Physical Assessment Class

Case Scenarios

ObjectivesState common Approaches to

Priorities in Assessment to Action

Adapt assessment to focus on common medical diagnosis & their complications

ObjectivesIndividualize 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 LevelABCS

Second levelMPULOR

Third levelKARR

1st Level - ABCS

Airway BreathingCardiac and Circulation Signs - Vital Signs

Emergent, Life threatening and Immediate

- Things you HAVE TO DO NOW!

Emergent, Life threatening and Immediate

- Things you HAVE TO DO NOW!

2nd Level - MPUOLR

MentalPainUrinaryOther Medical ProblemsLabsRisks

Next in Urgency, may stop further deterioration

-Things you NEED to take care of.

Next in Urgency, may stop further deterioration

-Things you NEED to take care of.

3rd Level - KARR

KnowledgeActivitiesRestRelations

Important to health but can be approached more slowly and deliberately

-Things you WANT to do

Important to health but can be approached more slowly and deliberately

-Things you WANT to do

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

TREATMENTAspirin. 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.

THROMBOLITICSAlteplaseReteplaseTenecteplase

TREATMENTOther 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 ThinnersHeparinLovenoxCoumadinXareltoPlavix

TreatmentPain relievers. If your chest

pain or associated pain is great, you may receive a pain reliever, such as morphine, to reduce your discomfort.

TreatmentSTATINSLipitorCrestor

TreatmentNitroglycerin. This medication,

used to treat chest pain (angina), temporarily opens arterial blood vessels, improving blood flow to and from your heart

TreatmentBeta 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 BlockersCoregLopressorToprolTenormin

TreatmentACE inhibitors. These drugs

lower blood pressure and reduce stress on the heart.

Vasotec, Prinivil, Altace, Mavik, Lotensin, Monopril, and Accupril.

Surgical InterventionsCoronary angioplasty and

stentinghttp://www.youtube.com/watch?

v=fL3Aak_PI-ICoronary artery bypass surgery. http://www.youtube.com/watch?

v=nZNQ0uliqHI

Tests for MIECG-ArrythmiaBlood- CKMB (Creatine Kinase)

elevated in first 4-6 hoursChest 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

TreatmentAlbuterol Sulfate (Inhaler)Proventil (Inhaler)Ventolin (Inhaler)Solu Medrol (IV)Theo Dur (PO)

Lung SoundsAsthmahttp://www.youtube.com/watch?

v=YG0-ukhU1xECOPD (Chronic Obstructive

Pulmonary Disease)http://www.youtube.com/watch?

v=5JA6D1Mguh0Listen for the Difference

DocumentationSOB- Shortness of BreathNow 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

DiabetesType I (Insulin Dependent)Type II (Non-Insulin Dependent)Type 1.5 LADA (Latent Autoimmune

Diabetes in Adults)Gestational DiabetesIf left uncontrolled long enough, all

four have the same set of complications

Diabetes Complications Hyper-/

Hypoglycemia Delayed Wound

Healing-Amputation

Hypertension Eye Problems -

retinal hemorrhage See also Angina /

MI / CVA

Type IType 1 diabetes, once known as juvenile

diabetes or insulin-dependent 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/SIncreased thirst and frequent urination

(nocturia)Extreme hungerWeight lossFatigueBlurred visionYeast Infections

Test A1C

TestsFBS- Fasting Blood Sugar(70-110)_RBS- Random Blood Sugar(70-120)PPG- Post Prandial Glucose 2-3

hours after eating(<140)

Tests URINEMicroalbumin 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 URINEKetonesKetones 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 DrugsInsulin 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 IIType 2 diabetes, once known as

adult-onset or noninsulin-dependent 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 TestingGlycated hemoglobin (A1C) testAn 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 DrugsGlucophage (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 FXBreaking of the BoneClosed or Simple: No open

wound presentCompound 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 FXKeep the broken bone from

moving and prevent further injuryUsing 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

DislocationWhen 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 DislocationDeformity, Limited or

abnormal movement, swelling, discoloration, pain, tenderness, and shortening or lengthening of the affected arm or leg

TX for DislocationSame as FracturesEnsure the patients body

extremity is immobilized until it can be set.

Sprain/StrainSwelling, pain, discoloration,

and sometimes impaired movement

Frequently resemble fractures and dislocations

If in doubt, treat it as a fracture

TX for Sprain/StrainApplication 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 421Used 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 SpineNeck 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’sWatch Again Tonight!!http://www.youtube.com/watch?

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

Failure Sepsis Septic Shock

Pulmonary EmbolusSee 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

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

Anesthesia/ Surgical or Invasive Procedure

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

Phlebitis / Thrombophlebitis

Infitration / Extravasation Fluid Overload Infection / Sepsis Bleeding Air embolism (3cc)

Intravenous Therapy

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