. AVPU. The AVPU scale is a rapid method of assessing LOC. The patient's LOC is reported as A, V, P, or U.
(1) A: Alert and oriented.
(a) Signifies orientation to person, place, time, and event. Ask your patient simple open ended questions that can not be answered with yes or no to determine the LOC. For example, “Where are you right now?” and “What time is it?” Do not ask your patient, “Do you know were you are right now?” since this can be answered with a yes or no.
(b) If the patient is alert, you can reported your results as a patient oriented score from 1 (lowest) to 4 (highest), noting any areas not oriented to. For example, you can state the patient is "A and O X 4" (fully alert and oriented) or "A and O x 2 and does not know time and place."
(2) V: Responds to verbal stimulus. This indicates that your patient only responds when verbally prompted. It is also important to note if the patient makes appropriate or inappropriate responses. If you ask your patient, “What is your name?” and he responds with, “Flaming monkeys,” this would be an inappropriate response and shows that although he responds to verbal, he is not appropriately oriented.
(a) Response to normal voice stimuli.
(b) Response to loud voice stimuli.
(3) P: Responds to pain.
(a) Use if patient does not respond to verbal stimuli.
(b) Gently but firmly pinch patient’s skin.
(c) Note if patient moans or withdraws from the stimulus.
(4) U: Unresponsive.
(a) If the patient does not respond to painful stimulus on one side, try the other side.
(b) A patient who remains flaccid without moving or making a sound is unresponsive.
NOTE: Anything below Alert is unconscious; from there we need to determine how
unconscious the patient is. A patient can be unconscious with response to
stimuli or unresponsive.
b. Glasgow Coma Scale. The Glasgow Coma Scale is an assessment based on numeric scoring of a patient’s responses based on the patient's best response to eye opening, verbal response, and motor response. The patient's score (3 to 15) is determined by adding his highest eye opening, verbal response, and motor response scores.
(1) Eye opening (1 to 4 points).
(a) Spontaneous: E4. Eyes are open and focused; the patient can recognize you and follow eye movements.
(b) To voice: E3. The patient opens his eyes when spoken to or when directed to do so.
(c) To pain: E2. The patient opens his eyes when given some sort of painful stimuli.
(d) None: E1.
(2) Verbal response (1 to 5 points).
(a) Oriented: V5. The patient can talk and answer questions about his location, time, and who he is. In some situations, it is also appropriate to question the patient to see if he is oriented to the event that led him to be in his current condition.
(b) Confused: V4. The patient can talk and speak coherently, but is not entirely oriented to person, place, time, and event.
(c) Inappropriate words: V3. The patient answers with some sort of inappropriate response to the question that was asked or answers with excessive use of profanity that is not associated with anger toward the event.
(d) Incomprehensible words: V2. Unintelligible words or sounds.
(e) None: V1
(3) Motor response (1 to 6 points).
(a) Obeys command: M6. The patient can follow appropriate commands or requests. It is also important to asses the patient for the ability to follow commands across the central plane of the body. For example, the command, “Please touch your left shoulder with your right arm,” helps to ensure the patient can cross the hemispheres of the brain
since the left and right sides of the body are controlled by the opposite sides of the brain.
(b) Localizes pain: M5. Can the patient localize the pain that he is feeling? If you elicit a pain response by pinching of squeezing the right side, watch for the patient to reach across with the opposite arms to check for cross body localization.
(c) Withdraws to pain: M4. This indicates a correct pain response. The body should withdraw away from the pain and not towards it.
(d) Flexion (decorticate posturing): M3. This is an abnormal posturing usually caused by severe brain trauma. The body curls into a protective posture by flexing the arms into the chest.
(e) Extension (decerebate posturing): M2. In this form of posturing, the body is abnormally extended. The arms and legs may be extended and very rigid or difficult to move.
(f) None: M1.
c. PEARRL. Use the guide PEARRL when assessing the pupillary response of the patient's eyes.
(1) P: Pupils. Are they both present? What is their general condition?
(2) E: Equal. Are both pupils the same size? Unequal pupils can indicate a head injury causing pressure on the optic nerve. There is a small percent of the population that has unequal pupils normally, so a good patient history is critical.
(3) A: And.
(4) R: Round.
(5) R: Regular in size.
(6) L: React to light. Both eyes should be assessed twice for reaction to light. The first time the light is shined in the right eye, for example, you should watch the right eye for reaction, the second time the left eye should be watched to ensure sympathetic eye movement is present. (both eyes are doing the same thing at the same time).
d. Vital Signs.
(1) The first set of vital signs establishes an important initial measurement of the patient’s condition and serves as a key baseline.
(2) Monitor vital signs for any changes from initial findings throughout care.
(3) Reassess and record vital signs at least every 15 minutes in a stable patient and at least every 5 minutes in an unstable patient.
(4) Reassess and record vital signs after all medical interventions.
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