Transcript Summary Putting it All Together

Physical
Assessment
Class
Case
Scenarios
Objectives
State common Approaches to
Priorities in Assessment to
Action
Adapt assessment to focus
on common medical
diagnosis & their
complications
Objectives
Individualize assessment to
incorporate common
treatments and diagnostic
procedures and their
complications
State areas to focus
assessment on for a changing
patient case scenario
Common
Approaches
First Level
ABCS
Second level
MPULOR
Third level
KARR
1st Level - ABCS
Emergent, Life threatening and Immediate
- Things you HAVE TO DO NOW!
Airway
Breathing
Cardiac and Circulation
Signs - Vital Signs
2nd Level - MPUOLR
Next in Urgency, may stop further deterioration
-Things you NEED to take care of.
Mental
Pain
Urinary
Other Medical Problems
Labs
Risks
3rd Level - KARR
Important to health but can be approached
more slowly and deliberately
-Things you WANT to do
Knowledge
Activities
Rest
Relations
Adapt Assessment
to Focus
 Treatments for 1st and 2nd are
usually rapid in succession or
simultaneous.
 At time priorities will change depending on seriousness of the
problem - ie abnormal labs can be life
threatening
 Important to consider the relationship
between the problems - one causing
or worsening another
Common Diagnosis
and their Potential
Complications
 Angina / MI
 Asthma / COPD
 Diabetes
 Fractures
 Head Trauma
 Hypertension
 Pneumonia
 Pulmonary
Embolus
 Renal Failure
 Trauma
 UTI
Angina / MI











Dysrhythmia
Congestive Heart Failure
Shock - cardiogenic, hypovolemic
Infarction / Infarction Extension
Thrombi/emboli formation
Hypoxemia
Electrolyte imbalance
Acid Base Balance
Pericarditis
Cardiac Tamponade
Cardiac Arrest
TREATMENT
Aspirin. You may be instructed to
take aspirin by the 911 operator, or
you may be given aspirin by
emergency medical personnel soon
after they arrive. Aspirin reduces
blood clotting, thus helping maintain
blood flow through a narrowed
artery.
Enteric Coating? (Chew IT UP)
Treatment
 Thrombolytics. These drugs, also called
clotbusters, help dissolve a blood clot that's
blocking blood flow to your heart. The earlier
you receive a thrombolytic drug after a heart
attack, the greater the chance you will survive
and lessen the damage to your heart. However,
if you are close to a hospital with a cardiac
catheterization laboratory, you'll usually be
treated with emergency angioplasty and
stenting instead of thrombolytics. Clotbuster
medications are generally used when it will
take too long to get to a cardiac catheterization
laboratory, such as in rural communities.
THROMBOLITICS
Alteplase
Reteplase
Tenecteplase
TREATMENT
Other blood-thinning
medications. You'll likely be
given other medications, such
as heparin, to make your
blood less "sticky" and less
likely to form more dangerous
clots. Heparin is given
intravenously or by an
injection under your skin after
a heart attack.
Blood Thinners
Heparin
Lovenox
Coumadin
Xarelto
Plavix
Treatment
Pain relievers. If your chest
pain or associated pain is
great, you may receive a pain
reliever, such as morphine, to
reduce your discomfort.
Treatment
STATINS
Lipitor
Crestor
Treatment
Nitroglycerin. This
medication, used to treat
chest pain (angina),
temporarily opens arterial
blood vessels, improving
blood flow to and from your
heart
Treatment
Beta blockers. These
medications help relax your
heart muscle, slow your
heartbeat and decrease blood
pressure, making your heart's
job easier. Beta blockers can
limit the amount of heart
muscle damage and prevent
future heart attacks
Beta Blockers
Coreg
Lopressor
Toprol
Tenormin
Treatment
ACE inhibitors. These drugs
lower blood pressure and
reduce stress on the heart.
Vasotec, Prinivil, Altace,
Mavik, Lotensin, Monopril,
and Accupril.
Surgical
Interventions
Coronary angioplasty and
stenting
http://www.youtube.com/watc
h?v=fL3Aak_PI-I
Coronary artery bypass
surgery.
http://www.youtube.com/watc
h?v=nZNQ0uliqHI
Tests for MI
ECG-Arrythmia
Blood- CKMB (Creatine Kinase)
elevated in first 4-6 hours
Chest Xray- Size and Fluid (See Pic)
Angiogram – Dye to show narrowing
or blockage (See Pic)
STRESS TEST
http://www.youtube.com/watch?v=oIPaRAf6sQ0
CT or MRI
Asthma / COPD
 Hypoxemia
 Acid Base /
electrolyte
imbalance
 Respiratory
Failure
 Cardiac Failure
 Infection
Treatment
Albuterol Sulfate (Inhaler)
Proventil (Inhaler)
Ventolin (Inhaler)
Solu Medrol (IV)
Theo Dur (PO)
Lung Sounds
Asthma
http://www.youtube.com/watc
h?v=YG0-ukhU1xE
COPD (Chronic Obstructive
Pulmonary Disease)
http://www.youtube.com/watc
h?v=5JA6D1Mguh0
Listen for the Difference
Documentation
SOB- Shortness of Breath
Now get out your Bottle and
grab a pair of scissors and
wait for my instructions
Next Get with a Partner and
Clean your stethescope (men
with men and ladies with
ladies)
Where to Listen
Posterior
Anterior
Diabetes
Type I (Insulin Dependent)
Type II (Non-Insulin Dependent)
Type 1.5 LADA (Latent
Autoimmune Diabetes in Adults)
Gestational Diabetes
If left uncontrolled long enough,
all four have the same set of
complications
Diabetes
Complications
 Hyper/Hypoglycemia
 Delayed Wound
HealingAmputation
 Hypertension
 Eye Problems retinal
hemorrhage
 See also Angina
/ MI / CVA
Type I
Type 1 diabetes, once known as
juvenile diabetes or insulindependent diabetes, is a chronic
condition in which the pancreas
produces little or no insulin, a
hormone needed to allow sugar
(glucose) to enter cells to produce
energy.
Type I S/S
Increased thirst and frequent
urination (nocturia)
Extreme hunger
Weight loss
Fatigue
Blurred vision
Yeast Infections
Test A1C
Tests
FBS- Fasting Blood Sugar
(70-110)_
RBS- Random Blood Sugar
(70-120)
PPG- Post Prandial Glucose 23 hours after eating
(<140)
Tests URINE
Microalbumin
 A microalbumin test checks urine for the
presence of a protein called albumin.
Albumin is normally found in the blood and
filtered by the kidneys. When the kidneys
are working properly, albumin is not
present in the urine. But when the kidneys
are damaged, small amounts of albumin
leak into the urine. This condition is called
microalbuminuria.
Tests URINE
Ketones
Ketones build up when there is
insufficient insulin to help fuel the
body’s cells.
High levels of ketones are therefore
more common in people with type 1
diabetes or people with advanced
type 2 diabetes.
Type I Drugs
Insulin lispro (Humalog)
Insulin aspart (Novolog)
Insulin glargine (Lantus)
Insulin detemir (Levemir)*
Insulin isophane (Humulin N,
Novolin N)
* can be used with Type II
drugs
Type II
Type 2 diabetes, once known
as adult-onset or noninsulindependent diabetes, is a
chronic condition that affects
the way your body
metabolizes sugar (glucose),
your body's main source of
fuel.
Type II S/S
 Increased thirst and urination mainly
nocturia
 Increased hunger
 Weight loss
 Fatigue
 Blurred vision
 Slow-healing sores or frequent infections
 Patches of Darkened skin (acanthosis
nigricans)
 Yeast Infections (thrush)
Type II Testing
Glycated hemoglobin (A1C) test
An A1C level of 6.5 percent or higher
on two separate tests indicates you
have diabetes. A result between 5.7
and 6.4 percent is considered
prediabetes, which indicates a high
risk of developing diabetes. Normal
levels are below 5.7 percent.
A1C Flowchart
Type II Drugs
Glucophage (metformin)
Glucotrol, Diabeta, Glynase,
Amaryl
Actos
Standards for DM
 BS everyday(More Frequent when ill)
 Treat Hyper/Hypo quickly
 Know Your ABC’s (A1C, BP, Cholesterol)
 Constant Oral Hygiene (Dentist 2xyr)
 Always have your Meds!
 Diet (ADA) and Exercise is a must!
 Frequent Eye Exams
 Know your TEAM:
MD/Dietician/Pharmacist/Trainer/etc..
Fractures
 Bleeding
 Fracture Displacement
 Thrombus/embolus
formation
 Compromised
circulation
 Nerve Compression
 Infection
 see also Skeletal
traction/casts
Types of FX
Breaking of the Bone
Closed or Simple: No open
wound present
Compound or Open: Open
wound watch for
hemorrhaging and infection
Deformity, limited motion or
loss motion, pain and
tenderness at the site,
swelling and discoloration,
and the protrusion of the
bone through the skin
The victim may hear the bone
snap, feel crepitation
(grinding), and have abnormal
movement of the parts
Spiral FX- Abuse?
TX of FX
Keep the broken bone from
moving and prevent further
injury
Using Splints, Slings, and Air
Splints, you can prevent the
injured body part from moving
When Splinting, splint above
and below the break
You must get EMS and medical
help ASAP
Dislocation
When the end bone moves out
of place or is out of normal
position in the joint
Frequently accompanied by
tearing or stretching of
ligaments, muscles, and other
soft tissue
TX of Dislocation
Deformity, Limited or
abnormal movement,
swelling, discoloration,
pain, tenderness, and
shortening or
lengthening of the
affected arm or leg
TX for Dislocation
Same as Fractures
Ensure the patients body
extremity is immobilized until
it can be set.
Sprain/Strain
Swelling, pain, discoloration,
and sometimes impaired
movement
Frequently resemble
fractures and dislocations
If in doubt, treat it as a
fracture
TX for Sprain/Strain
Application of cold (ice with
barrier 15 on 15 off) to decrease
swelling and pain, elevation of
the affected part and rest
An elastic bandage can be
applied for support and if
swelling is severe or there is a
question of fracture/dislocation
treat it as a fracture
Splints pg 421
Used to immobilize fractures,
dislocations, and other similar
injuries that are present or
suspected
Splints can be created using
anything that provides support and
does not further injure the patient
 Splints should immobilize the injury
above and below the site while
preventing movement or further injury
 Splints should be padded especially
over boney areas
 Strips of cloth, roller gauze, triangular
bandages can be folded, or any other
object that can be stretched and tied
 Splints must be applied in a manner
that does not put pressure directly
over the site of injury
 If an open wound exists, use sterile
dressing and apply pressure
You must monitor circulation and
nerve endings when the splint is
in place.
Skin should be warm to touch
and watch for any edema,
cyanosis, numbness or tingling,
and always check the pulse
IF any S/S of changes in
circulation occurs or numbness
occurs, loosen the splint while
still supporting the area
Neck and Spine
Neck and Spine injuries can
be life threatening and my
result in permanent paralysis
so avoid moving the patient
at all cost until EMS arrives
Watch for SHOCK since most
bone injuries can result in
shock
Always watch for HALO
Effect!!
Head Trauma
 Increased Intracranial
Pressure - bleeding or
swelling
 Respiration
Depression
 Shock
 Hyper-/Hypothermia
 Coma
Diuresis and brain
edema
 Diuretics are powerful in their ability to
decrease brain volume and, therefore, to
decrease ICP. Mannitol, an osmotic diuretic, is
the most common diuretic used. Mannitol is a
sugar alcohol that draws water out from the
brain into the intravascular compartment. It
has a rapid onset of action and a duration of
action of 2-8 hours. Mannitol is usually
administered as a bolus because it is much
more effective when given in intermittent
boluses than when used as a continuous
infusion. The standard dose ranges from 0.25-1
g/kg, administered every 4-6 hours.
Neuro ck’s
Watch Again Tonight!!
http://www.youtube.com/watc
h?v=V2MBiS1kc_0
Craniotomy for Aneurysm
http://www.youtube.com/watch
?v=jySbT86tJqM
Hypertension
 Cerebral Vascular
Accident
 Transient
Ischemic Attack
 Renal Failure
 Hypertensive
crisis
 see also Angina /
MI
Pneumonia
 Respiratory
Pulmonary
Failure
Embolus
 Sepsis
 Septic Shock
See Angina / MI
Pulmonary
Embolus
 See Angina
Myocardial
Infarction
Renal Failure
 Fluid Overload
 Hyperkalemia
 Electrolyte /
Acid-base
imbalance
 Anemia
 See also
Hypertension
Trauma
 See
Anesthesia/
Surgical or
Invasive
procedures
UTI
 Urinary Tract
Infection
 SEPSIS??
Individualize Assessment
for Common Treatments &
Procedures
 Anesthesia/ Surgical or
Invasive Procedure
 Cardiac Catherterization
 Chest Tubes
 Foley Catherter
 Intravenous Therapy
 Medications
 Nasogastric Suction
 Skeletal Traction/Casts
Anesthesia/ Surgical
or Invasive Procedure
Bleeding / hypovolemia / Shock
Respiratory Depression / Atelectasis
Urinary Retension
Fluid / Electrolyte imbalances
Thrombus/ embolus formation
Paralytis Ileus
Incisional Complication - infection,
poor healing, dehisence, eviseration
 Sepsis / Septic Shock







Cardiac
Catheterization
 Bleeding
 Thrombus /
embolus
formation
Chest Tubes
 Hemo /
Pneumothorax
 Bleeding
 Atelectasis
 Chest tube
malfunction /
blockage
 Infection / sepsis
Foley Catheter
 Infection /
Sepsis
 Catheter
Malfunction /
Blockage
Intravenous Therapy
 Phlebitis /
Thrombophlebitis
 Infitration /
Extravasation
 Fluid Overload
 Infection / Sepsis
 Bleeding
 Air embolism (3cc)
Medications
 Adverse
Reactions

Allergic
Response
 Exaggerated
Effect
 Side Effects
 Drug Interaction
 Incomplete effect
 Overdose /
Toxicity
Nasogastric Suction
 Electrolyte
Imbalance
 Tube
Malfunction
or blockage
 Aspiration
Skeletal Traction /
Casts
 Poor Bone Alignment
 Bleeding / Swelling
 Compromised
circulation
 Nerve Compression
 See also Fractures