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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