Focused History and Physical Exam: Critically Ill Patients Nelia B. Perez RN MSN PCU Mary Johnston College of Nursing
Transcript
1. Focused History and Physical Exam: Critically Ill Patients
Nelia B. Perez RN MSN PCU Mary Johnston College of Nursing
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. 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. 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. 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. 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. 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. 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. 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. OPQRST Hx Severity Severity 1-10 scale gauging pain On a
scale of 1-10, 1 being the least pain youve felt and 10 being the
worst pain youve ever felt can you rate the pain?
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. 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. 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. 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. INITIAL ASSESSMENT OF THE CRITICALLY ILL PATIENT
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. 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: patients PHILOSOPHY OF MANAGEMENT
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. 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 patients PRIORITIES
20. CARDIOVASCULAR SIGNS 1. HR 2. BP 3. PERFUSION 4. OLIGURIA
5. ARREST How To Recognize?
23. 1. Initial assessment 2. Immediate management 3. Monitoring
4. Initial investigations What are the steps to be followed?
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. FLUID MANAGEMENT
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. ALGORITH OF SHOCK
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. 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. b. Glasgow Coma Scale. The Glasgow Coma Scale is an
assessment based on numeric scoring of a patients 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. c. PEARRL. Use the guide PEARRL when assessing the
pupillary response of the patient's eyes. Level of Consciousness
(CONT)
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. g. Emotion. h. Gravity. i. Exercise. j. Disease. k. Drugs.
l. Eating. m. Bleeding.
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. f. Coughing. g. Sputum.
36. FACTORS NOTED WHEN TAKING A PATIENT'S PULSE a. Pulse Rate.
b. Strength. c. Rhythm. PULSE RATE
37. A Regular. B Tachycardia. C Bradycardia, D Bounding. E Weak
(thready). F Irregular. G Intermittent (irregular).
38. WHAT CAUSES ABNORMAL TEMPERATURES? a. Infection. b.
Environmental Conditions. BODY TEMPERATURE