Transcript Supervision and Delegation

EMERGENCIES
Natalia Fernandez, MPT and Alyssa Trotsky, DPT
University of Michigan Health System
May 23rd, 2013
LEARNING OBJECTIVES:
By the end of this lecture, students will be able to:
VITAL SIGNS
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In emergency situations, always assess vital
signs!
Blood Pressure
Heart Rate
Oxygen Saturation
Respiratory Rate
Temperature
Pain
Monitor vitals at rest, during activity, and after
recovery.
BLOOD PRESSURE
Definition: pressure exerted by the blood upon
the walls of the blood vessels, especially arteries.
 Measured by a sphygmomanometer, indwelling
lines, or automatic
 Systolic pressure (top number) is defined as the
amount of pressure that blood exerts on arteries
and vessels while the heart is contracting.
 Diastolic pressure (bottom number) is defined as
the pressure that is exerted on the walls of the
arteries when the heart is relaxing and the
ventricle is filling.
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BLOOD PRESSURE CONTINUED
Classification of Blood Pressure (BP) for Adults:
Classification
Systolic (mmHg)
Diastolic (mmHg)
Hypotension
<90
<60
Desired
90-119
60-79
Prehypertension
120-139
80-89
Stage I
Hypertension
140-159
90-99
Stage II
Hypertension
160-179
100-119
Hypertensive Crisis >180
>110
BLOOD PRESSURE CONTINUED
Precautions/Contraindications to Initiating
Activity:
 Mild (150/90) to Moderate (170/100)
Hypertension: light activity only. monitor vitals
at rest, with activity, and after recovery.
 Moderate to Severe (180/110) Hypertension: light
supine exercises only. monitor for changes. no out
of bed activity.
 Activity contraindicated for resting systolic blood
pressure >200 and diastolic blood pressure >110.
 Low BP (90/60): proceed with caution. Light
supine or seated exercises only.
 Low BP (<90/60): passive range of motion only.
No out of bed activity.
ORTHOSTATIC HYPOTENSION
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Decrease >20mmHG systolic pressure after
standing from supine within 3 min (or a diastolic
drop >10mmHg.
Normal response is to accommodate to the
posture change within 1-2 min for BP and 45-60s
for HR.
BLOOD PRESSURE CONTINUED
Precautions/Contraindications During Activity:
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Stop activity during exercise if systolic blood
pressure >240 or diastolic blood pressure >110.
Severe changes in diastolic pressure (>10 mmHg)
from rest to exercise: proceed with caution.
BLOOD PRESSURE CONTINUED
If a patient is found to have an abnormal blood
pressure:
1. Look at patient’s medication list. Have they
taken their medications?
2. In acute care or inpatient rehab, contact the
patient’s nurse and/or doctor. Patient may be
able to quickly receive medication that could
allow you to continue with treatment.
3. In the outpatient setting, cease activity, and call
patient’s primary care physician to determine if
the patient should come in to the office or get
sent straight to ER (patient should not drive).
HEART RATE (HR)
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Definition: number of heart beats per minute (bpm).
Normal HR is between 60-100 bpm
Precautions/Contraindications to Activity:
 Resting HR <50: light exercises and light activity only. monitor for
decreases. cease activity if there is a decrease more than 10 bpm.
 Resting HR <40: PROM only and monitor.
 Resting HR 110-130: light exercise and light activity only. monitor
for increases. cease activity if increases more than 10 bpm
 Resting HR 130-150: light exercise only. monitor. cease activity if
there is a increase more than 10 bpm and allow rest.
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Failure of HR to increase from supine to sit and sit to stand is
associated with an impaired cardiovascular system. Symptoms may
include dizziness, lightheadedness, and even syncope.
If abnormal HR found, check to see if patient is on medications which
would increase/decrease heart rate.
PULSE PRESSURE
Definition: difference between the systolic and
diastolic blood pressures.
 At rest, 30-40 mmHg is normal value. With
activity, pulse pressure should not to increase
>100 mmHg.
 The larger the difference, the more perfused the
organs are.
 Ex: 10 mmHg is not as good 50 mmHg
 90/60 VS. 90/80
 180/90 VS. 210/90
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RESPIRATORY RATE
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Definition: number of breaths per minute
Normal RR is between 12-20 breaths/minute
Precautions/Contraindications to Activity:
 >20: proceed with activity, but cautiously
 >30: light supine exercise only
 >35-40: passive range of motion only and monitor
response
 >40: no gentle exercise, possible relaxation
exercises/guided imagery. provide hypnotic-like
commands to relax breathing
 <10: no gentle exercise or activity.
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If patient is on a ventilator, there may be alarms that
will beep if RR is too high/low.
OXYGEN SATURATION (SAO2)
Definition: amount of oxygen the blood is carrying
as a percentage of the maximum it could carry.
If patient without a cardiopulmonary disorder:
 SaO2 should be in the mid to high 90s.
 If SaO2 between 90%-94% monitor and proceed
cautiously with activity.
 If SaO2 drops below 90% cease activity.
If patient has a cardiopulmonary disorder:
 <85%: cease activity
 If patients baseline resting SaO2 is between 88%90%: do not allow for more than a 2% drop with
activity below patients norm.
TEMPERATURE
Low Body Temperature:
 Patient may not want to participate due to
feeling “cold”
 Depending on how low, patient may be “crashing”
 Some interventions for medical treatment call for
cooling patients body temperature to slow
metabolism (patients most likely semi-comatose
or comatose). PT interventions could include
passive range of motion, joint compression,
stretching, and assist with repositioning
 Hypothermia = <94oF
TEMPERATURE CONTINUED
High Body Temperature:
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Low grade fever 99-102oF may be normal in a
post surgical population. Patients can perform
light activity like supine or seated exercise, and
short distance ambulation with a slower gait.
Higher fever >102oF: should not perform aerobic
activity, light supine exercises only.
PAIN
 Ask
pain level and pain tolerance.
 Pain tolerance can be lower or higher than
actual pain level.
 Attempt to modify and coordinate pain
medications to help patient achieve
maximal participation.
 Report findings to MD if pain is limiting
maximal participation.
ASSESS OTHER SIGNS
In emergency situations, make sure to also check
the following:
 Change in mental status
 Change in mood
 Fatigue/Exhaustion/Lethargy
 Slow to respond or react
 Decreased response to verbal or tactile stimuli
 Complaints of nausea, syncope, vertigo
 Diaphoresis
 Changes in appearance (cyanotic, pallor)
 Pupil constriction or dilatation
 Loss of consciousness
PREPARATION FOR AN EMERGENCY
Acute Care, Inpatient Rehab, SNF, and ECF:
 Know codes in facility
 Familiarize location of emergency equipment
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Know how to use equipment
Take control of the situation
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If the emergency is initiated in your presence
Know your role
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Code buttons
CPR release on bed
Crash cart
Oxygen tank
Vital machines/pulse oximeter
Oxygen regulator
During the emergency
After the emergency
Plan ahead – in case of an emergency
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Practice and Review
Recognize signs, precautions, contraindications
Proper procedures during evaluation or treatment
PREPARATION FOR AN EMERGENCY
Outpatient and Home:
 Know codes in facility or how to respond in the home
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Dial 911
In Case of Emergency (ICE) information
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Automatic Electronic Defib (AED) location
Oxygen tank
Blood Pressure cuff/stethoscope/pulse oximeter
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During the emergency
After the emergency
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Practice and Review
Recognize signs, precautions, contraindications
Proper procedures during evaluation or treatment
Familiarize location of emergency equipment
Know how to use equipment
Take control of the situation
Know your role
Plan ahead – in case of an emergency
EMERGENCY SITUATION
 Emergency
 Calling
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State your name
Type of injury
Time of incident
What is being done for the patient
Location
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Place next to phone with specific directions from the
N, S, E, or W
DO NOT HANG UP
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911
Telephone Numbers
More specific directions – best entrance, your phone
number
Ask estimated time of arrival
To save the patient’s life
 To prevent further harm
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Time is of the essences
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Primary Assessment takes about 30 seconds to 2
minutes
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Emergency Evaluation
Check responsiveness 5-10sec
 Active emergency response system-get an AED
 Check for pulses/HR 5-10secs
 Begin with chest compression if no HR
 IF there is a pulse begin rescue breathing.
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Airway
 Ventilation
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Circulation/heart rate 20 – 30 sec
Blood loss
 Neurological injury
Total time
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5 – 7 sec
5 – 8 sec
20 – 30 sec
10 – 20 sec
60 – 95 sec
EMERGENCY SITUATION
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Prioritize
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Airway Obstruction
Respiratory Failure
Cardiac Arrest
Severe Bleeding
Head (craniocerebral) Injury
 Cervical Spine Injury
 Severe Heat Injury
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Prioritize
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Airway Obstruction: Heimlach
Respiratory Failure: CPR
Cardiac Arrest: CPR
Severe Bleeding
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Pressure
Severe Heat Injury: Cool the patient
 Head (craniocerebral) Injury
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Neuro Assessment – cognition, sensory, motor
Cervical Spine Injury
Neuro Assessment – cognition, sensory, motor
 Stabilize
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EMERGENCY
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Levels of Decision
Is the injury life threatening
 Can the patient be moved and how
 How transported? – ambulance or car
 Follow up after emergency
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Physician clearance through script
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Helping to Make the Decision
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Abnormal pupil or extraocular movement
Increasing facial or extremity weakness
Amnesia, confusion, or lethargy
Sensory or cranial nerve abnormality
Post traumatic seizures
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Incident Reports
System form
 Detail of what occurred
 Facility to investigate, make improvements, not to
penalize
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Documentation
Briefly write what happened
 Do not write you completed an incident report
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If you do it now becomes part of the medical record and may
be included in the subpena