The Respiratory System
Normal Vital signs for an average: Male, Female, Child & Infant. It should also be noted that Body temperature reflects that of taken Orally, NOT Rectal.
One of the most important vital signs is the patient’s blood pressure: the amount of pressure that the surging blood exerts against the arterial walls. Blood pressure (BP) is an index of the efficiency of the complete circulatory system. The sphygmomanometer (blood pres- sure cuff) is the instrument used to measure blood pressure. Blood pressure normally varies with the age, sex, and medical history of an individual. The usual guide for systolic pressure in the male is 100 plus the individual’s age, up to 140-150 mm Hg. Normal diastolic pressure in the male is 66-90 mm Hg. Both the systolic and the diastolic pressures are 8-10 mm Hg lower in the female than in the male. Blood pressure is reported as systolic/diastolic as in 120/80 mm Hg (millimeters of mercury) The result of contraction of the heart which forces blood through the arteries is called systolic pres- sure. The result of relaxation of the heart between contractions is called diastolic pres- sure. All Patients should be taught how to take blood pressures, but many do not realize that it is not unusual for a patient’s blood pressure to vary from 24 to 34 mm Hg (both diastolic and systolic) between the first reading at the accident scene and the reading at the hospital emergency room. The blood pressure may actually change as a result of medication, but the problem may be the sphygmomanometer, the person taking it, or both! Blood pressure readings may also fluctuate from the right to the left arm for a number of reasons. Record the pressure accurately so that the receiving physician can tell how much it has changed since you first saw the patient.
To take a blood pressure:
- Fasten the cuff of the sphygmomanometer on either arm above the elbow. Apply the cuff on the arm one inch above the anterior crease of the elbow with the bladder can- centered over the brachial artery, then wrap snugly. (Proper size of BP cuff is deter- mined as follows: Bladder of the cuff should cover one half (1/2) of the arm cir- conference. If not, a larger or smaller BP cuff will need to be used.)
- Now inflate the cuff rapidly with the rubber bulb while palpating the radial pulse until it cannot be felt. Make a mental note of the reading (as this may be the only BP recorded). This is known as the pulse obliteration method. Without stopping, continue to inflate the cuff to 30 mm above the level where the pulse was obliterated (cannot be felt).
- Apply the stethoscope. Place the diaphragm of the stethoscope over the brachial artery at the antecubital fossa (artery on the medial anterior surface). The diaphragm may be held with the thumb. Deflate the cuff at approximately 2 mm per second (faster if skill permits), watching the mercury column or needle indicator drop.
- Record as the systolic level the point on the gauge when you hear the first pulse sounds.
- Continue releasing air from the bulb. Re- cord the diastolic level as the last sound is heard. The point at which the pulse sounds disappear is the diastolic pressure. Continue to deflate slowly for at least 10 mm. Note: Slow pulses require slower-than- normal rates of deflation.
- Record the limb on which the BP was taken. Record the position of the person when the BP was taken if other than supine. Record the size of the cuff if other than standard.
If, in an emergency situation, a BP cuff and stethoscope were not available, you could quickly establish an idea of the approximate blood pressure by palpating the different pulses and using the following rule of thumb: If the radial pulse is palpable, the blood pressure is at least 80 systolic. If the brachial pulse is palpable, the blood pressure is at least 70 systolic. If the femoral pulse is palpable, the blood pressure is at least 60 systolic. If the carotid pulse is palpable, the blood pressure is at least 50 systolic.
To assess a patient’s pulse, you can auscultate at the heart’s apex with a stethoscope or palpate a peripheral pulse with your fingers. Although either method can determine heart rate [beats per minute], auscultation
proves superior for assessing heart rhythm (regularity). You can palpate or auscultate the pulse in various locations. [For an illustration of these locations, see
Locating pulse sites]. Typically, you assess the radial pulse because of its easy accessibility. To do this, palpate the radial artery with the pads of your index and middle fingers for 60 seconds while compressing the artery gently against the radial bone. Don’t use your thumb because it has a pulse of its own that you could confuse with the patient’s pulse. Although some practitioners count the pulse for 15 seconds and multiply by 4, avoid this practice, especially if the patient doesn’t have a normal heart rate and rhythm. If you have trouble distinguishing a faint peripheral pulse from your own pulse, check another site. Amplitude and rhythm As you obtain the pulse rate, also assess pulse amplitude and rhythm. Document pulse amplitude (which reflects the strength of left ventricular contractions) by using a numerical scale or a descriptive term. Different health care facilities may use numerical scales that differ slightly. If you use a numerical scale, make sure it corresponds to the one used in your facility or by your colleagues. The scale below, along with the corresponding descriptions of pulse amplitude, is among the most commonly used.
Remember, only + 2 describes a normal pulse.
- + 3 = bounding – readily palpable, forceful, not easily obliterated by finger-pressure
- + 2 = normal- easily palpable and obliterated only by strong finger-pressure
- + 1= weak or thready, hard to feel and easily obliterated by slight finger-pressure
- O = absent-not discernible When you assess pulse rhythm, you evaluate the regularity of the electrical conduction of the heart.
Check the rhythm as you count the pulse rate for 60 seconds. Normally, rhythm should be regular, with roughly the same interval between pulsations. If you detect an irregular rhythm, describe its pattern. Also auscultate the apical area and palpate the radial area simultaneously to identify a potential pulse deficit [difference between the two pulse rates].
A pulse deficit occurs when a premature heartbeat can’t produce the wave of blood needed to fill the Arteries- thus, peripheral radial artery pressure is too low to palpate every heartbeat. To calculate a pulse deficit, have another nurse record one pulse rate while you.
Respiration. When assessing respiration, focus on the rate, depth, and rhythm of each breath. To determine the respiratory rate, count the number of respirations for 60 seconds. (One respiration consists of an inspiration and an expiration.) Do this as unobtrusively as possible – a patient who knows that you’re counting respirations may inadvertently alter the rate. In one unobtrusive method, hold the patient’s wrist against his chest or abdomen as if checking the pulse rate. If respirations are too shallow to see a rise and fall of the chest wall, hold the back of your hand next to the patient’s nose and mouth to feel expirations. To estimate respiratory depth, observe the chest as it rises and falls, and assess the effort required to breathe. Respirations should be quiet and easy. Note any abnormal breath sounds, such as wheezing. Describe respirations as shallow, moderate, or deep. As you assess the respiratory rate and depth, note the respiratory rhythm, or pattern. Irregular rhythms in children or adults, such as Blot’s or Cheyne-Stokes respirations, commonly result from NEUROLOGIC disorders.
The first step of basic life support is to:
Actually determine whether the patient is breathing on his own. In some cases this will be evident, such as when a patient is gasping. At other times, you will need to carefully assess the patient’s condition.
To quickly determine whether the patient is breathing, follow these steps:
- Find out if the patient is conscious. Gently try to arouse him by shaking his shoulder, leg, or foot. Speak loudly to him. If he does not respond, lightly scratch the palm of his hand with a pin or needle, or rub his sternum with your knuckles. If he does not respond to pain, he is unconscious.
- Position the patient on his back. Do this only if cervical or spinal injury can be ruled out and if the patient is not already lying on his back. If you suspect spinal injury, determine respirations and heartbeat if possible, then find help and roll the patient as a unit (head and neck in alignment) onto his back.
- Open the airway. Head Tilt This is the most important step in opening the airway. Place the palm of one hand on the patient’s forehead. Apply firm, backward pressure, tipping the patient’s head backward as far as possible. Additional assistance is gained by using either the neck lift or chin lift, performed with the other hand.
It has been known for twenty years that head tilt-chin lift offers a better opening of the airway than head tilt-neck lift. The American Heart Association has not emphasized this for fear of confusing the issue. The 1979 National Conference on CPR recognized that the chin lift is superior in some ways and may eventually supersede the neck lift; however, the proven efficacy of the head tilt-chin lift and worldwide acceptance of this sequence was also appreciated.
It was recommended that:
- the two techniques be accepted as alternatives
- chin lift be emphasized as having certain advantages that may eventually make it the approach of choice; have had a previous episode of pulmonary embolism
With the answers to these questions, you should obtain a general idea of the patient’s problem. The physical assessment will enable you to check your hypotheses and gain further information.
By the time you complete the history, you will already have some important information about the patient’s physical signs. Did he appear anxious, uncomfortable, in distress! Did his dyspnea cause him difficulty in speaking? Did he have to stop to catch his breath? Or did your questions easily distract him from his symptoms? What position did he assume? Was he lying down or sitting very upright, straining to breathe? Did his answers Co your questions seem appropriate and coherent, or was he confused and disoriented! By making such observations, you are per- forming the preliminary steps of the physical assessment — that is, assessment of the patient’s general appearance and mental status. The patient in severe respiratory distress is frightened and intensely uncomfortable; he is usually sitting upright, and he may be gasping or laboring to breathe. Confusion and disorientation may also be evident. Injury often causes the patient to breathe up to twice the normal rate (twenty-four to twenty-eight times per minute). If an injury patient is breathing under the normal rate, he most likely has problems in the airway, diaphragm, lungs, chest wall, and or central nervous system. After completing your primary survey, take the patient’s vital signs. Pay particular attention to the breathing. Are the respirations abnormally rapid [tachypnea] or unusually deep [hyperpnea]? Is the respiratory pattern abnormal such as the Cheyne-Stokes respirations, consisting of rhythmic waxing and waning of the depth of breathing with periods of absent breathing suggesting a disorder in the central nervous system? An irregular respiratory pattern may be associated with severe head injuries.
Look for the signs of respiratory distress, which include:
- Nasal flaring: the nostrils open wide during inhalation.
- Tracheal tugging: the Adam’s apple is pulled upward during inhalation.
- Retraction of intercostal muscles (those between the ribs) during inhalation.
- Use of the diaphragm and neck muscles to assist in inhalation.
- Use of the abdominal muscles during exhalation.
- Cyanosis (bluish discoloration of the skin and mucous membranes).
- And Hands grasping at the throat & Neck (classic)
Cricothyrotomy consists of the insertion of a knife through the cricothyroid membrane. A horizontal incision of less than one-half inch is usually performed . The handle of the knife is inserted into the incision and rotated 90″ to maintain the patency of the opening, but it is usually necessary to insert a tubular device such as a small leg, 4 mm internal diameter) endotracheal tube or metal cannula. This may be attached to a bag-valve or other such device for providing positive-pressure ventilation with high oxygen concentrations. This should only be performed by a trained & qualified person.
Remember to call 911
Remember! Brain Death can occur after only 4 minutes.
Medical & Trauma
Common Poisonous Plants
If you should come in contact with these plants: Wash with soap and water being careful not to spread the affected area to the eyes or face, or any other part of your body. Wash your clothes thoroughly.
Appearance of plant: slightly glossy green leaves, growing in groups of three; flowers and berries, when present, are greenish-white; grows as either a trailing vine or erect shrub; most common in eastern and central United States. Symptoms of reaction: initial redness of affected area, followed by development of bumps and blisters; oozing lesions appear and crust over; severe itching accompanies symptoms; symptoms appear anywhere from four to seventy-two hours after exposure and are usually self-limiting. Emergency care: wash skin and clothing with soap and water, making sure all sap is removed; wipe skin with solution of 70 percent alcohol; in self-care use wet compresses of cold water, boric acid, or liquid aluminum acetate to relieve inflammation while lesions are oozing; use calamine location to relieve itching; obtain allergy shots if you are in constant contact with plants or if symptoms are severe.
Appearance ofplant: green leaves, slightly glossy, shaped like oak leaves; plant usually grows in shrub like clusters; found on west coast of the North American continent. Symptoms of reaction: same as for poison ivy. Emergency care: same as for poison ivy.
Appearance of plant: found chiefly in uninhabited areas, such as swamps and damp mountain terrain; leaves grow singly, and are veined; berries are green and drooping (harmless sumac have erect, red berries); grows as a tree, achieving heights of five to six feet. Symptoms of reaction: same as for poison ivy. Emergency care: same as for poison ivy.
Potentially Poisonous Insects
All Insects below, including Bees and Wasps, can cause a severe allergic reaction (Anaphylactic Shock) in some people if bitten or stung. If you start to feel an allergic reaction coming on, Call 911 Immediately.
Symptoms of Anaphylactic Shock: Severe itching, Redness or Blotching of the skin, Breathing Problems, A Choking sensation in your throat, Light-Headiness, Swelling of the Hands, Face and Extremities, Nausea and Vomiting, and in some cases a feeling of Impending Doom. Patients susceptible to Bee Stings and or have had Anaphylactic Shock in the past, Should carry a Bee Sting Kit. The kit contains a syringe filled with Epinephrine 1:1000 and usually a tablet of some sort of antihistamine. Contact your Doctor to get a prescription for one if you think you are susceptible.
Ticks are small arthropods belonging to the spider class (arachnids) that feed on blood and transmit diseases, such as Lyme disease, Tularemia, and Rocky Mountain spotted fever, through their bites. The prolonged bite of a certain female tick can cause ascending paralysis, a condition in which a toxin in the tick’s saliva affects the motor neurons. The paralysis usually begins in the legs, which is usually the site of the bite. In severe cases, this can lead to paralysis of the respiratory muscles and can be fatal. Ticks are found in grass and weeds and attach themselves to the exposed skin of the host. As the female tick engorges herself with blood, she swells and turns red or purple in color. The male tick generally remains unchanged. There are two categories of ticks: hard ticks and soft ticks. Hard ticks have a hard shield on their back and may attach themselves to the host for days. Soft ticks are nocturnal and attach themselves to the host for short periods of time. Ticks should be encouraged to drop off by placing a drop of alcohol or ether on the tick or coating it with petroleum or nail polish. If a tick is pulled off forcibly, its mouthparts may be left behind and cause infection.
Lice are small insects, about 1/8th of an inch (3 mm) in length, that feed on blood. Three species of lice affect humans: Pediculosis humanus capitis (head lice), Pediculosis humanus corpus (body lice), and Phthirus Pubis (pubic lice, commonly known as crabs). Lice cause dermatitis (severe skin irritation and inflammation) and, in some cases, transmit disease. The microorganisms that cause typhus, lapsing fever, and trench fever are transmitted to human hosts through the saliva of the lice. The Pediculosis capitis lice infest and feed on blood from the scalp. They infest people of all social classes. The lice are transferred form person to person through contact with infested hair or use of a comb, towel, hats, and hair ornaments of an infected person. The bites cause severe itching and scratching can lead to a secondary infection. The adult lice live for several weeks. The adult females lay eggs, called nits, that are firmly attached to the shaft of the hair. The eggs hatch in about two weeks. Head lice can be treated with lotions or shampoos containing malathion or carbaryl, which kill the lice and nits (eggs). The dead lice and nits must be removed with a special comb. The Pediculosis corpus lice infest the entire body. They infest people who do not change and launder their clothes regularly and do not practice good hygiene. When the lice feed on the blood of the host, they leave small red marks that itch. Scratching may lead to a secondary bacterial infection. Body lice often transmit epidemic diseases. The lice are transferred from person to person through infested clothing or bedding. The lice live in the seams. Proper hygienic practices and laundering clothes with very hot water (140 degrees Fahrenheit- 60 degrees Celsius) will kill the lice, although the nits remain viable for as long as a month. They hatch when they come into contact with body heat. Body lice can be treated with lotions containing malathion or carbaryl, which kill the lice and their nits (eggs). The dead lice and nits must be removed with a special comb. The Phthirus pubis lice infest the area of the genitals causing severe irritation. They are passed from person to person through sexual contact or from infested clothing and linen. This form of lice is often referred to as crabs because of their crab-like claws. Pubic lice can be treated with lotions or shampoos containing malathion or carbaryl, which kill the lice and nits (eggs). The dead lice and nits must be removed with a special comb. Prolonged use of these chemicals, however, can cause irritation to these sensitive areas of skin. An infested person’s sexual partner should also be treated. After consulting with your doctor or pharmacist for the best treatment plan, remember to use the delousing agents exactly as directed. The usual steps are: thoroughly scrub the infected area; apply the medication and leave it on for the recommended amount of time; rinse the area to remove the medicine; when the hair is dry comb out the nits with a nit comb; and repeat the treatment in another week to kill any newly hatched eggs that survived. It is important to consult your physician or pharmacist before using any over-the-counter drugs or treatments. They will be able to advise you on proper usage and can warn you of possible side effects and contraindications.
Chiggers, also called harvest mites or red mites, are the larvae of trombicula mites and are found among the grass and weeds. Mites are arachnids, small eight-legged animals. They are less than 1/20 of an inch (1.2 mm) long. Mites attach themselves to exposed parts of the skin of the host and feed on the blood. The mouthparts are specially adapted for piercing the skin. When they bite, they promote an allergic reaction that causes a swelling about a half-inch in diameter that itches. The swelling may develop into a blister. Chiggers stick to the skin and cause irritation and severe itching.
Fleas are small insects, only about 0.1 inches in length. They are of the order Siphonaptera and feed solely on the blood of mammals and birds. More than two hundred different species of fleas can be found in the United States. Fleas cause irritation to the skin through their bite. They have specially adapted mouths to puncture the skin of the host and feed on the blood. The bites cause temporary pain and itching, although some people have a severe allergic reaction to them. Flea bites are characterized by a rash or small red blotches and bumps at the site of the bites. Scratching the rash can lead to secondary bacterial infection. In some instances, fleas transmit disease, such as bubonic plague, and murine typhus, through their bites. The virus that causes bubonic plague is carried by rats and transmitted to humans by fleas, specifically the Xenopsylla cheopis flea. The bubonic plague killed millions of people during the middle ages. Advancements in sanitation methods, pest control, and better public hygiene practices have reduced the episodes of plague caused by fleas. The flea Pulex irritans is a species of fleas parasitic on the skin of humans. It is a host to the larval stage of Dipylidium caninum, a species of tapeworm found primarily in dogs. The larva and, thus, the tapeworm is passed on to humans by the fleas. The flea ingests the larvae by feeding on the blood of an infected dog. The larvae are passed to the human host through the saliva of the flea when it bites the new host. The larvae enter the bloodstream of the human host and travel to the lungs. They then ascend the respiratory tract to the mouth where they are swallowed. The larvae mature in the intestine and compete with the host for nutrients. The adult female deposits eggs in the intestine. The eggs are excreted with feces, although some enter the bloodstream and begin the cycle again.
Other insects shown above (such as the black widow spider) can cause you to become very sick, and with the Brown Recluse Spider, a very dangerous ulceration can occur. Seek Medical attention as soon as possible!
Deer Tick’s can carry LYME Disease. Have your Doctor check you for LYME Disease if you have been bitten by a Tick. For poisonous bites or stings, a constrictive band can be placed apx 2 inches above the bite making sure that it is tight enough to only limit Venous blood flow. You can check this by making sure that you can place your pinky finger snugly under the constricting band. If you can not slide your finger under! The band is to tight. A constricting band can be made from a piece of string or clothing material. Remember do not use a tourniquet.
First-degree burns are caused by a flash, a flame, or the sun. They are the most common and the most minor of all burns. The skin surface is dry; no blisters or swelling occur. The skin is reddened and extremely painful, but the epidermal layer is the only one affected. First-degree burns heal in two to five days with no scarring. Peeling of the outer epidermal layer usually occurs, and some temporary discoloration may result.
Second-degree burns result from contact with hot liquids or solids, flash or fame contact with clothing, direct fame from fires, and contact with chemical substances. The skin appears moist and mottled, and it ranges in color from white to cherry red. The burned area is extremely painful. The epidermis and dermal layers of skin are usually burned, and damage may result to some fat domes of the subcutaneous (fatty tissue lust under the skin) layer. Second-degree burns are considered minor if they involve less than 15 percent of the body surface in adults and less than 10 percent in children. Fifteen to 30 percent of adult body surface and 10 to 20 percent of a child’s body surface indicates a moderate second degree burn. The burn is also considered moderate if it involves the face, hands, feet, or genital area. A second-degree burn is considered critical if it involves more than 30 percent of the total body surface in an adult and 20 percent in a child. Healing of a minor second-degree burn usually requires five to twenty-one days. If infection occurs, healing time is extended to over thirty-five days, and the burn is con- sidered third-degree.
Third-degree, or full-thickness burns, are the most serious, resulting from contact with hot liquids or solids, flame, chemicals, or electricity. The skin becomes dry and leathery; charred blood vessels are often visible. The skin is a mixture of colors: white (waxy- pearly), dark (khaki-mahogany), and charred. The patient feels little or no pain, because the nerve endings have been destroyed. Hair pulls out easily with no pain. The burn extends through all dermal layers and can involve subcutaneous layers, muscles, organs, and bone. Third-degree burns are considered minor if they occur on less than 2 percent of the body surface. Moderate burns involve 2 to 10 per- cent of the body surface. Third-degree burns are classified as critical if they occur on more than 10 percent of the total body surface, if there is any involvement of the face, hands, feet, or genital area, or if the burns are caused by chemicals or electricity. Third-degree burns that cover large areas usually require skin grafting and take months or years to heal completely; small areas require weeks.
- Do not put anything on the burn. Tell the caller that under no circumstance should grease, oil, ointment, butter, or any other substance be applied to the burn.
- Remove all clothing and jewelry from the burned area. Instruct the caller not to pull off any item that is sticking to the skin but to remove any clothing or jewelry that might be dangerous if swelling should occur. Also make sure that any jewelry that might conduct heat is removed promptly.
- Immediately immerse the burned area in cool water. In addition to providing pain relief, cool water can stop the spread of the heat damage to surrounding tissues. Make sure that the patient does not get immersed in ice water — the rapid temperature extreme can cause severe complications. Direct application of ice to the burn can cause frostbite and complicate the severity of the burn. Tell the caller to halt the application of cool water after thirty minutes. Further treatment by immersion is ineffective and may actually lead to complications, such as causing a chill that may induce shock.
- Leave the burn uncovered if possible. Stress that the burn will heal more rapidly and more completely if it is not covered. If a dressing is necessary, tell the caller to apply only a clean (sterile if possible) cloth and to leave it as loose as possible. Applying constricting bandages will further damage the burned area and may even tear burned skin loose from the body.
- Give the patient emergency care for shock. Even if the patient manifests no signs and symptoms of shock, have him lie down, drink fluids, and stay warm. Such a course of action may prevent any shock that may occur after the burn incident. If the burn is not severe enough to require medical attention or hospitalization, make sure that the patient receives the best care possible, and instruct the caller to consult his physician if any complications occur. If the burn is severe enough to require hospitalization or close medical attention or even if you think that it might require such care, get the Patient to the Hospital as quickly as possible.