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Picture

Assessing Vitals: Not As Easy As Pushing A Button

4/28/2014

2 Comments

 
Whenever evaluating a new patient, I always start of my objective portion with a pulse and blood pressure assessment. I've always been leery of using machines to do this due to the frequency with which they provide inaccurate findings. This became even more evident a couple weeks ago. I was assessing a patient's pulse when I noted an abnormal rate. The rhythm was 3 consistent pulses followed by a rest. This pattern continued. I had another PT assess the patient's pulse as well to confirm my findings. The patient denied any previous cardiac issues. Due to the irregularities, I advised the patient to return to his PCP for further assessment and likely cardiologist referral. About a week later, the patient phoned in and said he was going to a cardiologist and would start PT once everything was taken care of.

The reason I bring this up is because a machine does not typically pick this up. When relying on blood pressure machines or pulse-oximeters for heart rate, we often end up just getting the bpm. The actual rhythm is missed. This patient showed no other signs of cardiovascular disease. I'm not saying you shouldn't use machines, but be sure to assess for rhythm and intensity of the pulse as well.
Picture
Expected ECG Findings

The easiest way to explain the heart rhythm is to refer back to an electrocardiogram (ECG - as depicted below). For review, we will go over the basics of an ECG first:

-P Wave: depolarization of atria (starting at the SA node, then spreading out to the atria)
-PR Interval: time it takes for the electrical pulse to get from the SA node to the AV node)
-QRS Complex: depolarization of ventricles (starting at the AV node; re-polarization of atria hidden here)
-T Wave: re-polarization of ventricles

This patient in particular, as you recall, had 3 pulses followed by a pause. This likely signifies a Second Degree AV Block: Mobitz Type I (Wenckebach). This would be depicted at a slowly increasing PR interval, before a lack of QRS complex occurs. The cycle then restarts. Basically this means the signal from the SA node to the AV node slows until it doesn't make it through to initiate ventricular contraction, before the next SA node initiates again to restart the cycle.

If you've ever struggled with interpretting ECG's, I recommend reading this book by Dale Dubin. It provides a step-by-step understanding and asssessment of ECG's along with the associated pathologies, at an MD level. It is an excellent source for reviewing for a CardioPulm course or preparing for the Cardiovascular section of the boards!

-Chris
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2 Comments
Kristin
4/28/2014 09:29:34 am

First off--- thank you all very much for being such a positive representation of our field and to the continuation of our education! Your website has been my homepage for over a year now and I love that it keeps me up to date/reminds me of current topics in PT!

In response to this article, I couldn't agree more on the use of taking vitals manually. My current CI puts a lot of pressure on me when taking BP manually and I've been increasingly understanding why--

It is SO SO important that we make ourselves, our time w/ our patients, and our skills put to good use. We did not attend (and pay) for 7 years of PT school to let machines do our jobs. We need to be able to identify when something is not right, hence our differential diagnosis skills.

In addition to maintaining our skill value as PT's, my CI has helped me to value the time we are able to spend with our pt's. More often than not pt's are in and out w/ their PCP and miss a large majority of 'the story.' Short story to emphasize the importance of manual vitals then I'll end my rant! :) As mentioned before, my CI is so hard on me w/ manual vitals and shared w/ me that he would typically always take vitals on his 'at risk' pt's and the one time he did not, his OP orthopedic pt coded on him during a low intensity ther. ex session and passed away. Naturally he took it very hard and felt that if he would have just monitored his vitals that day he could have prevented this from occurring.

Hopefully this helps to serve as a supplemental piece of information to help others provide optimal inpatient and/or outpatient care for our pt's! Sorry.. I can't be concise in anything, resulting in long rambles of knowledge! Lol! Thank y'all again!


Reply
Chad shafer
4/29/2014 11:42:54 pm

Great article about the importance of taking vitals as part of our examination process. Screening is becoming more important, especially in the states that are awaiting direct access!

Reply



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  • Home
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    • About Insider Access
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    • Return to Sport Essentials Course
  • Resources
    • Newsletter
    • Business Minded Sports Physio Podcast
    • Day in the Life of a Sports PT
    • Residency Corner
    • Special Tests >
      • Cervical Spine >
        • Alar Ligament Test
        • Bakody's Sign
        • Cervical Distraction Test
        • Cervical Rotation Lateral Flexion Test
        • Craniocervical Flexion Test (CCFT)
        • Deep Neck Flexor Endurance Test
        • Posterior-Anterior Segmental Mobility
        • Segmental Mobility
        • Sharp-Purser Test
        • Spurling's Maneuver
        • Transverse Ligament Test
        • ULNT - Median
        • ULNT - Radial
        • ULNT - Ulnar
        • Vertebral Artery Test
      • Thoracic Spine >
        • Adam's Forward Bend Test
        • Passive Neck Flexion Test
        • Thoracic Compression Test
        • Thoracic Distraction Test
        • Thoracic Foraminal Closure Test
      • Lumbar Spine/Sacroiliac Joint >
        • Active Sit-Up Test
        • Alternate Gillet Test
        • Crossed Straight Leg Raise Test
        • Extensor Endurance Test
        • FABER Test
        • Fortin's Sign
        • Gaenslen Test
        • Gillet Test
        • Gower's Sign
        • Lumbar Quadrant Test
        • POSH Test
        • Posteroanterior Mobility
        • Prone Knee Bend Test
        • Prone Instability Test
        • Resisted Abduction Test
        • Sacral Clearing Test
        • Seated Forward Flexion Test
        • SIJ Compression/Distraction Test
        • Slump Test
        • Sphinx Test
        • Spine Rotators & Multifidus Test
        • Squish Test
        • Standing Forward Flexion Test
        • Straight Leg Raise Test
        • Supine to Long Sit Test
      • Shoulder >
        • Active Compression Test
        • Anterior Apprehension
        • Biceps Load Test II
        • Drop Arm Sign
        • External Rotation Lag Sign
        • Hawkins-Kennedy Impingement Sign
        • Horizontal Adduction Test
        • Internal Rotation Lag Sign
        • Jobe Test
        • Ludington's Test
        • Neer Test
        • Painful Arc Sign
        • Pronated Load Test
        • Resisted Supination External Rotation Test
        • Speed's Test
        • Posterior Apprehension
        • Sulcus Sign
        • Thoracic Outlet Tests >
          • Adson's Test
          • Costoclavicular Brace
          • Hyperabduction Test
          • Roos (EAST)
        • Yergason's Test
      • Elbow >
        • Biceps Squeeze Test
        • Chair Sign
        • Cozen's Test
        • Elbow Extension Test
        • Medial Epicondylalgia Test
        • Mill's Test
        • Moving Valgus Stress Test
        • Push-up Sign
        • Ulnar Nerve Compression Test
        • Valgus Stress Test
        • Varus Stress Test
      • Wrist/Hand >
        • Allen's Test
        • Carpal Compression Test
        • Finkelstein Test
        • Phalen's Test
        • Reverse Phalen's Test
      • Hip >
        • Craig's Test
        • Dial Test
        • FABER Test
        • FAIR Test
        • Fitzgerald's Test
        • Hip Quadrant Test
        • Hop Test
        • Labral Anterior Impingement Test
        • Labral Posterior Impingement Test
        • Long-Axis Femoral Distraction Test
        • Noble Compression Test
        • Percussion Test
        • Sign of the Buttock
        • Trendelenburg Test
      • Knee >
        • Anterior Drawer Test
        • Dial Test (Tibial Rotation Test)
        • Joint Line Tenderness
        • Lachman Test
        • McMurray Test
        • Noble Compression Test
        • Pivot-Shift Test
        • Posterior Drawer Test
        • Posterior Sag Sign
        • Quad Active Test
        • Thessaly Test
        • Valgus Stress Test
        • Varus Stress Test
      • Foot/Ankle >
        • Anterior Drawer
        • Calf Squeeze Test
        • External Rotation Test
        • Fracture Screening Tests
        • Impingement Sign
        • Navicular Drop Test
        • Squeeze Test
        • Talar Tilt
        • Tarsal Tunnel Syndrome Test
        • Test for Interdigital Neuroma
        • Windlass Test