A vital signs survey is completed to establish a baseline of the patients condition in order to determine time criticality and identify emerging trends. A full set of vital signs should be obtained early and should be repeated at regular intervals as appropriate for patient’s condition.
The following are a list of vital signs, some of which are mandatory in ePCR, others may need to be assessed based upon clinical presentation and scope of practice:
Once vital signs have been obtained, an Early Warning Score should be calculated based on the Recognising and Responding to Acute Deterioration guideline, and any patient meeting an escalation level should have appropriate action taken.
History gathering is an important skill. Through appropriate questioning and investigation, crucial information may be gathered to assist in patient management. It is very important to be objective so as to avoid tunnel vision.
Develop your own method of questioning that will assist in producing the information listed below:
Assess complaints and signs and symptoms using OPQRST mnemonic:
|Onset||Was onset of symptoms fast or slow?|
|Pain||When did the pain start? Was it sudden or gradual? What were you doing when the pain started?|
|Quality||What words would you use to describe your pain?|
|Radiates||Point to the area that hurts the most, where does it go from there?|
|Severity||Use the PAINLOG™ as the determination of severity of pain levels or if PAINLOG™ not available verbally ask pain level e.g. on a scale of 0 - 10, 0 being no pain and 10 the worst pain imaginable, what is your pain level.|
|Treatment / Tablets||What treatment (if any) are you receiving from your doctor/hospital? What tablets (if any) have you been prescribed? Are you taking any other tablets?|
Obtain patients pertinent medical history using SAMPLE mnemonic:
|Signs and Symptoms||What can be seen? What is the patient complaining of?|
|Allergies||Do you have any allergies?|
|Medications||Are you taking any prescribed medication(s)?|
|Pertinent History||Do you have any i.e. cardiac problems / diabetes?|
|Last oral intake||What was the last time food or drink was consumed?|
|Events leading up to...||How and when did it occur? Has it occurred before?|
For Trauma gather information relating to the Mechanism of Injury.
Past Medical History