Early Clinical Experience Gathering Information for Patient Care

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Early Clinical Experience Gathering Information for Patient Care

  1. 1. Early Clinical Experience <ul><li>Gathering Information for Patient Care </li></ul>
  2. 2. OBJECTIVES <ul><ul><li>Discuss the importance of treatment planning </li></ul></ul><ul><ul><li>Discuss the role of data gathering in this process </li></ul></ul><ul><ul><li>Differentiate between signs and symptoms </li></ul></ul><ul><ul><li>- Discuss blood pressure including how to </li></ul></ul><ul><ul><li>take blood pressure </li></ul></ul>
  3. 3. 1. TREATMENT PLANNING <ul><li>Treatment Plan: </li></ul><ul><li>Blueprint for care following careful assessment of patient’s needs and priorities </li></ul>
  4. 4. Treatment Planning <ul><li>PRE-REQUISITES </li></ul><ul><li>► DIDACTIC & CLINICAL KNOWLEDGE </li></ul><ul><li>What is normal, what is pathologic, what to address, what is an issue, what is not </li></ul><ul><li>► DECISION MAKING – what IS best treatment? </li></ul><ul><li>► INFORMED CONSENT </li></ul><ul><li>► SEQUENCING (actual treatment) </li></ul>
  5. 5. 2. Data Gathering <ul><li>ESSENTIAL FOR </li></ul><ul><li>► DIAGNOSIS </li></ul><ul><li>► PROGNOSIS </li></ul><ul><li>► TREATMENT PLAN </li></ul>
  6. 6. INFORMATION TO GATHER <ul><li>PERSONAL HISTORY </li></ul><ul><li>MEDICAL HISTORY </li></ul><ul><li>DENTAL HISTORY </li></ul><ul><li>CLINICAL OBSERVATIONS </li></ul><ul><li>CLINICAL EXAMINATION </li></ul><ul><li>DIAGNOSTIC AIDS - RADIOGRAPHS, DIAGNOSTIC CASTS </li></ul>
  7. 7. #3. CLINICAL OBSERVATIONS <ul><li>SYMPTOMS and SIGNS </li></ul>
  8. 8. SYMPTOMS <ul><li>THAT WHICH ONLY THE PATIENT CAN RELATE TO YOU </li></ul>
  9. 9. How do you find out the symptoms?
  10. 10. SIGNS <ul><li>WHAT CAN BE OBSERVED OR MEASURED </li></ul>
  11. 11. OBSERVATIONS <ul><li>VITAL SIGNS </li></ul><ul><li>1. PULSE </li></ul><ul><li>2. BLOOD PRESSURE </li></ul><ul><li>3. RESPIRATORY RATE </li></ul><ul><li>4. TEMPERATURE </li></ul>
  12. 12. PULSE
  13. 13. <ul><li>Result of alternate expansion and contraction of an artery as a wave of blood is forced through the heart </li></ul>
  14. 14. LOCATION OF ARTERY? <ul><li>Several “good” sites: </li></ul><ul><li>radial artery </li></ul><ul><li>carotid </li></ul><ul><li>brachial, temporal, facial </li></ul>
  15. 15. HOW? <ul><li>Tell the patient what you are doing </li></ul><ul><li>Place two or three fingers on area (not thumb) </li></ul>
  16. 16. <ul><li>COUNT/ TIME </li></ul><ul><li>OBSERVE - RHYTHM: regular or irregular </li></ul><ul><li>VOLUME and STRENGTH - full, strong, poor, weak, thready </li></ul><ul><li>RECORD AS BEATS/MIN </li></ul>
  17. 17. <ul><li>RANGES </li></ul><ul><li>ADULT: 60-100 bpm </li></ul><ul><li>CHILDREN: up to 130 for newborn </li></ul>
  18. 18. BLOOD PRESSURE
  19. 19. BLOOD PRESSURE <ul><li>Screening for hypertension in dental offices is an effective health care service </li></ul>
  20. 20. WHAT IS BLOOD PRESSURE? <ul><li>THE FORCE EXERTED ON THE BLOOD VESSEL WALLS </li></ul>
  21. 21. SYSTOLIC PRESSURE <ul><li>THE PEAK OR THE HIGHEST PRESSURE - CAUSED BY VENTRICULAR CONTRACTION </li></ul>
  22. 22. <ul><li>“ NORMAL” </li></ul><ul><li><130 mm </li></ul><ul><li>“ Range” </li></ul>
  23. 23. DIASTOLIC <ul><li>LOWEST PRESSURE - EFFECT OF VENTRICULAR RELAXATION </li></ul>
  24. 24. “ NORMAL” <ul><li>< 85 mm Hg </li></ul>
  25. 25. Factors that influence BP <ul><li>Force of the heart beat </li></ul><ul><li>Peripheral resistance – elastic condition of the arteries – decreases with age </li></ul><ul><li>Volume of blood in the circulatory system </li></ul>
  26. 26. Factors that acutely increase BP in a healthy individual <ul><li>Exercise </li></ul><ul><li>Eating </li></ul><ul><li>Stimulants </li></ul><ul><li>Emotional experiences </li></ul>
  27. 27. Factors that decrease BP in a healthy individual <ul><li>Fasting </li></ul><ul><li>Rest </li></ul><ul><li>Depressants </li></ul><ul><li>Calming environment </li></ul>
  28. 28. How is blood pressure taken? <ul><li>Use a sphygmomanometer which consists of an inflatable cuff and two tubes – one connected to the pressure hand control bulb, the other to the pressure gauge measured in mm Hg </li></ul><ul><li>The cuff is wrapped around the arm and the pressure increased so that the artery deflates </li></ul><ul><li>When the pressure is released, the blood rushes back into the artery  this is maximum pressure or systolic which can be heard with a stethoscope </li></ul>
  29. 29. <ul><li>When the cuff pressure is below the lowest pressure against the arteries (diastolic pressure) – we no longer hear anything </li></ul>
  30. 30. How to measure? <ul><li>AUSCULTATORY METHOD most widely used </li></ul><ul><li>Locate the pulse of the brachial artery – circle it with pen for your classmates only </li></ul><ul><li>Located on medial side of the arm at the elbow </li></ul><ul><li>Bisect just to the medial of middle of the elbow with the middle, ring, and pointer fingers , ‘fall’ medially and the pulse should be palpable </li></ul>
  31. 31. Brachial and radial arteries
  32. 32. Next <ul><li>Place the cuff of the sphygmomanometer following instructions on the cuff about 2 finger’s width above the pulse </li></ul><ul><li>Tight enough it doesn’t come off if you gave a gentle tug, loose enough that you can fit 2 fingers underneath </li></ul>
  33. 33. Placement of the cuff
  34. 34. Cuffs come in various sizes <ul><li>“ Normal” adult size </li></ul><ul><li>“ Large” adult size </li></ul><ul><li>“ Pedo” size </li></ul>
  35. 35. Stethoscope
  36. 36. Infection Control <ul><li>No gloving necessary when performing BP </li></ul><ul><li>Disinfect the ear pieces both before and after using – remember that disinfection requires that the disinfectant be in contact with the surface being disinfected for manufacturer recommended time </li></ul><ul><li>Optim = 1 minute </li></ul>
  37. 37. Preparing your stethoscope Place it into your ears - Note the correct direction
  38. 38. Make sure that it is ‘turned’ on <ul><li>Some can </li></ul><ul><li>be twisted </li></ul><ul><li>here </li></ul><ul><li>Tap the </li></ul><ul><li>diaphragm </li></ul><ul><li>to check that </li></ul><ul><li>you can hear it </li></ul>
  39. 39. <ul><li>Biggest mistake that students make is thinking that they should hear the brachial pulse as soon as the cuff is put on </li></ul>
  40. 40. Taking blood pressure <ul><li>Tell your patient what you are doing </li></ul><ul><li>Seat the patient with the arm slightly flexed, palm up, with the forearm supported on a level surface at the level of the heart </li></ul><ul><li>Do not take pressure through sleeve of clothing- roll or remove </li></ul>
  41. 41. Procedure <ul><li>Place fingers of one hand on the radial pulse. </li></ul><ul><li>Pump the cuff pressure just until the radial pulse is lost, then pump it 30mm higher than this </li></ul><ul><li>Place stethoscope </li></ul>
  42. 42. ‘How To’ continued…. <ul><li>Let pressure fall 2-3mm/second until you hear first sound, note it, and keep listening until there are no more sounds, note it, and release totally </li></ul><ul><li>Record first reading and last reading </li></ul>
  43. 43. SYSTOLIC PRESSURE <ul><li>FIRST SOUND - CALLED SYSTOLE or systolic </li></ul>
  44. 44. <ul><li>INDICATES THE BEGINNING OF THE FLOW OF BLOOD PAST THE CUFF </li></ul>
  45. 45. <ul><li>CONTINUE TO RELEASE THE PRESSURE SLOWLY UNTIL THERE IS NO LONGER A SOUND - NOTE ON THE GAUGE WHERE THE LAST TAP WAS - ANOTHER 10 mm - LAST SOUND </li></ul>
  46. 46. <ul><li>DIASTOLIC </li></ul>
  47. 47. <ul><li>LET THE LAST OF THE AIR OUT RAPIDLY </li></ul><ul><li>REMOVE THE CUFF </li></ul><ul><li>RECORD AS mm Hg SYSTOLIC/DIASTOLIC </li></ul><ul><li>DISINFECT/RETURN </li></ul>
  48. 48. Phases of Korotkoff Sounds
  49. 49. Auscultatory Gap <ul><ul><ul><ul><ul><li>Doesn’t occur often but if it does, it could have far reaching consequences </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>This gap represents a loss of sound between systolic and diastolic pressures, with the sound reappearing at a lower level </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>(Malamed, Stanley F. Malamed. Medical Emergencies in the Dental Office, 5th Edition . Elsevier, 1999. 2.2.4.1). </li></ul></ul></ul></ul></ul><ul><li>( </li></ul>
  50. 50. To prevent this from happening <ul><li>Always perform a radial pulse check </li></ul>
  51. 51. Silent Auscultatory Gap
  52. 52. Patient management is performed depending on blood pressure range <ul><ul><ul><li>A patient with a systolic pressure in excess of ~200 mmHg or a diastolic in excess of ~115 (ASA IV) is at significant risk and ought not to undergo invasive elective dental care until the blood pressure elevation has been brought under control. </li></ul></ul></ul><ul><li>(Malamed, Stanley F. Malamed. Handbook of Local Anesthesia, 5th Edition . Elsevier, 2004. 10.3.2). </li></ul>
  53. 54. BP CLASSIFICATIONS <ul><li>CATEGORY SYSTOLIC DIASTOLIC </li></ul><ul><li>NORMAL <130 <85 </li></ul><ul><li>HIGH NORM 130-139 85-90 </li></ul><ul><li>STAGE 1 140-159 90-99 </li></ul><ul><li>STAGE 2 160-179 100-109 </li></ul><ul><li>STAGE 3 180-209 110-119 </li></ul><ul><li>STAGE 4 210+ 120+ </li></ul>
  54. 55. BP Less than 140/90 <ul><li>Routine dental treatment </li></ul><ul><li>Recommend lifestyle modifications </li></ul><ul><li>Retake BP at continuing care appointments as a screening strategy for detection of hypertension </li></ul>
  55. 56. BP 140-159/90-99 <ul><li>Allow patient to relax; retake BP after 5 minutes </li></ul><ul><li>Routine dental treatment </li></ul><ul><li>Employ stress-reduction strategies </li></ul><ul><li>If BP is above normal on three separate appointments and if patient is not under physician’s care for hypertension, refer to physician </li></ul>
  56. 57. BP 160-179/100-109 <ul><li>Retake BP after patient has rested for 5 minutes </li></ul><ul><li>If still elevated, inform patient of readings </li></ul><ul><li>Refer to physician within 1 month; delay treatment if patient cannot handle stress or if dental procedure to be performed is stressful </li></ul><ul><li>Routine dental treatment can be provided </li></ul><ul><li>Employ stress-reduction strategies </li></ul>
  57. 58. BP 180/110 <ul><li>Retake BP after 5 minutes </li></ul><ul><li>If still elevated, delay treatment until BP is controlled </li></ul><ul><li>Refer to physician for immediate evaluation </li></ul><ul><li>Require written medical release form from physician prior to dental treatment </li></ul><ul><li>Emergency dental treatment can be done in a hospital dental setting </li></ul>
  58. 59. Summary Blood Pressure
  59. 60. Summary <ul><li>BP is the pressure created against the vessel walls when the heart beats. </li></ul><ul><li>Systolic pressure is the most important in management of blood pressure. </li></ul><ul><li>High blood pressure has no symptoms. </li></ul><ul><li>High blood pressure is easy and painless to detect in a few minutes with a blood pressure cuff and stethoscope. </li></ul>
  60. 61. <ul><li>Blood pressure assessment should be a routine part of the initial appointment for all new dental patients. </li></ul><ul><li>The Korotkoff sounds are the series of sounds heard as the pressure in the BP cuff is released. </li></ul><ul><li>Failure to recognize the auscultatory gap results in an inaccurate blood pressure reading. </li></ul><ul><li>Management for patients with hypertension is recommended. </li></ul>
  61. 62. Pulse and Respiratory Rate
  62. 63. Respiratory rate and Temperature <ul><li>Respiratory rate – done without the patient knowing or during pulse taking – changes as soon as someone knows it is being done – done more during emergency than in normal practice </li></ul><ul><li>Temperature – can be done, but is rarely done in GP dental office </li></ul>
  63. 64. Chart Entries <ul><li>Record blood pressure on the screening page only – not on DRT and date it </li></ul><ul><li>In Daily Treatment Record (DTR) write: </li></ul><ul><li>DATE: NCMH (or change if it has occurred) </li></ul><ul><li>Recorded blood pressure </li></ul><ul><li>then Print your name & Sign your name </li></ul><ul><li>- GET AN INSTRUCTOR’S SIGNATURE </li></ul>
  64. 65. Please ensure that…. <ul><li>#1. You always fill out the chart after performing any clinical activity and have an instructor sign it. </li></ul><ul><li>#2. Hand in your chart before leaving. </li></ul><ul><li>#3. ‘Check out’ units with the assistants before leaving clinic. </li></ul><ul><li>#4. Complete Evaluation forms </li></ul>

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