Critical care 1

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  • A: Alert and oriented. (2) V: Responds to verbal stimulus. (3) P: Responds to pain . (4) U: Unresponsive .
  • Critical care 1

    1. 1. Focused History and Physical Exam: Critically Ill Patients Nelia B. Perez RN MSN PCU Mary Johnston College of Nursing
    2. 2. Focused History and Physical Exam • Pt Hx • Pt story of significant events related to current problem • Usually begins with pt C/C • Many disease conditions are 1st suspected by symptomology • MI • Diabetics • Allergic rxn • OD
    3. 3. Focused History and Physical Exam: Medical Patients • What: • Rapid assessment of medical conditions that may require emergency care OR early hospital tx. • Who: • Non traumatically injured pt with medical c/c • How: • Focus • C/C • Signs/Symptoms • SAMPLE history • Medical PAST • OPQRST history • Medical PRESENT • Baseline vitals • Plan of FUTURE treatment
    4. 4. SAMPLE HISTORY • S= Signs and Symptoms • A = Allergies • M = Medications • P = Past pertinent medical hx • L = Last oral intake • E = Events prior to the condition
    5. 5. OPQRST HISTORY • OPQRST Hx • Branch of SAMPLE Hx • Focuses on Signs and Symptoms • Gives a clearer picture of pt C/C and its severity
    6. 6. OPQRST Hx Onset • O = Onset • When the complaint first started. • The pt activities at the time of onset/immediately before • “What were you doing when this started” • Chest pain pt – mowing lawn • Anaphylaxis pt – stung by bee • Diabetic pt – Working in hot day without food
    7. 7. OPQRST Hx Provocation • P = Provocation • What actions make the symptoms better/worse • “Is there anything that makes it better? Anything that makes it worse?” • Chest pains – Worse with activity Better with rest • SOB – Better when sitting Worse when lying flat • Etc…
    8. 8. OPQRST Hx Quality • Q = Quality • Subjective description of complaint in pt own words • “Would you please describe the pain. What does it feel like” • Chest pains – Crushing, vice-like, elephant Crushing Stabbing Burning
    9. 9. OPQRST Hx Radiation • R= Radiation • Is the pain local or does it travel to another part of the body • “Is the pain in one place or does it spread to other parts of your body?” • Chest pains • L shoulder, arm, jaw, neck ,back
    10. 10. OPQRST Hx Severity • Severity • 1-10 scale gauging pain • “On a scale of 1-10, 1 being the least pain you’ve felt and 10 being the worst pain you’ve ever felt can you rate the pain?”
    11. 11. OPQRST Hx Time • T = Time • Duration of the C/C and assoc complaints • “How long has this been going on?” • Chest pains – Woke pt from sleep that night • Allergic rxn- 15-20 min
    12. 12. Problem Focused Medical Assessment • Responsive Medical Pt • Problem Focused Medical Assessment • SAMPLE Hx • OPQRST Hx • Focused Physical Exam • Chest/neck- chest pains • Pharynx/chest- SOB • Etc… • Baseline Vitals
    13. 13. Rapid Medical Assessment • Unresponsive/AMS Medical Pt • Rapid Medical Assessment • Rapid assessment of ALL body regions (DCAP-BTLS) • Try to define C/C or ID trauma • Rule in/out trauma • Medical ID tags • Baseline Vitals • SAMPLE & OPQRST Hx when/if possible • Tx in recovery position
    14. 14. Focused History and Physical Exam: Medical Pt Recap • S – Signs/Symptoms • A - Allergies • M - Medications • P – Past pertinent medical hx • L – Last oral intake • E – Events leading to condition • O - Onset • P - Provocation • Q - Quality • R – Radiation • S - Severity • T – Time • BASELINE VITALS
    15. 15. INITIAL ASSESSMENT OF THE CRITICALLY ILL PATIENT
    16. 16. A critically ill patient is one at imminent risk of death; the severity of illness must be recognized early and appropriate measures taken promptly to assess, diagnose and manage the illness.
    17. 17. ∗ The approach required in managing the critically ill patient differs from that required in less severely ill patients with immediate resuscitation and stabilization of the patient s condition taking precedence: patient’s PHILOSOPHY OF MANAGEMENT
    18. 18. 1. Prompt resuscitation & adhering to advanced life support guidelines 2. Urgent treatment of life threatening emergencies such as hypotension, hypoxaemia , hyperkalaemia , hypoglycaemia and dysrhythmias life-hypoxaemia, hyperkalaemia, PRIORITIES
    19. 19. cont.; 3. Analysis of the deranged physiology 4. Establish a complete diagnosis as history & further diagnostic results are available 5. Careful monitoring of the patient s condition and response to treatment patient’s PRIORITIES
    20. 20. CARDIOVASCULAR SIGNS 1. HR 2. BP 3. PERFUSION 4. OLIGURIA 5. ARREST How To Recognize?
    21. 21. 1. RATE 2. DISTRESS 3. THREATENED OBSTRUCTION/OBSTRUCTION 4. RISING PaCO2 5. DECREASING SPO2 6. ARREST RESPIRATOY SIGNS
    22. 22. 1. THREATENED AIRWAY OBSTRUCTION/OBSTRUCTION 2. SUDDEN DETERIORATION IN CONSCIOUSNESS 3. GCS 4. ABSENT GAG/COUGH 5. FAILURE TO OBEY COMMANDS 6. REPEATED SEIZURES NEUROLOGICAL SIGNS
    23. 23. 1. Initial assessment 2. Immediate management 3. Monitoring 4. Initial investigations What are the steps to be followed?
    24. 24. ∗ Basic hemodynamic monitoring ECG, BP, CVP, PAP, CO ∗ ABGs, lactate, H ion, ∗ Urine output ∗ Fluid balance ∗ Lung mechanics, capnography ∗ Peripheral skin temp ∗ O2 transport MONITORING
    25. 25. FLUID MANAGEMENT
    26. 26. ∗ Failure to supply sufficient oxygen to meet the metabolic requirements of the tissues is the cardinal feature of circulatory failure or ‘shock’. SHOCK & LOW CO
    27. 27. ALGORITH OF SHOCK
    28. 28. Level of consciousness Level of consciousness should also be assessed upon initial contact with your patient and continuously monitored for changes throughout your contact with the patient. THE COMMON VITAL SIGNS
    29. 29. ∗ a. AVPU. The AVPU scale is a rapid method of assessing LOC. The patient's LOC is reported as A, V, P, or U. Level of Consciousness
    30. 30. ∗ b. Glasgow Coma Scale. The Glasgow Coma Scale is an assessment based on numeric scoring of a patient’s responses based on the patient's best response to eye opening, verbal response, and motor response. The patient's score (3 to 15) is determined by adding his highest eye opening, verbal response, and motor response scores. Level of Consciousness (CONT)
    31. 31. ∗ c. PEARRL. Use the guide PEARRL when assessing the pupillary response of the patient's eyes. Level of Consciousness (CONT)
    32. 32. BLOOD PRESSURE several factors that can affect a patient's blood pressure. a. Condition of Cardiovascular System. b. Age. c. Gender. d. Physical Fitness. e. Obesity. f. Pain. VITAL SIGNS
    33. 33. g. Emotion. h. Gravity. i. Exercise. j. Disease. k. Drugs. l. Eating. m. Bleeding.
    34. 34. FACTORS NOTED WHEN TAKING A PATIENT'S BREATHING RATE AND QUALITY a. Rate. b. Depth. c. Rhythm. d. Quality. e. Unusual Position. RESPIRATORY RATE
    35. 35. f. Coughing. g. Sputum.
    36. 36. FACTORS NOTED WHEN TAKING A PATIENT'S PULSE a. Pulse Rate. b. Strength. c. Rhythm. PULSE RATE
    37. 37. A Regular. B Tachycardia. C Bradycardia, D Bounding. E Weak (thready). F Irregular. G Intermittent (irregular).
    38. 38. WHAT CAUSES ABNORMAL TEMPERATURES? a. Infection. b. Environmental Conditions. BODY TEMPERATURE
    39. 39. PQRST PAIN
    40. 40. Thank You for Bearing with me!

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