Why is taking vitals important?

Detailed medical records are absolutely vital. Firstly, when you start taking over the care of a recovering guest it is fantastic to get as much information as possible. This will help you understand the important information about the guest/patient and can guide you in how treatment will be given.

A medical record is defined as “any relevant record made by a health care practitioner at the time of, or subsequent to a consultation and or examination or the application of health management”

By looking at said records, we, as health workers and the patient are empowered. For instance, we will be prepared if there is disfigurement (eg. a child coming for maxillofacial surgery or a patient with burn wounds) Referral letters from previous health workers can explain certain physiological issues, mental health issues, for example, a mention of obesity can alert you to the possibility of diabetes, a record of regular trips to the ER can alert you to domestic violence, admission at places like Tara could indicate eating disorders, mention of rehab facility could indicate drug or alcohol abuse.

Laboratory reports and other laboratory evidence like blood tests and x-rays can assist in general and specific treatment. Although not always essential, the more clinical information you obtain the better.

Do not dismiss other completed records such as insurance forms, disability assessments, occupational therapy reports, physio reports, police reports and clinical research. It is not always obvious what one can gather from this information but often leads to greater understanding as well as your ability to treat the patient holistically.

Having a relationship with referring specialist or doctor is hugely beneficial as one gets to know the way they communicate, and building relationships with the guests’ loved ones may not be a written report, but certainly a valuable indicator of the guests’ history.

When keeping records the time and date you take the vitals for example is hugely important, make sure this is documented and easily accessible for others taking over the care or sharing the care of the patient with you. This information can lead to spotting patterns and alert you of changes.

Making thorough notes and putting everything in writing must be routine and is not optional, but needs to be part of your daily tasks. I often giggle at the things we write down, especially for those of us who do not speak English as a first language, but after a while, you realize the importance of these little notes and input.

Records should be detailed and should include all aspects of patient care, for instance, mention that the patient was uncooperative or weepy or indulged in too much chocolate. Document discussions which were had with patients and instructions given by physicians and other health workers. Although details are important only include relevant information and keep it factual and unemotional.

Proper record keeping minimises risk for yourself and the patient, as well as protecting yourself in case of a claim or complaint and can be seen to reflect the quality of care provided.

Keeping good records helps care workers in providing the best possible continuous care.

One of the first and easiest vital signs to check is their temperature (we have all become accustomed to this taking place often due to COVID-19) The normal body’s temperature is between 36 – 38 but generally, a reading above 37.2 is seen as too high. One can also not rely on one reading, often the patient’s temperature could be affected by exposure to cold (aircon is often a culprit and all our rooms are equipped with these), heat, exercise or hormonal changes can affect the temperature.

Our bodies function optimally within a certain range of temperatures and this is constantly being controlled by bodily functions like sweating, shivering, flushing.

If we find that a patient’s temperature is unnaturally low, it could be indicative of shock or hypothermia which is very dangerous in older people.

Too high a temperature can indicate a fever, an increase in temperature is often a warning sign. This can be dangerous and need to be monitored.

Blood pressure needs to be measured as well, we do this three times a day. Blood pressure is the force of blood pushing against the artery walls. We measure blood pressure as high blood pressure can indicate the risk of coronary heart. Blood pressure is explained as this “Blood pressure which is high (hypertension) means that the arteries have increased resistance against the blood, causing the heart to pump much harder than usual to circulate the blood in the body.

Low blood pressure (hypotension) is generally not dangerous but should not be ignored. It can cause dizziness and even cause faint spells; it can also be indicative of dehydration.”

We also measure oxygen levels and glucose levels. Levels of pain get recorded three times a day.

One of the most important records we keep is that of our guests’ emotions, mental state and cognitive function. Reading these notes is insightful and also help our carers care for the guests to the best of their ability.

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