Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Dental degree wikipedia , lookup
Dental emergency wikipedia , lookup
Special needs dentistry wikipedia , lookup
Rhetoric of health and medicine wikipedia , lookup
Patient safety wikipedia , lookup
Medical ethics wikipedia , lookup
Adherence (medicine) wikipedia , lookup
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 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: 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