Transcript CAI Vitals ER part 1

Medical & Dental
Emergencies
Torres, Chapters 26, 27
Anderson, Chapter 10
Assignment: Review at the end of Chapter 10 &
Fill in the blank and multiple choice in Torres Workbook for
Chapter 27
Chapter 26 in Torres:
Introduction
The patient record is the principal
document that contains critical
information you will need to manage
each patient in the dental practice.
Prior to treatment, the dentist has to
make a complete diagnosis.
 Diagnosis- the act of identifying a
disease from its signs and symptoms.
The decision about treatment is
reached by the diagnosis.
 Prognosis- a forecast of the course of
a disease or treatment.
Critical Information
 Prior to dental treatment, the dental
team must have the following
information:
 Patient Registration
 Medical-Dental Health History
 Medical Alert Information
The Patient Record
 Permanent Record
 A personal and legal document of the
patient.
 Quality Assurance
 Primary source of information used by
the dental team to determine the overall
quality of care the patient has received.
Examples of Quality Assurance
 Routine forms completed by each patient.
 Timely recall of patients for their dental needs.
 Completed patient record for each “active”
patient.
 Documentation of when radiographs were
taken.
 Current and up-to-date emergency standards
maintained by the dental team.
 Current and up-to-date licenses, registrations,
and training.
The Function of the Patient Recordcont’d
 Risk Management
 Provides documentation of the
patient’s condition, diagnoses,
treatment, and the patient’s
responses to treatment.
 Research
 The patient record provides a source
of data for research purposes.
Patient Registration Form
 Patient Information: full name, date of birth,
residence, phone number, employment,
spousal information
 Insurance Information: employee’s name,
date of birth, employers name, address,
phone number, name of insurance, policy
number
 Responsible Party: person responsible for
payment of account
 Signature and Date: verifies the accuracy
of information
Medical-Dental Health History
Form
 Medical History Section
 Questions regarding the patient’s past
medical history, present physical
condition, chronic conditions, allergies,
and current medications taken.
 Dental History Section
 Gains information about the patient’s
previous dental treatment and care, and
their feelings toward dentistry and how
important dental care is to them.
Diagnostic signs evaluated by the
dentist when examining a patient:
Pulse
Respiration rate
Blood pressure
Temperature
Skin color
Pupils of eyes
State of consciousness
Ability to move the extremities and other parts of the
body
 Reaction to stimuli
 Breath odors
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Medical Alert Information
 Note to the dental healthcare team of
medical conditions, allergic reactions,
and medications that could interfere,
or be life threatening to the patient
during dental treatment.
 Adhere an Alert Sticker to the inside of the
patient’s record.
Health History Update
 Patients must update their
medical-dental health history at
every appointment
 Health information that may
have changed:
 Diagnosis of medical condition
 Medications
Clinical Examination Form
 Provides the dental team with past, present, and future
examination, analysis, and charting needs of the
patient.
 Patient’s name and date of exam
 Charting of existing restorations and present
conditions
 Charting of periodontal conditions
 Patient’s chief complaint
 Occlusal evaluations
 Temporomandibular joint (TMJ) evaluations
 Comments
Treatment Plan Form
 Sequenced to address all
problems identified during the
examination and diagnosis
portion of the patient visit.
Progress Notes Form
 Section of the patient
record where treatment is
recorded.
 Always include:
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Date
Tooth number
Completed treatment
Signature
Informed Consent Form
 Related to a specific treatment or
procedure. A document that provides
the patient with expected outcomes
of treatment, and describes any
possible complications that might
occur.
 Commonly used for invasive or extensive
treatment, such as in specialty
procedures.
Chapters 10 (Anderson) & 27
Torres: Vital signs
Attentiveness toward a patient’s
immediate health should be the first
priority of every health care provider.
Vital signs can provide you with a level
of determining a patient’s health
status and include temperature,
pulse, respiration, and blood
pressure.
Factors affecting Vital Signs
 Emotional Factors
 Stress
 Fear
 Physical Factors
 Illness
 Drinking or
eating
 Exercise
Temperature
 Degree of the hotness or coldness of
body
 Temperature Readings
 Average range for adult: 97.6–
99° F
 Body temperature higher in
infant and child than adult
 Thermometer Types
 Electronic
 Tympanic
Box 27-1 Average Fahrenheit (F) Temperature
Readings for Primary Body Sites
Fig. 27-1 Digital thermometer
Fig. 27-2 Tympanic thermometer
(Courtesy Welch Allyn, Skaneateles Falls, NY.)
Pulse
 A rhythmic expansion of the
artery each time the heart
beats.
 Pulse Sites
 Radial artery: inner surface of
wrist
 Brachial artery: inner fold of the
upper arm
 Carotid artery: alongside the
larynx
Fig. 27-4 Location of the radial artery
(From Kinn ME, Woods M: The medical assistant: administrative and clinical, ed 8, Philadelphia, 1999, Saunders.)
Fig. 27-5 Location of the brachial artery
(From Kinn ME, Woods M: The medical assistant: administrative and clinical, ed 8,
Philadelphia, 1999, Saunders.)
Fig. 27-6 Location of the carotid artery
(From Kinn ME, Woods M: The medical assistant: administrative and clinical, ed 8, Philadelphia, 1999,
Saunders.)
Pulse Characteristics
 Rate: Number of
beats
 Rhythm: Pattern
of beats
 Volume: Force of
beat
Pulse Characteristics-cont’d
 Pulse Readings
 Adult resting: 60-100 beats per
minute
 Child: 70-120 beats per minute
 Irregularity
 Arrhythmia: An irregularity in the
force or rhythm of the heartbeat
Respiration
 The process of inhaling and exhaling, or
“breathing.”
 Respiration Characteristics
 Rate: Total number of breaths per minute
 Rhythm: Breathing pattern
 Depth: Amount of air inhaled and exhaled
 Respiration Readings
 Adult: 10-20 breaths per minute
 Child to teenage: 18-30 breaths per minute
Blood Pressure
 The amount of work the heart has to do to
pump blood throughout the body.
 Two Pressures of the Heart
 Systolic: Reflects the amount of pressure it
takes for the left ventricle of the heart to
compress or push oxygenated blood out into
the blood vessels.
 Diastolic: The heart muscle at rest when it is
allowing the heart to take in blood to be
oxygenated before the next contraction.
Box 27-2 Blood Pressure Classifications for Adults
Blood Pressure Equipment
 Sphygmomanometer
 Blood pressure cuff
 Meter
 Rubber bulb
 Stethoscope
 Amplifies sounds
Blood pressure:
 Is measured on the brachial artery
 It can be done on either arm, just
record the arm you are taking it on
Fig. 27-8 Types of sphygmomanometers.
A, Aneroid (without liquid) dial system. B, Aneroid floor model.
(From Young A, Proctor D: Kinn’s The medical assistant: an applied learning approach, ed 9, St. Louis, 2003, Saunders.)
A
B
Fig. 27-9 Stethoscope
Box 27-3 Five Phases of Korotkoff
Sounds in Blood Pressure Measurement