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SWC W1 Vitals Heep
Western Clinical Sciences, SOAP and VItals, Heep, Bastyr
| Question | Answer |
|---|---|
| What does SOAP stand for?: | S:// Subjective: Interview/Health History O:// Objective: Physical Exam A:// Assessment: Differential Diagnoses, Working Diagnosis P:// Plan: Today’s treatment, case management |
| What do you include for Subjective Health History? | Date (& time) Time of visit should be documented in urgent/emergent situations Identifying Data age, gender, occupation, marital status… Source of History Patient, family member, friend Source of referral network, reports Chief Complaint/Present |
| Describe Chief Complaint: | One or more symptoms or concerns causing the patient to seek care |
| Do you make a diagnosis during chief complaint? | Do not make a diagnosis here! Use patient’s own words. Seen in chart as “CC” |
| Describe Seven Attributes: | Also known as “history of present illness (HPI)” Amplifies chief complaint Location Quality Quantity/severity Timing: Onset, duration, frequency Aggravation/Alleviation Setting Associated Symptoms or OLD CART / OPQRST |
| Describe OLDCART: | OLD CART: onset, location, duration, character, aggravating/alleviating factors, radiation, timing |
| Describe OPQRST | :OPQRST: onset, palliating/provoking factors, quality, radiation, |
| When do you review the Medications and supplements list? | Medications and supplements list reviewed every visit. If they bring in a list, review it with patient, sign and date it, and put in chart with the visit |
| What do you include with past medical history? | Childhood illnesses Surgeries Hospitalizations Immunization Adult illness |
| Describe Adult Illnesses: | Medical – medical conditions past and present Surgical – include dates OB/GYN Psychiatric |
| What constitutes Family History? | Cause of death of family members Focus on specific illnesses in the family such as: DM HTN CVD |
| Describe Personal and Social History: | Personal and Social history Education, Employment, hobbies Relationships, social support Exercise, diet |
| Describe Objective: | Objective= Physical Exam Tongue and Pulse |
| Describe Assessment: | Assessment= Diagnosis (Dx) Differential Diagnoses (DDx) |
| Describe Plan: | Plan for treatment and Follow up plan |
| What must every page include? | Every page must include: Name of patient DOB Date of service Practitioner name |
| Is a SOAP chart a legal document? | yes. it is a Legal document |
| How do you correct mistakes? | Strikethrough mistakes only – no erasing, scratching out. Initial any changes! |
| Do you sign every chart? | YES! Sign and date at the end of each chart. |
| What Vitals do you take? | Height Weight HR BP Respiratory Rate Temperature |
| How do you take Height? | Height in cm or inch. Should be measured from back of heel to the highest point of head – back straight against wall. For kids: lie supine on table, mark head and heel, then measure distance between marks. |
| How do you take Weight? | Tare Weight in Kg or lbs Remove heavy shoes and clothing beforehand |
| Describe BMI? | Body mass index (BMI), based on age height and weight, does not take muscle mass into account. Normal: 18.5-24.9 Underweight, < 18.5 Overweight: 25-29 Obese: ≥ 30 --Class 1: 30- 34.9 --Class 2: 35- 39.9 Extreme obesity: ≥ 40 Bates 10th ed. page 10 |
| What is the formula to calculate BMI: | Formula to calculate BMI: Multiply weight (in lbs) by 700 Divide the result by height (in inches) Divide the result by height (in inches) The final number would be the BMI |
| What two factors are important about Heart Rate? | Rate and Rhythm |
| Describe Rate: | Rate = bpm Normals: Adults 60-100 bpm Adult Males: about 72 bpm Adult Females: 76 to 80 bpm Elderly: 50 to 65 bpm Newborns: up to 140 Children: about 90 bpm |
| Describe different types of heart rhythm: | Rhythm: regular, irregular, r-ir, ir-ir. |
| Where do you measure heart rate? | Palpate both sides. Measured at the radial, carotid or femoral |
| What do you observe with Respiratory Rate? | Observe rate, rhythm, depth, effort of breathing Indirect measurement Normal: 12- 18 rpm Even, unlabored, respiratory distress (using accessory respiratory muscles)… 30 secs x 2 = respiratory rate. |
| Where do you take temperature? | Places to take temperature: Oral / Rectal / Axillary / Tympanic membrane |
| What is average body temperature? | Average body temperature is about 98.6º F (or 37º C). Temperature varies from 1 to 2º F (.5 to 1º Celsius) throughout the day. Temperature is usually low in the morning and increases during the day, going up in the late afternoon or evening. |
| What is the most accurate temperatures from best to worst? | Rectal>Oral>Axillary |
| Define Fever: | Fever/Pyrexia; Above Normal body temperature |
| Define hyperpyrexia: | Hyperpyrexia is a fever ≥106º F (41.1º C); |
| Define Hypothermia: | Hypothermia is body temperature ≤ 95º F (35º C) (rectal). |
| What does the BP reflect? | Blood pressure (BP) is the pressure exerted by circulating blood upon the walls of blood vessels, and is one of the principal vital signs. |
| Define Systolic Blood Pressure: | Systolic Blood Pressure is the maximum amount of pressure exerted by the heart on the arteries. |
| Define Diastolic Blood Pressure: | Diastolic Blood Pressure is the minimum amount of blood pressure held in the arteries. |
| What organs are affected by high BP? | Organs with more capillaries are effected first. Eyes: Retinopathy Kidneys: Nephropathy Heart: Cardiomyopathy Brain: Stroke |
| What is normal blood pressure? | <Systolic 120 / diastolic <180 |
| What is prehypertension blood pressure? | Systolic 120-139 / diastolic 80-89 |
| What is Stage 1 hypertension? | systolic 140-159 / diastolic 90-99 |
| What is Stage 2 hypertension? | systolic > 160 / diastolic > 100 |
| What we use to measure BP? | Proper blood pressure cuff (Sphygmomanometer) Stethoscope |
| Where do we measure it? | Brachial artery and Popliteal artery |
| How do we measure it? | Listen to Korotkoff sounds (turbulent and laminar flow) Use the bell of your stethoscope |
| Describe Orthostatic hypotension | Hypotension of blood pressure when a person stands up. BP and HR measured after sitting/supine for 10 minutes, then within 2 minutes of standing |
| What is normal Orthostatic blood pressure? | Normal orthostatic pressure shows no change or slight drop in systolic, slight increase in diastolic |
| What bp shows Orthostatic Hypotension? | Sys drops ≥ 20 mm Hg or Dias drops ≥ 10 mm Hg |
| Describe accompanied symptoms of orthostatic hypotension: | Accompanied symptoms: dizziness, faintness or lightheadedness which appear only on standing, and which are caused by low blood pressure |
| Causes of Orthostatic Hypotension} | Cardiogenic factors Low Blood volume Adrenal insufficiency Neurogenic |
| Describe Cardiogenic factors of Orthostatic Hypotension | Cardiogenic factors: not able to increase heart rate. |
| Describe Low Blood Volume factors of Orthostatic Hypotension | Low Blood volume: (anemia, dehydration) |
| Describe Adrenal insufficiency factors of Orthostatic Hypotension | Adrenal insufficiency: (adrenal glands not able to produce chemicals necessary to increase heart rate and blood pressure.) |
| Describe Neurogenic factors of Orthostatic Hypotension | Neurogenic: (inability of the nervous system to signal change in BP, Parkinson’s, Diabetes) |
Created by:
bastyr41
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