primary clinical care manual - part 1 manual...the primary clinical care manual (pccm) is now in its...

PD3501 PCCM Overview Version1 (2014)

Primary Clinical Care ManualPD3501 - PCCM Overview

Participant Manual

Name

Community

Site

Position

Date Completed

1

PD3501 PCCM Overview Version1 (2014)2

Contents

PD3500 - Part 1 – Course Overview 4

PD3500 - Part 1: Pre-Course Survey 5

PD3501 Introduction 6

Modules 6

PD3501-1 Introduction 7

PD3501-1 Learning Activity 10

PD3501-2 Background 11


PD3501 Theory to Practice Activity 15

PD3501 Quiz 16

PD3501-1 Learning Activity Feedback 18


PD3501 Theory to Practice Activity 20

PD3501 Quiz 22

PD3500 References 23


PD3500 - Part 1 – Course Overview

Session Overview

Welcome to Induction Session, IN201 – Team Work / Scope of Practice. This session discusses the process for ensuring all health team members, working in rural and remote and primary health care settings understand and work within their scope of practice. It includes two modules, which are divided by learning activities. There is also a theory to practice activity which authenticates the learning. This is not graded, but feedback will be provided.

Modules

The first module discusses scope of practice for Aboriginal and Torres Strait Islander Health Workers, Health Practitioners, Nurses and Midwives. Module 2 reviews and discusses the process of credentialing, to ensure scope of clinical practice for Medical Officers and Dental Practitioners.

Pre-Session Survey

Before you commence, we ask you to complete a quick survey to identify current knowledge base. This will provide a baseline you can refer to once you have completed this topic.

Quiz

Once you have completed the modules in this topic, you are asked to complete an interactive quiz which is graded. You can review your results and complete the quiz as many times as you like until you feel you have mastered the topic.

Post Session Survey

When you have completed this session, we ask you to complete another quick survey to determine if we have met your learning needs.

Certificate

The final section is the completion of a personalised certificate which provides evidence of your training. Included on this is the average time the session takes which can be used for professional development points.


PD3500 - Part 1: Pre-Course Survey

Before you commence this session we ask you to take a few moments to complete the pre-session survey for this topic. This will give us some indication what your learning needs might be.

At the end of this session we will also ask you to complete another survey to see how well we have met your needs.

Please indicate the degree to which you agree to the following, by ticking the box most relevant.

I understand and am able to discuss the scope, benefits and processes around the development of the PCCMI am aware of and understand the Governance framework supporting rural, remote and isolated health practiceI am aware of and understand the legislation around medicine use and the Primary Clinical Care ManualI am confident in my ability to conduct an initial assessment and history on an adult presenting for careI am confident in my ability to conduct a physical assessment on an adult presenting for careI am confident in my ability to use the Primary Clinical Care Manual to manage resuscitation and patient emergencies re-quiring resuscitation

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PD3501 Introduction The Primary Clinical Care Manual (PCCM) is the essential guide for best practice health care in rural and remote health care settings. It is currently used by health care providers in rural and remote hospitals, multi-purpose health centres and primary health care settings. Recently its use has been extended to the Australian Defence Forces. It is produced in partnership with Queensland Health, Queensland Ambulance Service and Royal Flying Doctor Service (Queensland Section). Content is developed by an expert editorial committee, endorsed by clinical networks and supported by legislation.

Session Overview

This session provides an overview of the use of the PCCM and discusses practice preceding the development of the PCCM

Learning Objectives

•On completion of this session participants will be able to:•Describe the geographic and user scope of the PCCM•Discuss the development and use of the PCCM•Describe structures and practice preceding and following the development and implementation of the PCCM.

Modules

•Module 1: Discusses the scope, benefits and processes around the development of the PCCM•Module 2: Reviews practice prior to and following the development and implementation of the PCCM and discusses the structure changes required to support the use of the PCCM.


PD3501-1 PCCM Overview

Notes

On completion of this module participants will be able to:

•Describe the scope of use of the Primary Clinical Care Manual (PCCM)•Describe the process of development of each edition of the PCCM

Introduction

Health professionals working in rural and remote Australia often work in isolation or in small teams. Between visits, support occurs via telephone, teleconference, videoconference consultation for emergency or general practice presentations.

Staff and patients need to have confidence that the clinical care they provide and receive is evidence based, and is tailored to their setting and their population. The Primary Clinical Care Manual (PCCM) is now in its 8th edition (16 years).

The PCCM was developed after a study found that staff in remote clinics were using poor quality adhoc orders that were not evidence based to deliver primary care.

After the study, Queensland developed a unique model to address this situation. The model has 3 components.

1. Legislation – the Health (Drugs and Poisons) Regulation 1996 was changed to acknowledge the expanded role of remote area nurse who completed an accredited course.

2. Evidence base clinical guidelines – the Primary Clinical Care Manual.

3. Accredited Isolated Practice Endorsement Course This model forms the basis of quality, evidenced based care to people and supports health professionals in an expanded role living and working in rural and remote Queensland.

The Primary Clinical Care Manual has evolved over the last 16 years and now covers ALL health professions working in rural and remote health care services in Queensland.

Endorsement courses have extended to Rural Nurses, Indigenous Health Workers, Isolated Area Paramedics, Sexual and Reproductive Health Nurses, Immunisation Program Nurses.

Eligible Midwives also use the PCCM.

State medicine legislation reflects these extended roles.


Very remote, isolated, rural regional area?

The Australian Institute of Health and Welfare has a guide to remoteness classification (published in 2004) [1]. They have 3 methods of classifying remoteness … each has strengths and weaknesses.

For this presentation the Australian Standard Geographical Classification (ASGC) will be used. This is based on distance from ‘service centre’, State borders, Hospital and Health Service boundaries and / or referral pathways, retrieval service evacuation flow, all influence patient flow.

•Very remote is the largest geographical area of Australia. Has little access to goods and services.•Remote areas have restricted access to goods and services.•Outer Regional – significantly restricted accessibility of goods and services.• Inner Regional – some restrictions to accessibility of some good and services. •Major cities – they’ve got everything!! • Isolated practice area (which reflect local governments) is the term used in Queensland medicine legislation

Populations and health care facilities vary in size and equipment in these very remote, remote and regional centres. The skill mix of staff varies.

With improvements in technology, access to generalist and specialist support for patients and staff working and living in regional and remote Australia is becoming more accessible.

BUT we all need to be reading from the same song sheet – or manual! That’s where the PCCM comes in.

[1] Australian Institute of Health and Welfare 2004. Rural, regional and remote health: a guide to remoteness classifications. AIHW cat. no. PHE 53. Canberra: AIHW.

Partners

From the very 1st edition of the PCCM the Royal Flying Doctor Service (Queensland Section) and Queensland Health have worked in partnership to publish a new version every 2 years.

Why 2 years? Currently the framework which supports the PCCM states that the Health Management Protocols contained in the PCCM “shall be effective for a maximum of two (2) years from the date of endorsement by the employer”. This also ensures that clinicians have the most up to date evidence. A partnership framework is used in the editorial development of content of the PCCM.

The PCCM editorial committee as a cross disciplinary partnership using the partnering principles of mutual benefit, transparency and equity between partners in the development, review, and evaluation of editorial content.

The PCCM editorial committee in acting as partners to produce a primary health care clinical


governance manual supports the standardised, evidence based delivery of safe and high quality health care at local, regional, state, national and international levels.

The range and level of involvement of partners will be voluntary and determined by consensus of the group.

Editorial

The review and update of each edition of the PCCM follows the steps set out in the National Health and Medical Research Council - A guide to the development, implementation and evaluation of clinical practice guidelines (1999).

The Editorial Committee in its decisions around content inclusion will take into consideration the setting of clinicians - cost and resource constraints, logistics of patient care and transfer.

These principles are drawn from the NHMRC – A guide to the development, implementation and evaluation of clinical practice guidelines”.

The PCCM is used by

•State and local health services – Queensland, NSW, Victoria and other states have scattered use •Royal Flying Doctor Service •Australian Defence Forces – Army, Navy and Air Force •Queensland Ambulance Service•Aboriginal Medical Services

Its use is also increasing within

•Teaching institutions, •Regional centres, •The mining and detention industries •Offender health services•And with various other Australian government departments and in commercial settings.

PCCMs can be ordered from the PCCM website.

PCCM website


PD3501-1 Learning Activity

1. Which of the following statements about the PCCM are true?

Correct Choice

It is used across rural and remote regions

Is developed in partnership with other service providers

Based on Health Management Protocols

Can only be used by government departments

Decisions about content inclusion are based around a number factors


PD3501-2 Background

Notes

On completion of this module participants will be able to:

• Identify the issues that preceded the development of the PCCM•Discuss why it was important to develop a clinical guideline to support practice•Describe the changes to policy to support the development and implementation of the PCCM

The PCCM is the principal clinical reference for health care in rural and remote health services.

Before the PCCM

Preceding the development of these evidence based clinical guidelines clinical, practice was very different for nurses in remote settings. Prior to the PCCM there were no approved standardised clinical guidelines in Qld remote areas.

The PCCM replaced poor quality standing orders, that were not evidence based and if written had no assessment or management guidelines and contained no drug information in regards to dose or frequency.

This is an example of a standing order:

- “do not ring me in the middle of the night ... for oral antibiotics give doxycycline” - “anything with pus give Erythromycin”- “All purpose Bicilillin for everyone”

Issues / Risks

This meant practitioner did not always ring the Medical Officer as they felt they could anticipate the Medical Officer’s orders.

This meant:

•Potential for unauthorised administration / supply by staff where a Medical Officer was not or could not be contacted•Prolonged periods before patients received medication•No standard process around which was the best medication for a particular condition•No standardised processes• Inconsistent care standards•Nurses working outside their scope of practice


Collaborative Practice Framework

The use of the PCCM is based on a collaborative practice framework.

For more detailed information on collaborative practice refer to PD3502-2

What was needed?

The Rural Health Support, Education and Training (RHSET) report 1995/1996 identified that practice in the Rural and Remote health setting was not standardised.

A key recommendation was to allow health practitioners to be able to administer and supply medication

This needed to be supported by:

•Standardisation of practice, supported by policy•Governance structures•Protocols•Authorisation for non Medical staff to meet medication needs of patients•Professional role statements

Structural Changes

To progress these recommendations a Multidisciplinary group was established between the Royal Flying Doctor Service (Queensland Section), Queensland Government, Representatives from professional bodies such as The Pharmacy Guild of Australia, Clinicians, Academics.

•Changes were made to the Health (Drugs and Poisons) Regulations 1996 which authorised registered nurses who had undergone an accredited course to administration and supply medicines in certain circumstances.•Under the Health (Drugs & Poisons) Regulations 1996 - Drug Therapy Protocols were developed which outlined medicines and what is required in a Health Management Guideline•The PCCM provided standardises evidenced based support for the changes•Professional body to provide scope of practice - this occurred in accordance with the Nurses Act •Needed clear levels of delegation between health professionals…using a collaborative environment but clearly setting out the boundaries for each of the professions.

Accreditated Course

The Isolated Practice Health (Drugs and Poisons) Regulation 1996 Registered Nurse Course (RIPRN) was developed at the same time to ensure Registered Nurses working under the Isolated Practice endorsement had the knowledge and skills required to assess and manage patients effectively and safely in a culturally appropriate manner at an advanced level.


Demand came from Registered Nurses working in rural hospitals to be included and use of the PCCM.

In 2001 with a QIEP grant (under Quality Use of Medicines) the endorsement offered to isolated practice Registered Nurses was extended to include RNs in Rural Hospitals and Indigenous Health Workers working in isolated practice areas.

Progress

Since 2001 further changes have been made to the Health (Drugs and Poisons) Regulations 1996 to include:

•Midwives and Nurse Practitioners all of whom use the PCCM• In 2007 Queensland Ambulance approached QH to support the expanded scope of Paramedics in isolated practice areas, • the Health (Drugs and Poisons) Regulation 1996 was amended to incorporate Paramedics, the RIPRN course was modified and the PCCM was reviewed to include Paramedics.



1. List some of the issues for rural and remote health practitioners prior to the development of the PCCM

2. List the changes required to accommodate the use of the PCCM


PD3501 Theory to Practice Activity

The aim of this activity is to familiarise yourself with the PCCM. You will need a hard copy of the 8th Edition. Please complete the following table.

1. List the 7 sections of the PCCM 8th edition and provide a brief overview of what is included in each section

Section Name and Number Overview


PD3501 Quiz

1. The PCCM is currently the principal clinical reference for health professionals working in rural and remote Queensland

Tick Choice

True

False

2. Which of the following statements about pre-PCCM practice is correct?

Tick Choice

There was potential for unauthorised administration / supply of medication

Standing orders were evidence based

There was no risk to patients if standing orders were used

Standing orders had assessment and management guidelines

Patients went for long periods without medication


3. Which of the following were identified as required in rural and remote practice to ensure safe supply and administration of medication?

Tick Choice

New standing orders

More Medical Officers to cover the night shift

Changes to the Health (Drugs & Poisons) regulations 1996

Pharmacists available to supply medication 24 hours a day

Development of Drug Therapy Protocols

Clear levels of delegation for health professionals

4. All registered nurses were able to supply and administer medications once the PCCM became available.

Tick Choice

True

False


PD3501-1 Learning Activity Feedback

1. Which of the following statements about the PCCM are true?

Correct Choice

It is used across rural and remote regions

Is developed in partnership with other service providers

Based on Health Management Protocols

Can only be used by government departments

Decisions about content inclusion are based around a number factors



1. List some of the issues for rural and remote health practitioners prior to the development of the PCCM

Answer

No approved standardised clinical guidelines for remote practiceAn order from Medical Officer was required before medication could be administeredStanding orders that were not evidence based were often usedPotential for hazardous and unauthorised administration of medicationProlonged periods before patients received medicationInconsistent standards of care

2. List the changes required to accommodate the use of the PCCM

Answer

Changes to the Health (Drugs and Poisons) regulationsDevelopment of Drug Therapy ProtocolsDevelopment of Health Management ProtocolsReview and develop Scope of Practice for Nurses and Health WorkersIdentify levels of rights of supply and administration of medicationsDevelop and implement endorsed training courses


PD3501 Theory to Practice Activity

The aim of this activity is to familiarise yourself with the PCCM. You will need a hard copy of the 8th Edition. Please complete the following table.

1. List the 7 sections of the PCCM 8th edition and provide a brief overview of what is included in each section

Section Name and Number Overview

Patient assessment and transport

Provides information on assessment process and describes each step of the process. The section also describes the process for preparing a patient for transport including the handover to the Medical Officer and pain management

Emergency Provides information on and responses to emergency presentations including resuscitation; cardio-vascular and neurological emergencies; trauma and injuries; acute wounds; burns; environmental emergencies; gastrointestinal and genitourinary emergencies; poisoning and drug emergencies and toxinology (bites and stings).

General Provides information on and responses to emergency presentations including resuscitation; cardio-vascular and neurological emergencies; trauma and injuries; acute wounds; burns; environmental emergencies; gastrointestinal and genitourinary emergencies; poisoning and drug emergencies and toxinology (bites and stings).

Mental health and sub-stance misuse

Provides information on and responses to mental health presentations; suicide risk; behavioural emergencies; delirium; dementia; psychotic, mood and eating disorders; sleep problems; alcohol misuse, intoxication and withdrawal; smoking and drugs and other substances.

Sexual and reproductive health

Provides information on and responses to women’s health checks and antenatal health; hypertension and birthing issues; labour, birth and postnatal care; contraception and sexually transmitted infections

Paediatrics Provides information on history and physical examination of a child; Responses to a child with fever, cough, stridor, vomiting, abdominal pain and chronic diarrhoea; Meningitis; ear; respiratory; gastro-intestinal, urinary tract and bone problems; Immune complications and abuse and neglect

Immunisation Provides information on the Australian immunisation program, sexual health immunisation program and tetanus immunisation.


PD3501 Quiz

1. The PCCM is currently the principal clinical reference for health professionals working in rural and remote Queensland

Tick Choice

True

False

2. Which of the following statements about pre-PCCM practice is correct?

Tick Choice

There was potential for unauthorised administration / supply of medication

Standing orders were evidence based

There was no risk to patients if standing orders were used

Standing orders had assessment and management guidelines

Patients went for long periods without medication


3. Which of the following were identified as required in rural and remote practice to ensure safe supply and administration of medication?

Tick Choice

New standing orders

More Medical Officers to cover the night shift

Changes to the Health (Drugs & Poisons) regulations 1996

Pharmacists available to supply medication 24 hours a day

Development of Drug Therapy Protocols

Clear levels of delegation for health professionals

4. All registered nurses were able to supply and administer medications once the PCCM became available.

Tick Choice

True

False

PD3502 Governance Framework Version1 (2014)

Primary Clinical Care Manual

PD3502 - Governance FrameworkParticipant Manual

Name

Community

Site

Position

Date Completed

1

PD3502 Governance Framework Version1 (2014)2

Contents

PD3502 Introduction 3PD3502-1 Governance Framework - Legislation 4PD3502-1 Learning Activity 7PD3502-2 Governance Framework - Guidelines (PCCM) 8PD3502-2 Learning Activity 11PD3502-3 Governance Framework - Workforce development 12PD3502-3 Learning Activity 15PD3502 - Theory to Practice Activity 16PD3502 - Quiz 17PD3502-1 Learning Activity Feedback 20PD3502-2 Learning Activity Feedback 21PD3502-3 Learning Activity Feedback 22PD3502 - Theory to Practice Activity 23PD3502 Quiz Feedback 25


PD3502 Introduction The Primary Clinical Care Manual (PCCM) guides the clinical practice of non-medical staff working in isolated practice areas. Its use is legislated by State and Territory Acts and Regulations. The PCCM is one of three components of the Governance Framework for rural, remote and isolated practice. The other components are legislation which dictates practice and workforce education and endorsement which supports expanded practice for health professionals.

Session Overview

This session introduces the Governance Framework for best practice rural, remote and isolated prac-tice including relevant legislation, evidence based guidelines (PCCM) and workforce development strat-egies.

Learning Objectives

On completion of this session participants will be able to:

• Identifyanddiscussthethreecomponentsofthegovernanceframeworkforrural,remoteand isolated practice including: The Health (Drugs and Poisons) Regulation 1996 The scope and use of the PCCM Workforce development strategies• DiscussthegovernanceofuseofthePCCMinjurisdictionsoutsideofQueensland

Modules

• Module1introducestheLegislativeFrameworksupportingrural,remoteandisolatedpractice• Module2discussestheuseofthePCCMand• Module3providesinformationonworkforcedevelopmentstrategiestosupporttheuseofthe PCCM

Learning Activities

A learning activity is included in each module – this should be completed before moving to the next module.


PD3502-1 Legislation

Notes

Learning Objectives

On completion of this module learners will be able to:

• Identify the three components of the governance framework for rural, remote and isolated practice•DiscusstheHealth(DrugsandPoisons)Regulation1996•DefineaDrugTherapyProtocol(DTP)•DiscusstheroleofaDTPinsupportingrural,remoteandisolatedpractice

The components of Governance Framework

The components which support rural, remote and isolated practice has three main components:

1. Health (Drugs and Poisons) Regulations 1996 - DrugTherapyProtocolsforeachhealthprofessionalsitsundertheregulations2. Evidence based clinical guidelines (PCCM) which ContainsclinicalcareguidelinesandHealthManagementProtocols. The principal of care is a collaborative practice model3. An accredited course to prepare health professionals for an advanced practice role to supply and administermedicationsusingtheHealthManagementProtocolsinthePCCM

Legislation

TheHealth(DrugsandPoisons)Regulations1996providesthelegislativeframeworkforrural,remoteand isolated practice.

DrugTherapyProtocols(DTP),ClinicGuidelines(PCCM),HealthManagementProtocols(HMP)andworkforce development (endorsement training) are supported by the legislation.


Health (Drugs & Poisons) Regulations 1996 (QLD)

TheQueenslandHealth (Drugs&Poisons)Regulations1996was legislated in rural hospitals andisolated practice areas.

Thisidentifiedtheneedforadrugtherapyprotocol(DTP)whichauthorisedtheadministrationand/orsupply of medicines in designated practice areas for:

•Registered nurses •Rural and isolated practice endorsement, sexual health, immunisation, •Midwives•Ambulanceofficers–isolatedareaparamedics•AuthorisedHealthWorkers

HealthManagementProtocolsinthePCCMcontaindrugboxes.

Drug Therapy Protocols (DTP)

ADrugTherapyProtocol(DTP)is:

•A“certifieddocumentpublishedbytheDepartmentstatingcircumstancesinwhich,and conditions under which, a person who may act under the protocol can use a stated controlled or restricted drug or poison for stated purposes”.•That is the restrictions and / or conditions under which the endorsed or authorised health professional may administer or supply a medicine. • ForexampleiftheyneedtoconsultMedicalOfficerorNursePractitionerbefore administering or supplying a medicine

AND• The approved route of administration of a medicine – Oral , IV, PR

AND • Medicine for adults only

OR• Maximum dose allowed to be administered e.g. Maximum Morphine dose is 10 mg

DrugTherapyProtocolAppliestoindividualhealthprofessionalswhohaveendorsement/authorisation under the Health (Drugs & Poisons) Regulations 1996.

TheDTPalsosetsoutwhatisrequiredinaHealthManagementProtocol(HMP)andtheresponsibilitiesofthehealthprofessionalpractisingundertheDTP.

TheDTPliststhemedicinesapprovedforuseundertheDTP.


CurrentlyhealthprofessionalwithDTP’swhoutilisethePCCMtoguidetheirextendedpracticeroleare: • IndigenousHealthWorkerIsolatedPracticeArea•SexualHealthProgramNurse•QueenslandAmbulanceServiceIsolatedPracticeAreaParamedic•RuralandIsolatedPracticeAreaEndorseNurse•Midwives• ImmunisationProgramNurse

TheendorsementofHealthManagementProtocols(HMP)byChiefExecutiveOfficerofaHospitalandHealthServiceortheChiefExecutiveOfficerofanon-QueenslandHealthemployingorganisation.

TheDTPstatestheHealthManagementProtocol(s)(HMPs)shallbeeffectiveforamaximumof2years from the date of endorsement by the employer.

Other states and Territories

TheadvancedpracticeofHealthprofessionalsnotemployedinQueenslandarenotgovernedbyQueenslandlegislation.

Theirpracticeisgovernedbytheirspecificstateorfederallegislation.

ModulePD3502-3providesmoreinformation.



1. Listthethreecomponentsofthegovernanceframeworkforbestpracticerural,remoteand isolated practice.

Answers


PD3502-2 Guidelines (PCCM)

Notes


•DiscussthefunctionandcomponentsofthePrimaryClinicalCareManual(PCCM)• ListtheareasthePCCM’suseisendorsedfor• ListthehealthpersonnelwhoareeligibleforendorsementtousethePCCM• IdentifythecomponentsofaHealthManagementProtocol

Evidence Based Guidelines

The second component of best practice rural, remote and isolated practice is Evidence Based Guide-lines (EBG) which includes:

•HealthManagementProtocols•Collaborative Practice Model•The PCCM is the evidence based guideline for this

The Primary Clinical Care Manual (PCCM)

The Primary Clinical Care Manual is the principal clinical reference for health care in rural and remote health services.

ThePrimaryClinicalCareManual(PCCM)containsevidencebasedHealthManagementProtocols(HMP)andClinicalCareGuidelines(CCG)forapproximately318presentationtypescustomisedtothepractice of rural and remote health care settings.

Endorsed for use

ThePCCMiscurrentlyendorsedforusebytheRoyalFlyingDoctorService(QueenslandSection)and19facilitiesacross15hospitalandhealthservicesinQueenslandHealth.

The PCCM is endorsed for use:

•ScheduledMedicineEndorsedRuralandIsolatePracticeRegisteredNursecourse– QueenslandandVictoria•OffenderHealthServices–13publicand2privateinQueenslandandWesternAustralia•Australian Air Force•RoyalAustralianNavy•Australian Army •QueenslandAmbulanceService


The PCCM is also used as a key resource for:

•FarWestNewSouthWalesLocalHealthDistrict•WesternNewSouthWalesLocalHealthDistrict•HunterNewEnglandLocalHealthDistrict•VictoriaHealthServices•QueenslandAboriginal&IslandHealthCouncil(QAIHC)–85AboriginalMedicalServices•Mining sites•Universities

Who uses the PCCM

The PCCM is the key resource to support endorsed or authorised health professionals working in an expanded role including:

•ScheduledMedicineEndorsedRegisteredNurses•AuthorisedIndigenousHealthWorkers(IHW)• Isolated Practice Area Paramedics (IPAP)

The PCCM is also used to guide the enhanced practice of:

•SexualandReproductiveHealthProgramAuthorisedRegisteredNurse• ImmunisationProgramAuthorisedRegisteredNurses•Endorsed Midwives•Medics–RoyalAustralianNavy•MedicalOfficers•RegisteredNurses

Collaborative practice framework

Collaborative practice is the term used to describe the practice relationship between registered nurse, medicalofficer,IndigenousHealthWorkerandotherhealthprofessionalswhowillusethePCCMasa guide to practice.

The collaborative practice relationship incorporates the due notions of collaboration and delegation.


Thedefiningcharacteristicsofthecollaborativepracticerelationshipare:

•Mutualrespectandacknowledgmentofeachprofession’srole,scope of practiceandunique contribution to health outcomes•Clearly stated protocols and guidelines for clinical decision-making which comply with relevant legislation and are supported by the health facility and the health organisation•Clearlydefinedlevels of accountability with an acceptance that joint clinical decision making is an integral component of collaborative practice•A belief that the best health outcomes are achieved when well prepared health professionals work in collaboration and partnership in both the practice and educational setting

Health Management Protocols (HMP)

Health management Protocols are contained in the PCCM which makes up the evidence based guidelines: They clearly identify:

1. The procedures for:

•Clinical assessment•Management•Follow-up of patients•Recommended drug therapy for the relevant clinical problem

AHealthManagementProtocolalsoprovides:

2. Aclinicalindicationortimewhenmedicalreferral/consultationmustoccurforthatcondition3. The name, form and strengthofthedrugandthecondition/situationforwhichitisintended4. The recommended dose of the drug5. The route of administration6. The frequency and duration of administration of the drug

Content of Health Management Protocol (HMP)

ThefollowingmeetsthecriteriasetoutintheDrugTherapyProtocol(DTP)forcontentwhichmust beinaHealthManagementProtocol(HMP):

•May present with• Immediate management•Clinical assessment•Management (includes a drug box)•Follow up•Referral and or consultation



1. Whichofthefollowingdefinecollaborativepractice?

Tick Answers

Respect for scope of practice

Protocols which comply with legislation

Definelevelsofaccountability

Joint decision making

Healthprofessionalsworkinginpartnership


PD3502-3 Workforce development


•Discussthethirdcomponentofthegovernanceframeworkforrural,remoteandisolatedpractice• ListtheendorsementsapplicabletouseofthePCCM•DiscussthegovernanceofuseofthePCCMinjurisdictionsoutsideofQueensland

Accredited Courses

The third component of governance is accredited courses including:

•ScheduledMedicinesEndorsedRuralandIsolatedPracticeRegisteredNurse(SMR&IP)•OtherauthorisedhealthprofessionaltrainingundertheirDTP

The Primary Clinical Care Manual is the key resource for Scheduled Medicines Endorsed Rural and IsolatedPracticeResistedNurses(SMR&IP)course,andotherauthorisedhealthprofessionalsundertheirDTP.

OnsuccessfulcompletionofaninemonthcourseRegisteredNursescanapplytotheNursingandMid-wiferyBoardofAustraliaforendorsementasaScheduledMedicine(ruralandisolatedpractice)Nurse.

Other accredited courses include:

•AuthorisationcoursesforImmunisationProgramNurses(IPN)•AuthorisedIndigenousHealthWorkers(IHW)•Midwife(MID)•SexualandReproductiveHealthNurse(SRH)•QueenslandAmbulanceIsolatedPracticeAreaParamedic(IPAP)• IndigenousHealthWorker–IsolatedandSexualHealthauthorisation

Regulatory / professional bodies

•Professionalbodiesdefinethescopeofpracticeforindividuals•Accreditation for endorsement to expand Scope of Practice is in accordance with professional legislation•Professional statement includes responsibility and accountability in expanded role

Governance in Other Jurisdictions

Each State and Territory has different legislation that governs access to medications by different groups of clinician, Clinicians, paramedics and defence health personnel must ensure they follow the


requirementsoftheoverarchingpolicythatdictatespracticeintheirparticulararea.

This may limit administration of some medication included in the PCCM but the other information on clinical response provides valuable information.

New South Wales

ThePCCMinusedinmanypartsofruralandremoteNewSouthWales.

StandingOrdersforDTPSmaybeobtainedfrommedicalofficersinaccordancewithNewSouthWalesHealthPolicyandstatelegislationforauthorisedregisterednursesandmidwivestoensurethatsafeand timely health care is provided to patients living in rural and remote areas.

Victoria

In 2010 legislative amendments were passed to enable registered nurses who are endorsed by law, to supplyandoradministerSchedule2,3,4or8poisonsapprovedbytheMinisterforHealth.

In2012theMinisterforHealthapprovedthelistofparticipatinghealthservicesandalimitedrangeofmedicines which could be administered or supplied by endorsed nurses.

This allowed trainedRIPERNS to practice in accordancewithQueensland’sPrimaryClinicalCareManual and supply medicines at authorised rural health services. ThelistofmedicinesapprovedbytheMinisterareasubsettotheHealthManagementProtocolsinthePCCMthatreflecttheconditionsthatarebothclinicallyappropriateItwasdeterminedthattheHealthManagementProtocols(HMP)intheQueenslandPCCMwouldbetheclinicalstandardfortheuseandsupplyofmedicinesbyRIPERNS.Schedule8drugsareexcluded.

Australian Defence Force

The alignment of the PCCM to the National Health andMedical Research Council Guidelines on Clinical Protocols and its evidence based approach to content has allowed its use in the Australian DefenceForces.

IntegrationandimplementationplansprovidedbytheDefenceForcesguidetheuseofthePCCMbyAuthorisedhealthpersonnelinthefield,atseaandondeployment.

In summary

Bestpracticeclientcare in rural, remoteand isolatedpracticeareas isprovidedbyqualifiedhealthprofessionals working at advanced practice role.

These professionals are authorised to administer and or supply scheduled medicines according to standardised evidence based clinical guidelines.


Bringing it all together

The PCCM provides the evidence base that supports the legislation to ensure medication safety is assured.

Itbringsallthecomponentsrequiredtoensurehealthpractitionersareabletosafelyadministerandsupply medication which includes:

•Support by professional bodies, •Clear boundaries for the health practitioner, •Health(Drugs&Poisons)Regulations•DrugTherapyProtocol•HealthManagementProtocol

Professional bodies

Clear boundaries

Health (Drugs & Poisons)

Regulations

Drug Therapy Protocol

Health Management

Protocol

= Medication Safety

= Safe patient care



1. This image depicts the components of what is required for best practice rural, remote and isolated clinical practice. Please complete.


PD3502 - Theory to Practice Activity

Pleaseanswerthefollowingquestionsrelevanttoyourjurisdictionandrole

1. What legislation dictates your practice in a rural, remote or isolated practice setting

Role/Location Answer

Allclinicians-Qld

Clinicians-NonQld

Clinicians-ADF

2. What accredited training may be available to you to support you in the provision of rural, remote andisolatedpracticehealthservices?

Role/Location Answer

RegisteredNurses(QLD,VIC)

RegisteredNurses(All)

IndigenousHealthWorkers(QLD)

IndigenousHealthWorkers

Paramedics(QLD)

Paramedics

ADFmedicalpersonnel

Endorsed practitioners

Non-endorsedpractitioners


PD3502 - Quiz

1. WhichofthefollowingstatementsaboutaHealthManagementProtocoliscorrect?

Tick Choice

HMPsarealistofdrugs

HMPsaregovernedbyaneditorialreviewcommittee

HMPsareonlyrelevantforParamedicsandIndigenousHealthWorkers

HMPsaregovernedbylegislation

HMPssupportanddetailtheclinicaluseofdrugs

2. Which of the following are authorised to administer and or supply medication in a designated practicearea?

Tick Choice

RuralandIsolatedPracticeEndorsedRegisteredNurses

Isolated Practice Endorsed Paramedics

RegisteredNursesworkinginGPclinics

AuthorisedIndigenousHealthWorkers

SexualHealthEndorsedRegisteredNurses


3. TheonlycliniciansabletousethePCCMtosupportpracticeareEndorsedRegisteredNurses.

Tick Choice

True

False

4. HealthManagementProtocolsmustincludewhichofthefollowing?

Tick Choice

Procedure for clinical assessment

Name,formandstrengthofadrug

Recommended dose of a drug

Route of administration of a drug

Frequencyanddurationofadrug


5. WhichofthefollowingstatementsaboutaDrugTherapyProtocolaretrue?

Tick Choice

Appliestoindividualhealthprofessionalswhohaveendorsement/authorisation.

Applies to anyone using the PCCM

ListsthemedicinesapprovedforuseundertheDTP

States circumstances in which a person can use a controlled or restricted drug or poison

Outlines clinical assessment of a presentation



Listthethreecomponentsofthegovernanceframeworkforbestpracticerural,remoteand isolated practice.

Answers

Health(DrugsandPoisons)Regulations1996 Evidence Based GuidelinesAccredited Training



2. Whichofthefollowingdefinecollaborativepractice?

Tick Answers

Respect for scope of practice

Protocols which comply with legislation

Definelevelsofaccountability

Joint decision making

Healthprofessionalsworkinginpartnership



This imagedepicts thecomponentsofwhat is required forbestpractice rural, remoteand isolated clinical practice.

= Medication Safety

= Safe patient care

Professional bodies

Clear boundaries

Health (Drugs & Poisons)

Regulations

Drug Therapy Protocol

Health Management

Protocol


PD3502 - Theory to Practice Activity Feedback

Pleaseanswerthefollowingquestionsrelevanttoyourjurisdictionandrole1. What legislation dictates your practice in a rural, remote or isolated practice setting

Role/Location Answers

Allclinicians-Qld The Health (Drugs and Poisons) Regulations 1996

Clinicians–NonQld Relevant state policy and legislation

Clinicians–ADF Policy that dictates practice

2. What accredited training may be available to you to support you in the provision of rural, remote andisolatedpracticehealthservices?


RegisteredNurses(QLD,VIC)

Scheduled Medicines Endorsed Rural and Isolated Practice Registered Nurse(SMR&IP)

RegisteredNurses(All)

AuthorisationCourseforImmunisationProgramNurse(IPN)SexualandReproductiveHealthNurse(SRH)

IndigenousHealthWorkers(QLD) AuthorisedIndigenousHealthWorker(IHW)

IndigenousHealthWorkers None

Paramedics(QLD) QueenslandAmbulanceIsolatedPracticeAreaParamedic(IPAP)

Paramedics None

Paramedics None


3. HowdoesthePCCMsupportyourpracticeinarural,remoteorisolatedpracticesetting?


Endorsed practitionersProvidesDrugTherapyProtocols,HealthManagementProtocolsand Clinical Guidelines for a variety of presentations – this includes supply and administration of medicines for applicable presentations

Non-endorsedpractitionersUsed as a clinical guideline only. Practitioners must follow the re-quirementsofthepolicythatdictatestheirpractice.Thiswilllimittheability to supply and administer medicine.


PD3502 Quiz Feedback

1. WhichofthefollowingstatementsaboutaHealthManagementProtocoliscorrect?

Tick Answers

HMPsarealistofdrugs

HMPsaregovernedbyaneditorialreviewcommittee

HMPsareonlyrelevantforParamedicsandIndigenousHealthWorkers

HMPsaregovernedbylegislation

HMPssupportanddetailtheclinicaluseofdrugs

2. Which of the following are authorised to administer and or supply medication in a designated practicearea?

Tick Answers


Isolated Practice Endorsed Paramedics

RegisteredNursesworkinginGPclinics

AuthorisedIndigenousHealthWorkers



3. TheonlycliniciansabletousethePCCMtosupportpracticeareEndorsedRegisteredNurses.

Tick Choice

True

False

4. HealthManagementProtocolsmustincludewhichofthefollowing?

Tick Answers

Procedure for clinical assessment

Name,formandstrengthofadrug

Recommended dose of a drug

Route of administration of a drug

Frequencyanddurationofadrug


5. WhichofthefollowingstatementsaboutaDrugTherapyProtocolaretrue?

Tick Answers

Appliestoindividualhealthprofessionalswhohaveendorsement/authorisation.

Applies to anyone using the PCCM

ListsthemedicinesapprovedforuseundertheDTP

States circumstances in which a person can use a controlled or restricted drug or poison

Outlines clinical assessment of a presentation

PD3503 Medicines and the PCCM Version1 (2014)


PD3503 - Medicines and the PCCMParticipant Manual

Name

Community

Site

Position

Date Completed

1

PD3503 Medicines and the PCCM Version1 (2014)2

Contents

PD3503 - Introduction 3

PD3503 - Legislation 4

PD3503-1 - Learning Activity 7

PD3503-2 - Administering and Supplying 8


PD3503-3 - Safe Practice 15


PD3503 - Theory to Practice Activity 22

PD3503 - Quiz 27

PD3503 Activity Feedback 29

PD3503 - Quiz 34


PD3503 - Introduction

The Primary Clinical Care Manual (PCCM) guides the clinical practice of non-medical staff working in isolated practice areas. Its use is legislated by State and Territory Acts and Regulations. The aim of the PCCM is to support practice, standardised by Health Management Protocols (HMP) and Clinical Care Guidelines (CCG) which provide information on:

• Patientpresentation• Clinicalassessment,managementandfollow-up;• Recommendedmedicineintext(CCG)ordrugbox(HMP)• Boundariesforescalation

Session Overview

This session provides introduces the legislation behind the scheduling of medicines and the use of HMPs and CCGs to ensure safety in medicine administration and supply

Learning Objectives

On completion of this session participants will be able to:

• Explainschedulingofmedicinesandhowthisimpactsonpractice• DifferentiatebetweenaClinicalCareGuidelineandHealthManagementProtocolinrelationto medicine use• UsethePCCMasguideinadministeringandorsupplyingmedicines

Modules

• Module1discussestheschedulingofmedicines• Module2providesintroductoryinformationontheuseofthePCCMwithaspecificfocusonthe administration and or supply of medicines


PD3503 - Legislation

Learning Objectives

On completion of this session participants will be able to: •Understandthelegislativeframeworkforschedulingmedicinesandpoisons•Discusstheclassificationsystemandwhatitmeans•DiscusshowschedulingisappliedinthePCCM

Legislative Framework

TheTherapeuticGoodsAct1989isanationalclassificationsystemtoregulateavailabilityofmedicinesand poisons.

Thescheduleamedicineisclassifiedatisbasedonitstoxicity,purposeoruse,potentialforabuse,safety and storage requirements for the substance.

Control of Drugs and Poisons

Control of drugs and poisons commence at the National level then, EachStateandTerritoryhas

•Acts e.g. Health Act 1937 (Qld) issue of licences, restrictions, conditions, records etc.•Regulationse.g.Health(Drugs&Poisons)Regulation1996coversdaytodayadministrationof act,•Such as packaging, labeling, storage, information about who has authority to prescribe, administer, supply drugs•Acts and regulations provide the legislative framework around all aspects of medicines

Schedule of Medicine

TheStandardfortheUniformSchedulingofMedicinesandPoisonsisestablishedunderSection52Dof the Therapeutic Goods Act 1989.

•Thisisanationalclassificationsystemwhichisputinplacetoregulatetheavailabilityofmedicines and poisons to protect the public•Classifiedinto9schedulesbasedonthedegreeofcontroloveravailability•Published in the poisons standard


Poisons Standard

PoisonsStandardistheStandardforUniformSchedulingofMedicinesinPoisons,whichisupdatedon an annual basis.

AlthoughtheSUSMPispublishednationally,itiseachstateandterritoriesthatgivelegaleffectforthe schedules.

Promotes uniform:

•Scheduling of poisons throughout Australia•Signal headings for labels • Labeling&packagingrequirements•Additional controls on availability and use of poisons

Unscheduled

Unscheduledsubstancesdonotbelongtoanyoftheaboveschedules.Manyofthesepreparationsare also sold in supermarkets in addition to pharmacies.

Examplesinclude:

•Antacids•Ranitidine in small packs (larger packs are schedule 2)• Ibuprofen200mginsmallpacks(<24;largerpacksareschedule2)•Paracetamol500mginsmallpacks(<24;largerpacksareschedule2)

Schedule 2

Schedule 2 medicines are also known as Pharmacy Medicine. They are generally safe to use and include advice or counselling if necessary.

•Packs of more than 24 of these medicines are available from pharmacies or a licensed person. •Packs of less than 24 can be sold from any shop. Paracetamol and ibuprofen are schedule 2 medicines.

Schedule 3

These medicines are available from pharmacies without a prescription. Salbutamol Aerosol is a Schedule 3 medicine.


Schedule 4

Schedule 4 drugs are Prescription only medicines, they are also known as restricted medicine.

They require professional management and monitoring by licensed persons. Schedule 4 drugs are only available on prescription and include most antibiotics, Midazolam and Salbutamol Nebules.

Schedule 8

Schedules 8 medicines are controlled substances – possession without authority is illegal.

Controlled drugs are restricted The manufacture, supply, distribution, possession and use is restricted and strictly controlled.

Schedule 8 drugs have a high potential for abuse, misuse and physical or psychological dependenceExamplesofschedule8drugsincludePethidine,MorphineandFentanyl.

Application in PCCM

It is important to understand the scheduling of medicines as the information is included in the PCCM.

TheHealthManagementProtocolscontainadrugboxthat:

• Indicates the schedule of the medicine or poison •WhoisauthorisedunderwhichDTPtoadministerorsupplythemedicine

Different schedules have specific handling, storage and reporting requirementswhich practitionersneed to be aware of.


PD3503-1 - Learning Activity

1. Completethefollowingstatements-Fillintheblankspace

1.1 The Therapeutic Goods Act 1989 regulates medicine can be administered and supplied.

1.2 Professional and State / Territory legislates can administer or supply medicines.


PD3503-2 - Administering and Supplying

Learning Objectives

On completion of this session participants will:

•Defineadministerandsupplyofamedicine•Explainschedulingofmedicinesandhowthisimpactsonpractice•DifferentiatebetweenaClinicalCareGuidelineandHealthManagementProtocol inrelationto recommended medicine supply and or administration

Definitions

Administer* means to ‘give a single treatment dose of the drug or poison, to be taken by the patient immediately’.

Supply* means to ‘give, or offer to give, a patient 1 or more treatment dose (s) of the drug or poison, to be taken by the patient during a certain period’

*Health (Drugs and Poisons) Regulation 1996 (Qld)

Who can administer and / or supply

Allhealthprofessionalshaveadefinedscopeofpracticetheymustadhereto.

Administrationandsupplyofmedicinesisinfluencedby:

•Schedule of the medicine•Health professional e.g. registered nurse, enrolled nurse, scheduled medicines nurse, nurse practitioner,medicalofficer,alliedhealthprofessional•State and / or Territory Act and Regulation• Local policy

Clinicians are advised to check local policy regarding the administration and supply of medicines which are outlined under State and Territory legislation.


Using the PCCM

One of the main reasons for the development of the PCCM was to provide evidence based standards around the supply and administration of medicines by non-medical staff.

The Primary Clinical Care Manual contains two types of guideline.

They are Health Management Protocols (HMP) and Clinical Care Guidelines (CCG).Health Management Protocol and Clinical Care Guidelines both contain information on:

•Patient presentation•Clinicalassessment,managementandfollow-up;•Recommendedmedicineintext(CCG)ordrugbox(HMP)•Boundariesforescalation


Health Management Protocol

HealthManagementProtocolsareidentifiedbyasymbol(whichlookslikesheetsofpaper)intheindexandbodyoftextinthemanual.

Theycontaindrugboxeswithdetailedinformationonmedicinesforadministrationandorsupplyinsome circumstances.

ThisisanexampleofaHealthManagementProtocolwhichisidentifiedbythesymbolagainstthetitle


HMP - Drug Box

ThisisanexampleofadrugboxthatmaybeincludedintheHealthManagementProtocol.

•Thefirstrowidentifiesthedrugschedulenumber,nameanddrugtherapyprotocol–whichidentifies who can supply or administer the medication.•The second and third rows provide information on actions that ensure clinicians are working within their scope of practice•Theembeddedboxidentifiesthemedicineformandstrength,routeofadministration,recommended dose and dosage requirements•The fourth rowprovidesextra informationon themedicationand thefifth row, required further action if there is an adverse event

ThedrugboxisincludedattheendoftheHealthManagementProtocol.

Schedule 4 AzithromycinDTP

IHW/SM R&IP/ IPAP/SRH

Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO/NPScheduledMedicinesRuralandIsolatedPracticeRegisteredNurseandSexual&Reproductive

Health Program Authorised Registered Nurse may proceed

Form Strength Route of administration

Recommended Dose Duration

Tablet 500mg Oral 1gStat

Given under observation

Provide Consumer Medicine Information: may be taken with or without foodManagementofassociatedemergency:ConsultMedicalOfficer

[1]

Thetoprighthandcornerofthedrugboxalertstheauthorised/endorsedhealthprofessionalastowhocanpractiseundertheauthorisationoftheirDTP.

Inthisexample,thefollowinghaveauthority.IHW (Authorised Indigenous Health Worker),

SMR&IP(ScheduledMedicinesRuralandIsolatedPracticeRegisteredNurse),IPAP (Isolated Practice Area Paramedic),

SRH(SexualandReproductiveHealthProgramRegisteredNurse).


Clinical Care Guideline

ClinicalCareGuidelineswhichhavenoidentificationanddonotcontaindrugboxesbutmaycontainrecommendedmedicinesinthetext.ThisisanexampleofaClinicalCareGuideline–notethereisnosymbolagainstthetitle.


Non-DTP Drug Box

DrugboxesthatdonotcontainmedicinesfromaDTPareshadedgreytoenableeaseofdifferentiationfrommedicinesfromhealthprofessionalDTP’s.

Schedule Nil Selenium Sulphide shampoo NON DTP

Authorised Indigenous Health Workers and Isolated Practice Area Paramedic may proceed

Form Strength Route of administration

Recommended Dose Duration

Shampoo 25 mg/mL (2.5%) Topical

Apply liberally over and beyond the affected area.

Leave on for 10 mins then wash off

Repeat daily for 2 weeks

Managementofassociatedemergency:ConsultMedicalOfficer



1. Matchtheword/statementwithitsdefinition.

Word / Statement Definition

1 Administer

2 Supply

3 Health Management Protocol

4 Clinical Care Guideline


PD3503-3 - Safe Practice


•Discusstheprocessforensuringcompleteandaccurateinformationaboutaclientisgiventoa MedicalOfficer•Discussthesaferecognitionandmanagementofadeterioratingpatient•Discusstheappropriateuseofpointoftestingdiagnostics•Discussthestepsforensuringsafemedicinereconciliation

Consulting Medical Officer

If it is necessary to consult with a Medical Officer, findings need to be presented in a clear and methodical way.

Itisofteneasiertowritefindingsdownfirst(timepermitting)sothatinformationisnotlostorforgottenMedicalOfficersshouldalwaysbeconsultedifyouarenotsureaboutapatient.

If you think a patient may need retrieval, advise the MO early in case there is patient deterioration and/or specialist or urgent resources need to be allocated e.g. rescheduling of aircraft who have already been tasked with other work may be required.

TaketheopportunitytodiscussdifficultiesandproblemsandgeneralorspecificcasesorissueswiththeMedicalOfficeratthenextclinicvisit.


IdentificationofboththecallerandthereceivingMedicalOfficerisimportantforexample:

•Startwithyournameandyourrole•Identifywhereyouarecallingfromandwhy

Situation and status can be communicated by statements such as

•“Ihaveapatient(andthenprovidename,ageandgender)……•Thenprovideclinicalimpressionorsuspected“diagnosis”e.g“Thepatienthas…”•Describebrieflyclinicalstatus“Thepatientisstableordeterioratingorimproving”•“Thepatientpresentedwith....”willallowyoutocommunicatethepresentingsigns&symptoms

Observations

Convey the most recent observations including the patient’s general appearance (and weight for all children)

Background and history should include:

•Patienthistoryincludingpresentingproblem,backgroundproblemsandcurrentissues•Evaluationthroughphysicalexaminationfindings,investigationfindingsandcurrentdiagnosis,and•Managementtodateandwhetheritisworking

Assessment and actions

Communicate what needs to be done and what has already been done

Responsibilityandriskmanagementisthefinalstepwhereanyrisksarealsoidentifiedandtherespon-sibilityformanagementandfollowupisidentified.

Thiscanbeconfirmedthroughreadingbackthecriticalinformation,especiallyifnotcommunicatingfacetoface,forexamplecovering:Re-identify the caller and location, patient details, presenting concern(s), observations, impression/diagnosis and orders for investigation, treatment and follow-up

Recognition and management of the deteriorating patient

ThePCCMadvocatesuseoftheChildren’sEarlyWarningTool(CEWT)andtheQueenslandAdultDe-teriorationDetectionSystem(Q-ADDS)formswhichareearlywarningandresponsesystemtoolsthat:

•Enableobservationstoberecordedgraphicallyandseparately•Providevisualcueswhenobservationsareabnormaland•Provideanoverallscorethatcorrespondswithanaction.


These actions change with observed or increasing deterioration and may include:

• an increase in the frequency of patient observations and/or• earlynotificationofapatienttotheMedicalOfficerand/or•ClinicianescalationofcaretoahigherlevelfacilitythroughretrievalbyRoyalFlyingDoctorService or Retrieval Services Queensland

All observations must be accurately taken and accurately recorded and graphed (plotted) for the form tofulfilitsfunction.

Childrenunder16yearsmusthavetheirobservationsdocumentedontheagespecificChildren’sEarlyWarning Tool.

Formsareavailableforagegroups:

• Less than 1 year• 1 – 4 years• 5 – 11 years• 12 years and older

These tools have been specifically developed to address human factor elements associated witha known patient safety issue i.e. clinician failures in recognising and appropriately managing deteriorating patients and comply with the National Safety and Quality Health Service Standard, Standard 9.

Diagnostic and Pathology

UsepointofcaretestingifavailableinsomefacilitiesforexampleiSTAT®bloodgases–except for snakebites where Point of care testing is not to be used as a substitute for formal laboratory testing. False negatives have been reported in envenomed patients.

All pathology requests made by endorsed workers must be compliant with the specific Health Management Protocol.

IfotherpathologyisrequireditmustbeorderedbyaMedicalOfficer.

If an endorsed person has initiated pathology testing according to the Health Management Protocol they are responsible for the follow up of pathology results.

AMedicalOfficershouldbeconsultedifresultsareabnormal.


Medication reconciliation

Medication reconciliation: 4 simple steps to improve patient safety.

Matching up medicines that the patient should be prescribed with those that are actually prescribed is a process called medication reconciliation.

This can help ensure continuity of care and prevent harm by reducing the opportunity for medication errors.

ThistablefoundintheappendicesofthePCCMshowsthefirsttwosteps.

1 Obtain best possible medication history 2 . Confirm the accuracy of the history

•Usinginformationfrompatientinterview,referrals, discharge summary and other sources compile a comprehensive list of the patient’s current medicines•Include prescription, over-the-counter and

complementary medicines•Include information about the medicine’s

name, dose, frequency and route•UsetheMedication history check list to

obtain the Best Possible Medication History (BPMH)•DocumentonMedication Action Plan form•TheBPMHisdifferentandmorecomprehensive

than a routine primary medication history, which is often a quick medication history•In Aboriginal and Torres Strait Islander and culturallyandlinguisticallydiverse(CALD)populations it is recommended to utilise interpreters and / or Aboriginal and Torres Strait Islander Health Workers to assist in the medication history taking process

•Useasecondsourcetoconfirmtheinformation obtained•Ensureyouhavethebestpossiblemedica-

tion history•Verify medication history through use of:

- reviewing the patient’s medicines list - inspecting medicine containers incl. dosett boxorwebsterpak - contacting community Pharmacist, tertiary or secondary facilities - talking with carers and other members of patient’s family - review previous patient health record


3 Reconcile the history with prescribed medicines 4 . Supply accurate medicine information

•Compare the patient’s medication history with the prescribed medications•Check that these MATCH or that any changes

are clinically appropriate•Where there are discrepancies, discuss these

with the prescriber•Documentreasonsforchangetotherapy

•Ensurecurrentaccuratemedicationinformationis available to all health care providers•When patients are transferred, ensure the

person taking over their care is supplied with an accurate and complete list of the patient’s medicines•Ensurethatthepatientandtheircarerisalso

provided with information about any changes that have been made to their medicines in language and format they can understand

This table shows the 3rd and 4th steps of the Medication reconciliation process.


Medication Checklist

A medication history is a record of all medicines that are taken at the time of presentation.

Obtaining a best possible medication history (BPMH) is one of the 4 steps in the medication reconciliation process, which aims to improve patient safety.

The checklist can be found in the appendices section of the PCCM.

Formoreinformationonmedicationsafety,theNPSprovidesonlinetraining.



1. Complete the following table

Tick Choice

I

S

O

B

A

R



This activity requires access to a current copy of the PCCM. Please search the PCCM for the following clinical presentations and answer the corresponding questions.

Section 3 – Upper Respiratory Tract Infection (URTI)

1.1 Is this Clinical Care Guideline or a Health Management Protocol?

Tick Answer



1.2 What is the immediate Management?

Answer

1.3 IsthereaDrugBox?

Yes No


1.4 If there is one or more drug boxes, complete the following tables for one of the recommended medicines

Schedule Name DTP

Instructions for administration and / or supply

Form Strength Route ofAdministration Dosage Duration

Schedule Name DTP




Schedule Name DTP



Schedule Name DTP


Form Strength Route ofadministration Dosage Duration


Section 6 – Pertussis (Whooping Cough)


Tick Answer


Answer


Yes No


1.4 If there is one or more drug boxes, complete the following table for one of the recommended medicines

Schedule Name DTP


Form Strength Route of administration Dosage Duration


PD3503 - Quiz

1. Which of the following statements about a Health Management Protocol is correct?

Tick Choice

HMPs are a list of drugs

HMPsaremanagedbasedonDTPs

HMPs are only relevant for Paramedics and Indigenous Health Workers

HMPs are governed by legislation

HMPs support and detail the clinical use of drugs

2. Which of the following are authorised to administer and or supply medication in a designated practice area?

Tick Choice


IsolatedPracticeEndorsedParamedics

Registered Nurses working in GP clinics

Authorised Indigenous Health Workers



3. A Clinical Care Guideline and Health Management Protocol are the same thing.

Tick Choice

True

False

4. Match the drug schedule with the correct description

Schedule Description

1 2

2 3

3 4

4 8

5 Unscheduled

5. The scheduling of medicines and poisons is based on

Tick Choice

Toxicity

Cost

Purpose

Potential for abuse

Where you get them from


PD3503 Activity Feedback


1. Complete the following statements

1.1 The Therapeutic Goods Act 1989 regulates what medicine can be administered and supplied

1.2 Professional and State / Territory legislates who can administer or supply medicines


1. Matchtheword/statementwithitsdefinition

Word / Statement Definition

1 Administer Give a single treatment dose

2 Supply Give one or more treatment doses

3 Health Management Protocol Containsadrugbox

4 Clinical Care Guideline Doesnotcontainadrugbox


This activity requires access to a current copy of the PCCM. Please search the PCCM for the following clinical presentations and answer the corresponding questions

Section 3 – Upper Respiratory Tract Infection (URTI)


Tick Answer





Answer

Not applicable


Yes No


Schedule Name DTP

2 Aspirin IHW / IPAP


Authorised Indigenous Health Workers and Isolated Practice Area Paramedic may proceed

Form Strength Route Dosage Duration

Tablet 300 mg Oral

Adults only2Tabletsevery4to6hourstoamax12tablets/ day

Once Only


Schedule Name DTP

4 Phenoxymethylpenicillin IHW/SMR&IP/IPAP

Instructions for administration and or supply

Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO / NPScheduledMedicines&IsolatedPracticeRegisteredNursesmayproceed


Capsule 250 mg500 mg Oral 500mgBD 10 days

Schedule Name DTP

4 Benzathinepenicillin(BicillinLA) IHW/SMR&IP/IPAP




DisposableSyringe 990 mg IM Adults 900 mg Stat


Schedule Name DTP

4 Roxithromycin IHW/SMR&IP/IPAP




Tablet 150 mg300 mg Oral Adults

300 mg daily 10 days

Section 6 – Pertussis (Whooping Cough)


Tick Answer




Answer

If severe consult MO immediately



Yes No


Schedule Name DTP

NotApplicable Not Applicable Not Applicable


Not Applicable

Form Strength Route of administration Dosage Duration

NotApplicable

NotApplicable

NotApplicable

NotApplicable

NotApplicable


PD3503 - Quiz

1. Which of the following statements about a Health Management Protocol is correct?

Tick Choice

HMPs are a list of drugs

HMPsaremanagedbasedonDTPs

HMPs are only relevant for Paramedics and Indigenous Health Workers

HMPs are governed by legislation

HMPs support and detail the clinical use of drugs

2. Which of the following are authorised to administer and or supply medication in a designated practice area?

Tick Choice


IsolatedPracticeEndorsedParamedics

Registered Nurses working in GP clinics

Authorised Indigenous Health Workers



3. A Clinical Care Guideline and Health Management Protocol are the same thing.

Tick Choice

True

False

4. Match the drug schedule with the correct description

Schedule Description

1 2 Pharmacy Medicine

2 3 Pharmacist Only Medicine

3 4 Prescription Only Medicine

4 8 ControlledDrug

5 Unscheduled Available in supermarkets

5. The scheduling of medicines and poisons is based on

Tick Choice

Toxicity

Cost

Purpose

Potential for abuse

Where you get them from

PD3504 History Version1 (2014)


PD3504 - HistoryParticipant Manual

Name

Community

Site

Position

Date Completed

1

PD3504 History Version1 (2014)2

Contents


PD3504 - Initial Assessment 4


PD3504-2 - Patient History 12



PD3504 - QuizPD3504-1 Learning Activity Feedback 21


PD3504 Theory to Practice Activity Feedback 23

PD3504 - Quiz Feedback 24



When patients present it is essential to gather an orderly collection of information to establish their health status. The following steps are required to achieve this:

• Takinganaccuratepatienthistory• Performingstandardclinicalobservationsandothervitalsigns• Performingphysicalexamination• Usingdiagnosticandpathologyservices,and• Collaborationwithothermembersoftheteam

Session Overview

Thissessionprovidesanoverviewoftheinitialassessmentofapatient,definesthevarioustypesofhistorythatcanbetakenanddiscussesthecomponentsrequiredforacomprehensiveandaccuratehistory.

Learning Objectives

On completion of this session learners will be able to

• Discusstheprocessforassessingapatientpresentingtoaclinic• Identifythegeneralprinciplesofaninitialassessment• Definerapidassessment• Definethetypesofhistorythatcouldbetakenonapatient• Discusstheprocessoftakingahistory• Identifycomponentsofgoodinterviewtechniques• DefinetheSOCRATESapproachtosymptomassessment• Identifyroutineclinicalobservations• Identifyotherobservationsanddiscusswhentheywouldbeconducted

Modules

Module1introducestheprocessforassessingpatientsincludingthegeneralprincipalsofassessment,rapidassessmentandtypesofhistorytaking.

Module 2 discusses history taking in detail, including effective interview techniques, establishingrapport,determiningthepresentingconcernandgathering informationrequiredforaccurateclinicalintervention.


PD3504 - Initial Assessment

Learning Objectives

On completion of this module learners will be able to

• Discusstheprocessforassessingapatientpresentingtoaclinic• Identifythegeneralprinciplesofaninitialassessment• Definerapidassessment• Definethetypesofhistorythatcouldbetakenonapatient

Presentation & Assessment

When a patient initially presents to a clinic it is important to immediately determine how ill they are and then conduct a rapid assessment as outlined.

General PrinciplesIsPatientseriouslyill

IspatientLessacutelyill

Rapid AssessmentDoes patient look well or sick?

• Airway-clearorcompromised• Breathing-yesorno• Circulation-pulseabsent,present,rate,bleeding• Levelofconsciousness-normalorimpaired• Rapidhistory• Observations-routineplusextraifneeded

Is life at immediate risk?


Presentation & Assessment - continued

TheflowchartinthefirstsectionofthePCCMprovidesageneralguidelineforpatientassessmentonpresentation.

Thisisthefirstpartoftheflowchartwhichoutlinestheimmediateresponse.

ThebluetextidentifieswherefurtherinformationcanbeobtainedinthePCCM.

General Principles

Thefirstpriorityistoassesswhetherthepatientisseriouslysickandneedsimmediatemanagement,orislessacutelysickgivingtimetoobtainafullhistory

Alwaysask‘openquestions’

Inchildren,alwaysbelievethecarer

Rapid AssessmentDoes patient look well or sick?

• Airway-compromised?• Breathing-notbreathing,significantrespiratorydistress?• Circulation-pulseabsent,slow,rapidorprofusebleeding?• Levelofconsciousness-impaired? See Glasgow Coma Scale / AVPU• Rapidhistory• Observations-temperature,HR,BP,respiratoryrateandoftenO2 saturation

Is the patient immediately compromised?


ThesecondpartoftheflowchartinthePCCMprovidesinformationontheimmediateresponseonceit is determined how ill the patient is.ThebluetextprovidesidentifieswherefurtherinformationcanbefoundinthePCCM.

Is the patient immediately compromised?

Performimmediatestabilisingorlifesavingmeasures

See DRS ABCD resuscitation / the collapsed patient

ConsultMOassoonascircumstancesallow

Ifthisisatrauma/presentatione.gfall/hitbyanobject/motorvehicleaccident,immediately assess the patient against

Criteria for early notification of trauma for interfacility transfer - see Trauma and injuries

Ifmeetscriteria,contactRFDSorRSQ1300799127

Yes No


Presentation and Assessment

Iflifesavingmeasuresarenotrequired,thenextstepsaretoobtainashistory,determineifthereisanappropriateHealthManagementProtocolofClinicalCareGuideline.

ThefinalstepsaretoeitherinitiatemanagementorcontacttheMedicalOfficer.

Obtainhistoryandperformphysicalexaminationasrelevant

Formaclinicalimpression

IsthereanappropriateHealthManagementProtocol(HMP)

ClinicalCareGuideline(CCG)

Initiatemanagement ContactMedicalOfficer

Yes No


ThefinalstepsinthePresentationandAssessment

General Principles

Thefirstpriorityonpresentationistoassesswhetherthepatientisseriouslyillandneedsimmediatemanagement,orislessacutelysickgivingtimetoobtainafullhistory

Alwaysask‘open’questions

Ifthepatientisachild,theinformationgivenbythecarermustbebelievedinthefirstinstance.

Obtainhistoryandperformphysicalexaminationasrelevant

See History and physical examination adult or History and physical examination - child

Formaclinicalimpression

IsthereanappropriateHealthManagementProtocol(HMP)

ClinicalCareGuideline(CCG)

Initiateappropriatemanagement

See HMP / CCG

ContactMedicalOfficer

Yes No


Rapid Assessment

ARapidassessment,basedpredominantlyonobservationneedstobeconductedimmediately,andincludes determining:

• Doesthepatientlookwellorsick?• Istheairwaycompromised?• Isthepatientbreathing,notbreathingorinsignificantrespiratorydistress?• Howisthepatient’scirculation–isthepulseabsent,slow,rapidorprofusebleeding?• Whatisthelevelofconsciousness–isitimpaired?SeeGlasgowComaScale/AVPU• Ifthepatientispresentingwithaseriousanorlifethreateningillnesstheyrequireanemergency history

Presentation

When patients present it is essential to gather an orderly collection of information to establish the patient’shealthstatus.

• The following steps are required to achieve this:• takingapatienthistory• performing standard clinical observations and other vital signs• performingphysicalexamination• usingdiagnosticandpathologyservices,• collaboration with other members of the team

Itisarequirementthatallcliniciansdocumenttheirfindingsinaclearandconcisewayandthissec-tion is set out to assist with this.

ItisrecommendedthatthepagenumberofHMP/CCGreferredtoisalsodocumented

Patient History

Ahistoryistakeninordertoascertainthecauseofapatient’sillness.Therearefourtypesofhistorytaking

1.Completepatienthistory-comprehensivehistoryofthepatient’spastandpresenthealthstatus.• Usuallydoneatinitialvisitinanon-emergencysituation

2.Episodichistory-isshorterandspecifictothepatient’scurrentpresentingconcern3.Intervalorfollowuphistory-buildsonaprecedingvisit.Itdocumentsthefollowuprequiredfrom the prior visit4.Emergencypatienthistory-onlyinformationrequiredimmediatelytotreatthelifethreatening condition is gathered from patient or witnesses.

• Amorecomprehensivehistorymaybetakenoncethepatienthasstabilised

Ifapatientisseriouslyill,anemergencypatienthistoryistakeninthefirstinstance


Emergency History

This includes information required to commence immediate treatment.

Informationcanbegatheredfromthepatientandorwitnesses

Itincludesimmediatevitalsignssuchastemperature,heartrate,bloodpressureandoxygensaturation.



1. Match the history type with the presentation.

No. Scenario HistoryType

1A21yearoldmanpresentsforthefirsttimetotheclinic,complainingofa sore throat and general lethargy

2Afatherbringsinhis4yearoldsonwho has attended the clinic before and who is complaining of a sore ear.

3Amotherbringsinher6yearolddaughterwhoneedsacheckfollow-ing a course antibiotics

4A55yearoldmanpresentscom-plaining of severe chest pain and is havingdifficultiesbreathing


PD3504-2 - Patient History

Learning Objectives

Acknowledgement

This presentation is based on Module 3 – History and Physical Assessment of the Rural and Isolated Practice Training Course for NursesdevelopedbytheCunninghamCentre(2013).

Learning Objectives


• Discusstheprocessofhistorytaking• Identifycomponentsofgoodinterviewtechniques• DefinetheSOCRATESapproachtohistorytaking• Identifyroutineclinicalobservations• Identifyotherobservationsanddiscusswhentheywouldbeconducted

History Taking

Historytakingshouldalwaysbecompletedpriortoaphysicalexaminationunlessthepatientisveryill.

• Providesthefirststepinformingimpression• Guidesthephysicalexamination• Requiresgoodinterviewtechniqueto• Generateinformationneededfordiagnoses• Provideabasisforphysicalexaminationandpathology

Interview Technique

• Effectiveinterviewingtechniqueincludes:• Establishingrapport• Questioninginalogicalmanner• Listeningcarefully• Interruptingappropriately• Notingnon-verbalclues• Correctlyinterpretingtheinformation


Establishing Rapport

Establishingrapportformsbasisforrelationshipwithpatient.ItIncludes

FriendlygreetingTreating patient with respect and courtesy by

• Usingapreferrednameandortitle• Shakinghandsifappropriate• Ensuringprocessisrelaxedandunhurried

Ensuringapatientcentredapproach• Clearfocusonthepatient• Allowpatienttimetothinkandrespond

HavingappropriateinformationEffectivecommunicationskills

• Listeningcarefully• Makingappropriatesoundsandgesturestoencourageongoingcommunication• Useopenendedquestions• Clarifyandparaphrasetoensureinformationisbeingreceivedcorrectly

Presenting Concern

The patient history starts with presenting concernOpen ended questions required to determine reason for presentation and should include statements such as:

• WhatcanIhelpyouwith• Why have you come to see me

MorespecificquestioninghelpsdeterminethepresentingsymptomsPatientmayselfdiagnose–acknowledgethisbutremainopen-minded.

The story needs to be documented in the words used by the patient not as the clinical interpretation.

Signs and Symptoms

Clarificationofthepresentationincludesdetailsofthesignsandsymptomswhichare:

• Site–whereisthepain/symptom?Doesitgoanywhereelse• Onset–Whendiditstart?Wasitgradualorsuddenonset?• Character–isitsharp,dullorburning?• Radiation–doesthepainorsymptomradiateanywhere?• Alleviatingfactors–whatmakesitfeelbetter?Sitting?Standing?• Timing–howlongdiditlast?Hasithappenedbefore?• Exacerbatingfactors–whatmakesitworse?


Associated Symptoms

Asking thepatient about associated symptomshelps elicitmore information that is relevant to thepresentationbutnotidentifiedassuchbythepatient.

Associatedsymptomsmayinclude:

• Nausea • Vomiting• Photophobia• Headache• Fever• Pain• Shortnessofbreath• Diarrhoea• Weight loss

Closeendedquestionscanbeaskedatthisstage,forexampleareyounauseatedorvomiting?

Treatment or Medications

Askthepatientwhattreatmentormedications(ifany)theyhaveusedtoalleviatesymptomse.g.

Havetheytriedanalgesia• What analgesia did they try• Howoftenhavetheytakenit• When did they last have it

DidthetreatmentworkHowlongdiditworkfor

Child presentations

Moreinformationisrequiredifthepatientisachildthismayincludeaskingthecarerabout:Behaviour and activity which includes

• Isthechilddrowsyoractingnormally• Isthebabyfeedingnormally,includingwakingupforfeedsorsleepingthrough

Whatisthechild/babiesappetitelike• Be precise with quantities• Howmanydrinksorbreastfeeds• Isthebabyalertandawake

Fluidintakeandoutput• Isthebaby,childvomitingorhavingdiarrhoeabetweenfeeds• Howlongafterafeedisthechildvomitingorhavingdiarrhoea• Howmanywetandordirtynappieshasthebaby/childhadinthepast24hours• What is amount an type of bowel motions.


Past history

PasthistoryPastmedicalandsurgicalhistory• Significantillnessesinthepast?Alwaysaskaboutdiabetes,hypertension,anginaandheartattacks,epilepsy,asthma,mentalhealthproblems• Previoushospitaladmissions,operationsorinjuries(where,whenandwhy?)

Familyhistory• Healthproblemsinthefamily,especiallysiblingsandparentse.g.• Diabetes,hypertension,ischaemicheartdisease,epilepsy,asthma,malignancies,mentalhealth

Socialhistory• Job,maritalstatus,housing,whoelselivesathomeandwhatresponsibilitiesdotheyhaveinthe family• Smoking-eversmoked?Howmanyaday?Evertriedgivingup?• Alcohol-howmuchandhowoften?Expressinstandarddrinksperdayorweek• Askabouttheuseofother‘recreational’drugs• Recentoverseastravel?• Diet/exercise

Medications• Regularmedicines(prescribed,herbal,bushmedicines,overthecounter)genericname(s)dose,frequency?• Aretheytakencorrectly?• Specificallyaskfemalesiftheyareontheoralcontraceptivepill

Allergiesandadversedrugreactions• Allergense.g.beestings,stickingplaster,nuts• Specificreactione.g.skinreaction,bronchospasm• IsanEpi-pen®/medicationusedtotreattheallergy?• Adversereactions/allergiestomedicines?--ifadversedrugreactions/allergiesattach “adversedrugreaction”stickertomedicationchart

Immunisations• Checkifuptodate.• Documentedevidenceofimmunisationstatusshouldbeobtained,followupwithopportunistic immunisation

Immunisations

• TheNIPsisantigenbasedandvaccinecombinationsmayvaryfromstatetostate• Targeted approved immunisation programs may vary from state to state and have to be endorsedbytheExecutiveDirector,HealthProtectionDirectorate• Forfurtheradviceonimmunisation-contactyourlocalPublicHealthUnit• ImplementationoftheImmunisationHMPmustbeinaccordancewith:

-currenteditionNHMRCAustralianImmunisationHandbook -NationalImmunisationProgramschedule(NIPs)

• Utiliseallclinicalencounterstoassessvaccinationstatusandwhenindicated,vaccinatechildren and adults• Administeralldueandoverdueimmunisationsattimeofpresentation,ifclientisassessedasfit


for vaccination. • Plananddocumentcatch-upimmunisationsiffurthervaccinationsarerequired• VaccinatechildrenandadultsaccordingtothecurrentNIPsand/orrecommendationsaspercurrenteditionNHMRCAustralianImmunisationHandbook

Clinical Observations

Standardclinicalobservationsaredoneforallpatientspresentingforacutecareandinclude:

• Heartrate• Blood pressure• Respiratoryrate• Temperature

Other Observations

Other observations that may be indicated include:

• Oxygensaturation• Blood glucose level• Levelofconsciousness• Capillaryrefill

SpecificHealthManagementProtocolsinthePCCMwillprovideinformationwhenandwhatotherob-servationsshouldbetaken.



1. Completethetableforapresentingorchiefconcern

Step Definition

Ask

S

O

C

R

A

T

E

S

Other symptoms

Treatment



1. A35yearoldphysicallyfitmanpresentstoyourcliniccomplainingofaheadachethathehas hadfor24hours.WhatopenendedquestionscouldyouaskusingtheSOCRATESmnemonic

Step Definition

Ask

S

O

C

R

A

T

E

S

Symptoms

Treatment


PD3504 - Quiz

1. Thefirstpriorityistoassessifapatientisseriouslyillandneedsimmediateattention

Tick Choice

True

False

2. Whichofthefollowingareopenendedquestions?

Tick Choice

Isthepaininyourrightknee

What brings you here today

Doyouhaveaheadache

Canyoutellmeaboutyourpain

Whathaveyoudonesofartomakeyoufeelbetter

3. Whichofthefollowingarecomponentsofarapidassessment?

Tick Choice

Airway

Currentmedication

Familymedicalhistory

Levelofconsciousness

Circulation


4. Whenwouldanemergencyhistorybetaken?

Tick Choice

When a patient complains of feeling unwell for the past couple of days

When a patient is seriously ill

Ifapatient’slifeisinimmediatedanger

Whenapatienthasafracturethatisnon-lifethreatening

Circulation

5. Which of the following may have a bearing on a current presentation

Tick Choice

Medical and surgical history

Familyhistory

Socialhistory

Medications

Allergies




No. Scenario HistoryType

1A21yearoldmanpresentsforthefirsttimetotheclinic,complainingofa sore throat and general lethargy

Complete

2Afatherbringsinhis4yearoldsonwho has attended the clinic before and who is complaining of a sore ear.

Episodic

3Amotherbringsinher6yearolddaughterwhoneedsacheckfollowing a course antibiotics

Interval

4A55yearoldmanpresentscomplaining of severe chest pain and ishavingdifficultiesbreathing

Emergency



2. Completethetableforapresentingorchiefconcern

Step Definition

AskWhat the problem isThe length of the illnessExactdetailsofthesignsandsymptoms

S Whereisthepain?

O Whatwereyoudoingwhenyoufirstbecameawareoftheheadache?Howlonghaveyouhadit?

C Whatcanyoutellmeaboutthetypeofpain?

R Canyoutellmewhereelseyoufeelthepain?

A Whathaveyoudonetorelievethepain?Howwelldidthiswork?

T Canyoutellmewhentheheadachestarted?Canyoutellmeaboutothertimeswhenyouhavehadasimilartypeofheadache?

E Whatthingshaveyounoticedmakethepainworse?

S Onascoreof1(minimal)to10(unbearable),wheredoyouratethepainnow?Whenyouhavehadrelief?Andwhenithasbeenatitsworse?

Symptoms Canyoutellmeaboutanyothersymptomsassociatedwiththeheadache

TreatmentWhattreatmentmedicineyouhavetriedtoeasepain?Canyougivemethedetailsabouthowmuch,when,howoftenandhoweffectivethistreatmenthasbeen?


PD3504 Theory to Practice Activity Feedback

3. A35yearoldphysicallyfitmanpresentstoyourcliniccomplainingofaheadachethathehashadfor24hours.WhatopenendedquestionscouldyouaskusingtheSOCRATESmnemonic.

Step Definition

AskWhyhaveyoucometotheclinictoday?Howlonghaveyoubeenunwellfor?Canyoutellmewhathasbeenhappening?

S Whereisthepain?

O Whatwereyoudoingwhenyoufirstbecameawareoftheheadache?Howlonghaveyouhadit?

C Whatcanyoutellmeaboutthetypeofpain?

R Canyoutellmewhereelseyoufeelthepain?

A Whathaveyoudonetorelievethepain?Howwelldidthiswork?

T Canyoutellmewhentheheadachestarted?Canyoutellmeaboutothertimeswhenyouhavehadasimilartypeofheadache?

E Whatthingshaveyounoticedmakethepainworse?

S Onascoreof1(minimal)to10(unbearable),wheredoyouratethepainnow?Whenyouhavehadrelief?Andwhenithasbeenatitsworse?

Symptoms Canyoutellmeaboutanyothersymptomsassociatedwiththeheadache

TreatmentWhattreatmentmedicineyouhavetriedtoeasepain?Canyougivemethedetailsabouthowmuch,when,howoftenandhoweffectivethistreatmenthasbeen?


PD3504 - Quiz Feedback

1. Thefirstpriorityistoassessifapatientisseriouslyillandneedsimmediateattention

Tick Choice

True

False

2. Whichofthefollowingareopenendedquestions?

Tick Choice

Isthepaininyourrightknee

What brings you here today

Doyouhaveaheadache

Canyoutellmeaboutyourpain

Whathaveyoudonesofartomakeyoufeelbetter

3. Whichofthefollowingarecomponentsofarapidassessment?

Tick Choice

Airway

Currentmedication

Familymedicalhistory

Levelofconsciousness

Circulation


4. Whenwouldanemergencyhistorybetaken?

Tick Choice

When a patient complains of feeling unwell for the past couple of days

When a patient is seriously ill

Ifapatient’slifeisinimmediatedanger

Whenapatienthasafracturethatisnon-lifethreatening

Circulation

5. Which of the following may have a bearing on a current presentation

Tick Choice

Medical and surgical history

Familyhistory

Socialhistory

Medications

Allergies

PD3505 Assessment Version1 (2014)


PD3505 - AssessmentParticipant Manual

Name

Community

Site

Position

Date Completed

1

PD3505 Assessment Version1 (2014)2

Contents

PD3505 - Introduction 3PD3505-1 - Learning Activity 9PD3505-2 - Physical Examination 2 10PD3505-2 - Learning Activity 14PD3505 - Theory to Practice Activity 15PD3505 - Quiz 18PD3505-1 Learning Activity Feedback 19PD3505-2 Learning Activity Feedback 20PD3505 Theory to Practice Activity Feedback 21PD3505 - Quiz Feedback 23



As part of the orderly collection of information to establish a patient’s health status and to determine how to progress with clinical interventions, it is necessary to conduct a comprehensive physical examination. This includes a general assessment as well as system specific examinations.

Session Overview

This session provides information on general and system specific examinations, working through each system. It provides information on possible presenting signs and symptoms and a step by step process through examination to pathology and diagnostic processes in response to the presentation.

The session also reviews safe practice, particularly around the use of medicines and clinical handover.

Learning Objectives

On completion of this session participants will be able to:• Discuss the reason for conducting a physical examination• Assess general appearance and hydration• Discuss how to complete a full assessment on the• Skin• Cardiovascular system• Respiratory system• Gastrointestinal system• Musculoskeletal system• Ears, nose and throat• Eyes • Discuss the process for requesting and reviewing diagnostic and pathology procedures• Discuss safe practice processes, including medication safety and clinical handover.

Modules

Module 1 introduces the adult physical examination, starting from a general appearance, assessing hydration and examination of the skin, cardiovascular, respiratory and gastrointestinal systems.

Module 2 continues through the nervous and musculoskeletal systems, ear, nose and throat and eyes. It also discusses urinalysis, diagnostics and pathology and referral processes to a medical officer.

Module 3 discusses aspects of safe practice including processes for ensuring safe administration and supply of medicines and clinical handover in an emergency situation.


PD3505-1 - Physical Examination 1

Learning Objectives

Notes

On completion of this session learners will be able to:

• Discuss the reason for conducting a physical examination• Assess general appearance and hydration• Discuss how to complete a full assessment on the

- Skin - Cardiovascular system - Respiratory system - Gastrointestinal system

Physical Examination

Most information required on presentation is gained from the history.

However, in order to make a provisional diagnosis on the presentation it is important to also conduct a physical examination:

• The history can be used to guide the examination – providing information on what the clinician needs to look for• A systemic approach is recommended – this means examine the relevant system first and proceed to further examination as guided by the history• However, a sick person should have all systems examined e.g. cardiac, respiratory, nervous and gastrointestinal etc.

General Appearance

The general appearance of the client is the first step of the examination and includes:

• Determining if the patient looks well or sick• Take note of their posture• Observe:

- mobility - any breathlessness? - conjunctiva and nail beds: are they pale? - lips, tongue and fingers: are they blue? - general skin colour - pale / jaundiced? - agitation, distressed? - body / breath odours?


- are they well nourished?• Conduct Weight, BMI, and waist measurements

Hydration

It is important to assess hydration which provides valuable information on the general recent state of health:

• Check if eyes are normal or sunken? If tears are absent or present?• Is the mouth and tongue wet or dry?• Is skin turgor normal or reduced?

- Pinch skin: normal skin returns immediately on release - normal to be reduced in elderly• Is the axillae dry?• Is their any recent weight loss?

Urinalysis

• Examine the urine of all sick patients, all patients with abdominal pain or urinary symptoms and all patients with a history of diabetes• Look at the colour - is it normal, dark or blood stained?• Does it smell normal?• Perform urinalysis• Perform βhCG in all females of childbearing age with abdominal pain

Skin

The major symptoms of a person presenting with a skin problem include: • Any rashes ? non blanching, petechiae, purpura• Bruising, unexplained or unusual marks• Signs of infection: redness, swelling, tenderness• Palpable and or tender lymph nodes in the neck, axillae or groin

It is important to take a comprehensive history of the presenting concern. It may include:

• Where did it begin• Where is it• Has it changed over time• Is their a relation with sun or pollen exposure• Has any treatment been tried and was it effective• Are their previous episodes• Do family members or friends have something similar• Are there any associated symptoms such as itchiness, blistering, pain, sensation, fever, headache, fatigue, anorexia or weight loss.


Cardio-vascular System

The most common cardiovascular presentation is a history of chest pain, Determine if there is any pain / pressure in neck, chest, arm?Determine details of the signs and symptoms including:

• Site – where is the pain / symptom? Does it go anywhere else• Onset – When did it start? Was it gradual or sudden onset?• Character – is it aching, tight, stabbing?• Radiation – does the pain or symptom radiate anywhere?• Associated Symptoms– are there any other symptoms associated e.g. breathlessness, clamminess• Timing – how long did it last? How often does it occur? Has it happened before?• Exacerbating or relieving factors – what makes it better or worse?• Severity – is it mild, moderate or severe? Use scoring system to ascertain.

However, other cardiovascular symptoms may include breathlessness, swelling, palpitations, dizzy spells and fatigue

• Determine if there is any shortness of breath on exertion?• Check skin colour: pink, white, grey, mottling? Compare trunk with limbs• Check skin temperature - hot, warm, cool or cold? Compare trunk with limbs• Test central perfusion - blanch skin over the sternum with your thumb for 5 seconds. Time how long it takes the mark to disappear• Test peripheral perfusion - blanch the skin on a finger or toe for 5 seconds. Capillary refill is the time taken for the mark to disappear• Look for any evidence of oedema, particularly feet, hands or face?• Look for distended neck veins• If skilled, listen to heart sounds


It is important to get a comprehensive patient history which includes:

• A past history of ischaemic heart disease, myocardial infarction, cardiac surgery - A history of rheumatic heart disease, chorea, sexually transmitted infections, recent dental work or thyroid disease - Prior medical examination revealing heart disease - History of drug taking

• Social history including tobacco and alcohol use and occupation• Family history of myocardial infarcts and other heart disease • Coronary artery disease risk factors including:

- Previous heart disease - Smoking - Hypertension - Hyperlipidaemia - Family history - Diabetes Mellitus - Obesity and physical inactivity - Gender and age.

Respiratory System

The most common presentation for respiratory problems include:

• Cough• Sputum• Haemoptysis• Dyspnoea• Wheeze• Chest pain• Fever• Hoarseness• Night sweats

Most information is gained from simple observation including:

• Anterior / posterior chest: equal chest movement, use of accessory muscles of respiration, tracheal tug• Auscultate for air entry into both lung fields: equal, adequate, any wheezes or crackles? Do they occur on inspiration or expiration?• Can they talk continuously - or only in words or sentences - or unable to talk at all?• Can they lie flat without breathlessness?• Measure the respiratory rate over one minute - note rhythm, depth and effort of breathing• Listen for extra noises - cough (loose, dry, muffled + / - sputum), wheeze, stridor, hoarseness• Percuss lung fields - dull, resonant, hyper-resonant?• Measure O2 saturation


Gastrointestinal system

Patients with gastrointestinal problems may present with:

• Pain, nausea, vomiting, bloating, and distension• Poor or increased appetite, difficulties swallowing and weight changes• Heart burn or acid regurgitation• Problems with bowels and urination including dark urine or pale stools• Bleeding including haematemesis, malaena and rectal bleeding• Jaundice• Pruritus (itchiness)• Lethargy • Fever and hoarseness

• Use the SOCRATES mnemonic to elicit information• Auscultate bowel sounds in all 4 quadrants - present or absent?• Palpate abdomen:

- Is it soft or firm? - Are there any obvious masses? - Is it tender to touch? Identify abdominal quadrant and exact area - Is there any guarding or rigidity? Even when the person is relaxed? - Is there any rebound tenderness? Press down and take your hand away very quickly,

• When and where is the pain greater• Question about change of bowel habits• Ask women:

- The date of last menstrual period - If they have had abnormal vaginal bleeding or discharge - Conduct a urinary βhCG on all females of childbearing age with abdominal pain

• In men: - Check the testes - any redness, swelling or tenderness? - Ask if there is any penile discharge? - See Acute abdominal pain for detailed assessment




Tick Choice

Tears are present

Sunken eyes

Normal skin turgor

Moist tongue

Dry axillae


PD3505-2 - Physical Examination 2

Learning Objectives


• Discuss how to assess patients presenting with problems of the - Nervous system - Musculoskeletal system - Ears, nose and throat - Eyes

• Discuss the process for requesting and reviewing diagnostic and pathology procedures

Nervous System

A person experiencing problems with the nervous system may be present with the following symptoms.

• Headache• Facial, neck or back pain• Fits, faints, dizziness or vertigo• Vision, hearing or gait disturbances• Loss of sensation, limb weakness• Problems with bowel or bladder control• Involuntary movement or tremor• Problems with speech and swallowing• Altered cognition

Obtain the history of the problem using the SOCRATES mnemonic.

Assess conscious state See Glasgow Coma Scale / AVPU.

• Checking for any dizziness, fainting, blackouts, problems with speech, vision, weakness in arm / leg, altered sensation, neck stiffness?• Examining pupils - size, symmetry, response to light• Assessing orientation to time, place and person:

- ask the patient their name, date of birth, location - ask them to tell you the time, date and year

• Looking for inequality between one side of the body and the other. Compare the tone and power of muscles of each side of the face and limbs• Testing touch and pain sensation using cotton wool and the sharp end of the percussion hammer• Testing finger nose coordination and if possible observe the patient walking


Musculoskeletal system

Musculoskeletal concerns often include sore and painful jointsUse SOCRATES to determine historyBe aware painful swollen joints could be symptomatic of other illnesses e.g. Acute Rheumatic Fever (ARF), Influenza, Mosquito borne diseasesDetermine if the problem is one or more joints and if they are affected symmetricallyThe assessment includes observing gait and inspecting joints for redness, swelling and pain

If the presentation is a result of an injury, determine:

• Where the injury is• How and when did it happen• What caused the injury• Why did the injury occur• What happened next

Conduct a physical examination which follows a look, feel and move process.

• Looking to see if the skin is intact and if there is associated bruising, swelling, deformity• Compare it with the non-injured side• Feeling for tenderness, heat, cold loss of continuity in structure or a gap in the muscle or tendon• Ask the patient to move the joint using own muscle power• If there is suspicion of a fracture, movement should not occur until after an xray is done.

Ears

Use SOCRATES to elicit history. Ask about associated symptoms

The main symptoms may include:

• Pain / discharge• Ear pulling / tugging in babies• Fever, irritability, headache, cough, diarrhoea, vomiting• Foreign body

Conduct examination• Look at the pinna for redness, swelling, nodules?• Look for any obvious swelling or redness of the ear canal? If there is, looking with an otoscope will be painful• Look at internal structures with an otoscope - inspect ear canal – is there any redness, swelling, discharge?• Inspect eardrum – is it normal? or redness, dullness, bulging / retraction, fluid or air bubbles, perforations or discharge?


Nose

Patients with problems with the nose may present with:

• Discharge, frequent colds• Sinus pain, trauma• Bleeding, allergies or altered smell

Elicit history using SOCRATES. Determine:

• Consistency and volume of discharge• Sinus pain or post nasal drip• History of trauma, allergies, altered smell

Examine nose by:

• Feeling for facial swelling (sinuses) inflammation, pain• Any discharge or obvious foreign body?

Mouth and Throat

Patients with mouth and throat problems may present with:

• Sores or lesions• Pain, bleeding• Hoarseness, lumps and swellings

Examine mouth and throat:

• Look at the lips, buccal mucosa, gums, palate, tongue, throat for redness / swelling.• Examine the teeth determine their condition• Inspect the tonsils for redness, enlargement or pus


Eyes

Determine history:

• Is one or both eyes affected• Is the presentation trauma related – how was the injury obtained• What are the symptoms including loss of vision, pain, grittiness, redness, discharge• Elicit past history of eye problems including use of corrective lenses• Determine family history

Examine eyes

• Always test the visual acuity of each eye, use a Snellen chart at 6 metres in good light• Look at the eyes and surrounding structures for any redness, discharge or swelling• Look at the pupils determine if they are equal in size and regular in shape. Check pupillary reflex to light• Check eye movements• See Assessment of the eye for detailed assessment



1. Match the presenting symptom with the system most likely being affected

No. Symptom System

1 Headache

2 Swollen knee

3 Hoarseness

4 Blood stained sputum

5 Jaundice



Scenario

A 40 year old man, who is being treated for hypertension by a visiting Medical Officer attached to your clinic, presents complaining of feeling generally unwell, lethargy, having a moist cough and increasing shortness of breath on exertion. He was last seen at your clinic 2 weeks ago by the Medical Officer.

1. What are the first steps of the assessment process?

Answer


2. What type of history will you take? Why?

Answer


3. What types of physical examination will you do?

Answer


PD3505 - Quiz

1. The level of dehydration is a good indicator of how ill a person is

Tick Choice

True

False

2. Which statements about urinalysis are true?

Tick Choice

Patients who are relatively well require urinalysis

Women with mild abdominal pain require urinalysis

Patients with diabetes should have urinalysis

Only patients with urinary symptoms require urinalysis

Patients with diarrhoea do not require urinalysis

3. Which of the following are components of a rapid assessment?

Tick Choice

Visual acuity is only conducted on patients with a foreign body in their eye

Most information for a presentation is gained from the history

The most common cardiovascular presentation is chest pain

Painful, swollen joints are never symptomatic of systemic illnesses

Limb weakness is usually a symptom of respiratory problems




Tick Choice

Tears are present

Sunken eyes

Normal skin turgor

Moist tongue

Dry axillae



2. Match the presenting symptom with the system most likely being affected

Step Definition System

1 Headache Nervous

2 Swollen knee Musculoskeletal

3 Hoarseness Ear, Nose and Throat

4 Blood stained sputum Respiratory

5 Jaundice Gastrointestinal



ScenarioA 40 year old man, who is being treated for hypertension by a visiting Medical Officer attached to your clinic, presents complaining of feeling generally unwell, lethargy, having a moist cough and increasing shortness of breath on exertion. He was last seen at your clinic 2 weeks ago by the Medical Officer.

1. What are the first steps of the assessment process?

Answer

Conduct a rapid assessment?Does the patient look well or sick?• Airway - compromised?• Breathing - not breathing, significant respiratory distress?• Circulation - pulse absent, slow, rapid or profuse bleeding?• Level of consciousness - impaired? See Glasgow Coma Scale / AVPU• Rapid history• Observations - temperature, HR, BP, respiratory rate and often O2 saturationDetermine Is the patient immediately compromised?

NB this patient is not in any immediate danger so proceed to the history


2. What type of history will you take? Why?

Answer

Episodic history.This man is an existing patient so he requires a shorter history, that is specific to his current pre-senting condition. The history will include the following

Ask what the problem is

Ask about length of illness and exact details of symptoms and signs. For each symptomthe following details are important

Site - where is symptom?

Onset - when did it start? Was it a gradual or sudden onset?

Character what does it feel like

Radiation - does it radiate anywhere else?

Alleviating factors - what makes it better? e.g. sitting up, medicine

Timing - how long has it been happening? Has it happened before?

Exacerbating factors - what makes it worse?

Severity - mild, moderate or severe: 0 - no discomfort to 10 – extreme discomfort

Any associated symptoms e.g. nausea, vomiting, photophobia, headache. Ask specifically about fever, pain, shortness of breath, diarrhoea, weight loss

Treatment and / or medication taken during this illness what, how much, when, how often, effec-tiveness?

The bulk of the history is known, because the man is currently attending this clinic, but in this in-stance it is important to ask about the medications he is on and whether or not he has been taking them.


3. What types of physical examination will you do?

Answer

Standard clinical observations – Heart rate, Blood Pressure, Respiratory rate and Temperature.

General appearance and hydration

The system to start with will be the respiratory system as this is the main presenting concern, and the symptoms are suggestive of a problem with the respiratory system.

The cardiovascular system should also be assessed given the medical history of the patient and the possibility that the presenting condition is a result of a cardiovascular problem.


1. The level of dehydration is a good indicator of how ill a person is

Tick Choice

True

False

2. 2. Which statements about urinalysis are true?

Tick Choice







3. Which of the following statements are false

Tick Choice

Visual acuity is only conducted on patients with a foreign body in their eye

Most information for a presentation is gained from the history

The most common cardiovascular presentation is chest pain

Painful, swollen joints are never symptomatic of systemic illnesses

Limb weakness is usually a symptom of respiratory problems

PD3506 Resuscitation Version1 (2014)

Primary Clinical Care ManualPD3506 - Resuscitation

Participant Manual

Name

Community

Site

Position

Date Completed

1

PD3506 Resuscitation Version1 (2014)2

Contents


PD3506-1 - Life Support 4


PD3506-2 - Other Emergencies 1 PD3506-2 - Learning Activity 18

PD3506-3 - Other Emergencies 2 19



PD3506 - Quiz 27




PD3506 Theory to Practice Activity Feedback 32

PD3506 - Quiz Feedback 34

PD3500 Post-Session Survey 36

PCCM Course - Part 1 References 37



Session Overview

The PCCM provides comprehensive information on resuscitation of patients presenting as emergencies. This session introduces the resuscitation section of the PCCM and provides brief information on the management of emergency presentations potentially requiring resuscitation.

Learners will need to have a hard copy of the PCCM, a printed copy of the downloadable PCCM or access to the electronic version of the PCCM to be able to complete this session.

Learning Objectives

On completion of this session participants will be able to:• Discusstheimmediatemanagementofacollapsedpatient• Utilisethebasicandadvancedlifesupportflowchartsforadults,childrenandinfants• Discussclinicalmanagementandassessmentofcardiorespiratoryarrest• Discussthemanagementandprinciplesofoxygentherapy• DiscusstheprinciplesofIntraosseousinfusion• UsethePCCMasaguideformanagingarangeofemergenciespotentiallyrequiringresuscitation

Modules

Module 1 provides information on immediate management of a collapsed patent of a patient in cardiorespiratoryarrest.ThisincludestheDRSABCDresponsetoapatient,clinicalassessmentandmanagementflowchartsonbasicandadvancedlifesupportforadults,childrenandinfants.

Module 2 provides information on using the PCCM to guide the management of:• Alteredlevelsofconsciousness• Shock• Upperairwayobstruction• Anaphylaxis• Fits,convulsionsandseizures Module 3 provides information on using the PCCM to guide management of:• Diabeticketoacidosis• Hypoglycaemia• AcuteAsthma• Drowning• Breathlessness


PD3506-1 - Life Support

Learning Objectives

Notes


• Discusstheimmediatemanagementofacollapsedpatient• Utilisethebasicandadvancedlifesupportflowchartsforadultsandchildrenandinfants• Discussclinicalmanagementandassessmentofcardiorespiratoryarrest• Discussthemanagementandprinciplesofoxygentherapy• DiscusstheprinciplesofIntraosseousinfusion

Collapsed Patient

The collapsed patient may present with a sudden collapse, or as part of an emergency presentation

The clinicians should always call for help if they have a collapsed patient.

AMedicalOfficerneedstobeconsultedassoonaspossibleandimmediatemanagementcommenced.

ImmediateManagement

The immediate management of the collapsed patient includes:

• Conductingaclinicalassessmentwhichincludestakingarapidhistoryandassessment• Commencing immediate management using basic or advanced life support• Initiatingfollowupasrequiredforthecondition• MakingareferralandorrequestingconsultationwithaMedicalOfficerassoonaspossible

TheimmediatemanagementfollowstheDRSABCDprocesswhichincludes:

DforDangerRCheckforresponseSSendforhelpAOpenAirwayBCheckbreathingC Give compressionsDAttachdefibrillator


TheDRSABCDflowchartislocatedintheresuscitationsectionofthePCCM.

Itprovidesinformationonbasiclifesupport

DDangers?

Checkforhazards/risks/safety

R

Responsive?Verbalandtactilestimuli(touchandtalk)

Give simple commands such as:“openyoureyes”,“squeezemyhand”,“letitgo”

Graspandsqueezeshouldersfirmlytoelicitaresponse

S Send for help

A

Open airwayLeavepatientonbackorpositionfound,unlesssubmersioninjuryorwhereairwayis

obstructedwithfluid(vomitorblood)inwhichcaserollontosideAdultandchild>1year-useheadtilt/chinliftmanoevre

Infant-useheadneutralposition

B

Normal breathing?Lookformovementoftheupperabdomenandlowerchest

Listen for the escape of air from nose and mouthFeelformovementofthechestandupperabdomen

CStart CPR

30 compressions : 2 breaths

DAttach defibrillator

Ifautomatedexternaldefibrillator(AED)followpromptsIfdefibrillatornotautomatic,SeeCardiorespiratory arrest

ContinueCPRuntilresponsivenessornormalbreathingreturns

UsedwithpermissionoftheAustralianResuscitationCouncil


Cardiorespiratory Arrest

Apatientwhohassufferedacardiorespiratoryarrestmaypresentwith:

• Suddencollapse• Ascomplicationofheartattack• Aspartofclinicalpictureseeninconditionsthatcanberegardedasemergencies

The immediate management includes:

• Perform rapid history and assessment• CommenceCPR-30compressions:2breathsSeeBasiclifesupport• Attachingdefibrillator

-ifdefibrillatorisanautomaticexternaldefibrillator(AED)itprovidessimpletofollowprompts -ifthedefibrillator,ismanual,rhythmisassessedasbeingshockablerhythm(VForpulseless VT)ornon-shockablerhythm -theshockisdeliveredifindicated

ThePCCMprovidesinformationandimagesonshockableandnon-shockablerhythms

Clinical Assessment & Management

The clinical assessment of cardiorespiratory arrest includes:

• Monitoringresponsetodefibrillation,medicationandimprovedoxygenation• Considering reversible causes in all cases of cardiac arrest which are listed in the PCCM

TheMedicalOfficerneedstobecontactedassoonaspossible


Advanced Life Support - Adult

Advanced lifesupportmaybe required in thecollapsedpatientwhodoesnot respond tobasic lifesupport measures.

Itisusuallyrequiredifapatienthassufferedacardiorespiratoryarrest.The PCCM provides information on:

• WhatneedstobedoneduringCPR• Drugsforshockablerhythms• Drugsfornon-shockablerhythms• Factorstoconsiderandcorrectincluding

-Hypoxia,hypovolaemia,metabolicdisorders -Hypo/hyperthermia,tensionpneumothorax,tamponade -Toxinsandthrombosis

• Post resuscitation care

Thisflowchartprovidesaneasytofollowguideonadvancedlifesupportforadults.

StartCPR15 compressions : 2 breaths

minimise interruptions

Attachdefibrillator/monitor

Assess rhythm

Shockable Nonshockable

Shock

Return of spontaneous circulation

Post resuscitation care

CPRfor2minutes CPRfor2minutes


Advanced Life Support - Child/Infant

Aseparateflowchartprovidesaneasytofollowguideonadvancedlifesupportforachildorinfant

The PCCM provides additional information on:

• WhatneedstobedoneduringCPR• Drugsforshockablerhythms• Drugsfornon-shockablerhythms• Factorstoconsiderandcorrectincluding

-Hypoxia,hypovolaemia,metabolicdisorders -Hypo/hyperthermia,tensionpneumothorax,tamponade -Toxinsandthrombosis

• Post resuscitation care

StartCPR15 compressions : 2 breaths

minimise interruptions

Attachdefibrillator/monitor

Assess rhythm

Shockable Nonshockable

Shock(4J/kg)

Return of spontaneous circulation

Post resuscitation care

CPRfor2minutes

Adrenaline10microgram/kg

immediatelythen every 2nd cycle

Nonshockable


Oxygen Therapy

FrequentclinicalassessmentisrequiredinallpatientsreceivingOxygentherapy.

IntheprimaryclinicalcaresettingarterialOxygensaturationismeasuredviaanon-invasivetechnique-pulseoximetryisdocumentedasSpO2

Deliverysystemsincludenasalprongs,simplefacemasksandnon-rebreathingmaskswhichdeliveroxygenconcentrations(%)thatmayvaryconsiderably.

Inselectingtheproperdeliverydevice,considerationshouldbegiventotheclinicalconditionofthepatientandtheamountofoxygenneeded.

InformationandimagesofOxygendeliverysystemsareincludedinthissectionofthePCCM.

Target range

• SpO2>93%formostacutelyillpatients(adults)andchildren>95%• SpO2 88-92%forpatientswithchronichypoxaemia• Utiliseoxygendeliverysystemtooptimisepatient’sclinicaloutcome

PrinciplesIntheemergencysetting:

• Oxygentherapyshouldneverbewithheldfromahypoxaemicpatientforfearofcomplicationsor clinical deterioration • Inapatientwithacutecoronarysyndrome,supplementalOxygenshouldbeinitiatedfor breathlessness,hypoxaemia(O2saturation<93%)orsignsofheartfailureorshock• Shockstatesresultingfromhaemorrhage,vasodilatorystatesand/orobstructivelesionscanall leadtotissuehypoxiaandshouldbenefitfromsupplementalOxygen• ItisreasonabletoadministerOxygentohypotensivepatientsandthosewithseveretraumauntil hypoxiacandefinitelybeexcluded• PatientswithcarbonmonoxidepoisoningshouldhaveOxygenadministered• Administer100%Oxygenat>10L/mintopatientswithdecompressionillness

Intraosseous Infusion

Intraosseous infusion provides a route for the administration of parenteral fluids and drugs in lifethreatening situations. Usethisroutewhenintravenousaccessisunabletobeestablishedorislikelytobedifficultandtimeconsuming.

Intraosseousinfusioncanbeusedinanyage.


Generallyintravenousaccessshouldbeestablishedwithin2to3hoursandtheIntraosseousinfusionceased.

BilateralIntraosseouslineswithpressureinfusioncuffsareeffectiveindeliveringlargevolumesquicklyincasesofsevereshock.

ThePCCMprovidesastepbystepprocessonhowtoestablishanIntraosseousinfusion.



1. WhichofthefollowingsitescanbeusedforIntraosseousinfusion

Tick Choice

Proximaltibia

Ileacfossa

Anteriortibia

Humerus

Femur

Fibula


PD3506-2 - Other Emergencies 1

Learning Objectives

• On completion of this module learners will be able to use the PCCM as a guide for managing• Alteredlevelsofconsciousness• Shock• Upperairwayobstruction• Anaphylaxis• Fits,convulsionsandseizures

Important Information

This module provides only basic, introductory information on emergency presentations.

Itincludesinformationon:

• Common causes for each presentation• Signsandsymptomspatientsmaypresentwith• Importantconsiderations• Learners will be directed to the PCCM for information on management

Altered Levels of Consciousness

The most common causes of altered levels of consciousness are:

• Alcoholanddrugmisuse• Stroke• Postseizure• Hypoglycaemia• Sepsis–particularlyinelderly

Patients may present with:

• Confusion;Drowsiness• Poor response to stimulation• Unresponsiveness,Fainting


When managing the unconscious or altered level of conscious patient:

• Ensuretheyareneverleftalone• UseTheGlasgowcomascale(GCS)orAVPUtomeasureconsciousness(seeappendix4)• DiscussallpatientswhohaveGCS<15withMedicalOfficer• Ifthepatientisachild,discussurgentlywiththeMedicalOfficer• DiscusswithMedicalOfficerurgentlyifGCSdrops2ormorepointssincelastassessment• ConsiderintubationifGCS<9• Apersonwhofailstorespondismanagedasifunconscious.• Apersonwhoshowsonlyaminorresponse,suchasgroaningwithoutopeningeyes,shouldbe managed as if unconscious• Careoftheairwaytakesprecedenceoveranyinjury,includingthepossibilityofspinalinjury

Shock

Shockisaclinicalstateinwhichhypotensionoccurs,duetohaemorrhage,cardiacfailure,decreasedvascular tone, resulting in inadequate tissue perfusion.

Thepatientinshocklookspaleandthebodytriestomakesureenoughbloodreachesvitalorganssuchasthebrain,heartandliver,bydivertingitfrome.g.theskinandthekidneys. Manyorganscanstopworking.

Therearedifferenttypesofshock:

• Hypovolaemicshock-duetoalargeamountofbloodorfluidlossfromthecirculatione.g.from severe bleeding, • Majorormultiplefracturesormajortrauma,severeburnsorscalds,severediarrhoeaand vomiting, severe sweating and dehydration• Cardiogenicshocke.g.myocardialinfarction• Obstructiveshocke.g.tensionpneumothorax,cardiactamponade,pulmonaryembolism• Distributiveshocke.g.severeinfection,allergicreactions,severebrain/spinalinjuries

Patientsinshockmaypresentwith

• HypotensionwithincreasedHR(tachycardia)• Pale,coolandclammy(coolandmoist)skinwithpoorcapillaryreturn(>2secs)• Increasedrespiratoryrate(tachypnoea)-“airhunger”• Shortnessofbreath• Decreasedurineoutput• Alteredmentation,irritability,confusion,drowsiness,unconsciousness• Very low or high temperature• Warmperipheriesindistributiveshock• Aspartofclinicalpictureofmostconditionsthatcanberegardedasemergencies


Theaimofmanagementofshockistoincreasetissueoxygenationbyimprovingtissueperfusion.

Thismaybeachievedbyreplacinglostintravascularfluidand/orincreasingvasculartoneand/orincreasing cardiac output.

AimtoachievesystolicBP>100mmHgandtreatthecause

Oxygensaturationreadingsinshockcanbeunreliableduetopoorperipheralperfusion

Upper Airway Obstruction

Upperairwayobstructionintheconsciouspersonmaybeduetoinhalationofforeignbody,traumatothe airway, anaphylactic reaction, angioedema, croup, epiglottitis or mass

Obstruction can be complete or partial.

Childrenoftenputobjectsintotheirmouths.Thereisriskofinhalationorswallowing.

Most commonly occurs aged 6 months to 4 years

Apatientwithupperairwayobstructionmaypresentwith:• Extremeanxiety,agitation,gaspingsounds• Coughingorlossofvoice(hoarseness)• Clutchingtheneckwiththumbandfinger• Stridor(highpitchednoisecausedbyinspiration)• Drooling• Ineffectiverespiratoryeffort• Cyanosis

Immediatemanagementistoperformchestthrustsorbackblowstorelieveinhaledforeignbodyintheconsciouspatientorchild>1yearofage.

Fornonbreathingpatientwithairwayobstructionseemanagementofpatientwithimpairedconsciousness

The PCCM provides information on management.


Anaphylaxis

Anaphylaxisencompassesavarietyofsymptomsandsigns.

Diagnosisislargelybasedonhistoryandphysicalfindings.

Onsetcanrangefromminutestohoursofexposuretoasubstance.

Itcanbecausedbymanyagentsbutthemostcommononesare:

• food-especiallynuts,eggsandseafood• drugs e.g. penicillin• venom of stinging animals e.g. bees, wasps or ants


• Skinsymptoms(itch)orsigns(generalisedrednessorhives),90%ofcases• Signsofupperairwayobstruction,suchashoarsenessandstridor• Indicationsoflowerairwayobstruction,suchassubjectivefeelingsofretrosternaltightness, dyspnoeaorwheeze• Hypoxiaandcyanosis• Swellingofthelipsand/ortongue,uvula• Profoundhypotensioninassociationwithtachycardia,and/orothersignsofcardiovascular disturbance• Lossofconsciousnessand/orcollapse• Limpnessorpallor,whicharesignsofsevereanaphylaxisinchildren• Abdominalcramps,diarrhoeaand/orvomiting

Importantconsiderationsforthepatientpresentingwithanaphylaxis:

• Rapidassessmentofconsciousstate,airway(riskorevidenceofobstruction),adequacyof respiratoryeffortandcirculation(includingHR,BP,andcapillaryrefill)isessentialtoguide treatment• Theintramuscularinjectionofadrenalineisfirstlinedrugtreatmentinlifethreateninganaphylaxis• Peoplewithdiagnosedallergiese.g.nuts,beesand/ormedication,shouldavoidtriggeragents andhaveareadilyaccessibleanaphylaxisactionplan,medicationandmedicalalertdev


Fits, Convulsions & Seizures

Afirstseizurecanoccuratanyage,butnewonsetepilepsyismorecommoninyoungchildrenandelderly.

Patientswithknownepilepsyareatriskofseizuresifthey:• donottakeepilepsymedicationsregularly• drinkexcessalcohol• areinalcoholwithdrawaland/or• are sleep deprived

Usuallyfitscausenodamage(unlessthepatientinjuresthemselvesordrowns).Thevastmajorityoffitslastlessthantwominutesandstopontheirown.

However fits lasting longer than five minutes (status epilepticus) need to be treated urgently, asprolongedfittingcancausedamagetothebrain.

Multipleseizureswithincompleterecoverybetweenalsoneedtobestoppedurgently.

Febrileconvulsions(fitsassociatedwithfever)

Clinicalsignsoffitsinchildrenmaybesubtle.

Ininfants: -flickingeyemovements -smilinginappropriateforage

Someconditionscanmimicafit: -faints(syncope)-episodesoflowsystemicbloodpressurepossiblyduetopain,fear, dehydration or drugs -cardiacarrhythmia-causingadropinbloodpressure -hypoglycaemia/hyperglycaemia-forexampleinadiabetic

Patientshavinghadafitorconvulsionmaypresentwith:

• Generalised-tonic-clonicseizure(convulsion)• Reportedhistoryof“havingafit”

-‘fallingandshakingallover’ -‘eyesrollback’and‘frothatthemouth’ -‘bitingtongue’duringtheseizure

Typicallypatientscannotrememberthefit,althoughtheymayrecallsomewarningsigns(aura).


Patients may be:

-drowsy,confused,incontinentorpossiblyagitatedafterthefitforabout10minutes(post-ictal phase).Patientmayhavebeenincontinent.

Duringthisphasebreathingoftensoundsheavy,withloud‘snoring’,duetopartialobstructionoftheairway

• Focalseizures -Localisedareaofjerking(mayreflectaTIAorbraintumour)

• Partial-complexpartialseizures -Thepatienthasimpairedconsciousness,butmayremainstanding/sitting,although behavingoddly.Usuallylastsaminuteortwo.Signsinclude: -maylicklipsrepetitively,orfidgetwithhands -mayhavefocaljerkingofonelimb -headandeyesmayturntooneside.Maystareblankly -patientwillusuallyhavenomemoryandmaydenyepisodesareoccurring

• Specialsyndromes-febrileconvulsions -commoninyoungchildren(3monthsto6years).Mostlybenigntemperatureover38°C -mostcommonlyassociatedwithviralURTI,otitismedia -prolongedfebrileconvulsions(greaterthanfiveminutes)needtobestoppedurgently -fitsinolderchildrenandadultscannotbeputdownto‘febrileconvulsions’,evenifthepatient hasatemperature.Anothercauseshouldbeconsidered

Special considerations

• Donotattempttoopenteethorwedgemouthopenduringaseizure• Considermeningitisinallchildrenpresentingwithconvulsions/fitsandfeveruntilproven otherwise• Children younger than 6 months of age who present with convulsions and fever, may have a serious underlying medical condition



1. Matchthetypeofshockwithitsdefinition

No. Type Definition

1 Hypovolaemic

2 Cardiogenic

3 Obstructive

4 Distributive


PD3506-3 - Other Emergencies 2

Learning Objectives

On completion of this module learners will be able to use the PCCM as a guide for managing:

• Diabeticketoacidosis• Hypoglycaemia• AcuteAsthma• Drowning• Breathlessness

Important Information

This module provides only basic, introductory information on emergency presentations.

Itincludesinformationon:

• Common causes for each presentation• Signsandsymptomspatientsmaypresentwith• Importantfactorstoconsider

Learners will be directed to the PCCM for information on management.

Diabetic Ketoacidosis

Diabeticketoacidosis(DKA)occursprimarilyintype1diabetesmellitus.

Resultsinthreeprimarymetabolicderangements-hyperglycaemia,severedehydrationandacidosisDKAmayoccur:

• at the onset of type 1 diabetes mellitus and therefore lead to its diagnosis• as a result of infection, omitted insulin doses, acute myocardial infarction, trauma etc



• Highbloodglucoselevels• Highbloodketonelevel• Largeketonesinurine• Dehydrated-excessivethirstandurination• Odourofbreath-fruity/acetone• Breathingpatternsaltered-deepslowlabouredbreathing(Kussmaulbreathing)• Rigidabdomen• Nausea and gastrointestinal problems• Recentweightloss(inundiagnosedtype1diabetes)• Hypotensive,tachycardic,hypothermic• Alteredlevelofconsciousness

Forpatientswithpossiblediabeticketoacidosis,cliniciansshould:

• CheckcapillaryBloodGlucoseLevelandketonesinanypatientwithalteredconsciousnessora neurological abnormality• Commence initial treatment as early as possible as may progress to coma, and death

SeethePCCMformoreinformationonmanagement

Hypoglycaemia

Hypoglycaemiaorlowbloodglucoselevele.g.BGL<4.0mmol/L,mayoccur:

• inpeoplewithdiabetestakingtabletsorinsulin• asaresultofheavyalcoholintake• innewbornsandsickchildren• as a result of some rare medical conditions

Patients with hypoglycaemia may present with:

• CapillaryBloodGlucoseLeveloflessthan4mmol/L• Sweating,tremor,rapidHR,anxiety• Hunger,headache,dizziness,irritability• Aggressivebehaviour,mayappeardrunk• Confusion,drowsiness,unconsciousorfitting• Neurological abnormality


Itisimportantforcliniciansto:

• CheckcapillaryBloodGlucoseLevelinanypatientwithalteredconsciousnessoraneurological abnormality• BeforegiventherecommendedtreatmentofintravenousDextroseconsultMedicalOfficerabout peoplewithknownalcoholuseorwhoaremalnourished,asIntraVenousdextrosecan precipitateseriousbraindamage(Wernicke’sencephalopathy)

SeethePCCMforinformationonmanagement

Acute Asthma

Patients with severe asthma may present with:

• Breathlessness• Wheeze/cough• Speakinginshortsentences• Indistress• Tiredness/exhaustion• Cyanosis• Oxygensaturation<90%• Symptomscontinuedespite‘reliever’medication

Importantpointsforthecliniciantorememberare:

• IftheadultorchildisacutelydistressedgivesalbutamolwithO2immediatelyaftertakingabrief historyandphysicalexamination• Bewareofthepatientwithasthmaindistresswhoisunabletospeakandwithoutaudible wheeze,thisindicatessevereasthma• Cyanosis, impaired conscious state and a quiet chest indicate a life threatening episode

SeethePCCMforinformationonmanagement

Drowning


• Historyofsubmersionwithnosymptoms• Cardiorespiratory arrest• Respiratoryarrest,distress,cyanosis,cracklesorwheezesinthelungs(pulmonaryoedema- fluidonthelung)• Alteredconsciousness-unconsciousfromhypoxia-decreasedO2tothebrain• Verylowtemperature(hypothermia)• Hypotension


Importantpointsforthecliniciantorememberare:

• Theaimofmanagementistoreversehypoxia-lackofO2tobodytissues• Considerheadandneckinjury,alcoholanddrugs,hypoglycaemia,seizures,heartattack,stroke as precipitating events

SeethePCCMformoreinformationonmanagement

Breathlessness

BreathlessnessoccurswhenthebodyreceivesinadequateOxygentotissuesbecauseoflung,heartor other problems.

Thebody’sfirstresponseistobreathefastertoincreasetheamountofairpassingthroughthelungs.


BreathingfastandoftenfrightenedIncreasedheartrateFeverChest pain, dull or sharpCough with purulent, frothy or blood stained sputumChestwheezesorcracklesHypotensionCyanosisConfused, drowsy

NearlyallpatientswithbreathlessnessrequireOxygeninhighconcentrations. Forpatientswithchronicobstructivepulmonarydisease(COPD),anoxygensaturationof88-92%maybenormalandoxygeninhighconcentrationmayputthepatientatriskbydecreasingtheirbreath-ing effort.

HoweverCarbonDioxideretentionisnotacontraindicationtooxygentherapy.

Ratheritdemandsthattheclinicianadministeroxygencarefullyandrecognisethepotentialforrespira-tory acidosis and clinical deterioration.

The PCCM provides more information on management of breathlessness.



1. Which of the following statements are correct

Tick Choice

Cardiorespiratory arrest

Alteredlevelofconsciousness

Minorchoking

Diabeticketoacidosis

Mildasthmaattack



Scenario

Please read the scenario and complete the questions. You will need access to a copy of the PCCM to complete this activity.

Youworkinthereasonablewellequippedlocalclinicandaretheleaderofanemergencyresponseteambasedinaruralseasidecommunity.TheclosestMedicalOfficerisbasedinalargerinlandruralcommunity which is 45 minutes away by road, and the nearest regional hospital, which provides an emergencyaero-retrievalserviceusinghelicopters,isanhourawaybyair.

At10amonaFridaymorningyoureceiveanemergencycallfromthelocalbeachabout23yearoldMichaelwhohasexperiencedasaltwatersubmersion.HehassufferedarespiratoryarrestandhasbeenmanagedwithCPRbybystanderswhohavepulledhimfromthewater.Youhavearrivedatthesitewithin5minutesofreceivingthecall.Michaelisunconscious,hypothermicandhypotensive.Healsohasanaudiblewheezeandiscyanotic.

1. What immediate management is required?

Answer


2. What clinical assessment needs to be conducted?

Answer


Michael’shasbeentransferredtotheclinicwhereyouandyourteamhavecontinuedtoprovideemer-gencycare.Michael’sconditionhasbeguntoimprove.Heisnowconsciousandtalking,hiscoretemphasrisento35degreesCelsiusandhisbloodpressurehasstabilised.Hestillhasaslightwheezebuthe is not distressed.

3. What is now required?

Answer

Michael’shadbeenintheclinicforthreehoursandisnowstable.Heisbreathingnormally,andmain-taininghiscoretemperatureandbloodpressure.HenolongerrequiresOxygentherapy,butawheezecan still be heard on auscultation.

4. What further management is required?

Answer


PD3506 - Quiz

1. Asystoleisashockablerhythm

Tick Choice

True

False

2. Which of the following emergencies has a Clinical Care Guideline?

Tick Choice






3. Matchthelevelofseverityofanacuteasthmaattackinanadultwithoneofitssignsandor symptom and one of its management strategies.

Severity Sign/Symptom Management

Mild

Moderate

Severe


4. Capillarybloodglucoselevelsshouldbecheckedinallpatientswithalteredconsciousness

Tick Choice

True

False

5. Which of the following emergency presentations always requires referral or consultation with a MedicalOfficer

Tick Choice



Minorchoking


Mildasthmaattack



1. WhichofthefollowingsitescanbeusedforIntraosseousinfusion.

Tick Choice

Proximaltibia

Ileacfossa

Anteriortibia

Humerus

Femur

Fibula



2. Matchthetypeofshockwithitsdefinition

Step Definition System

1 Hypovolaemic Bloodorfluidloss

2 Cardiogenic Cardiac event

3 Obstructive Interruptedbloodflow

4 Distributive Systemicresponsetoinjury



3. Which of the following statements are correct

Tick Choice

OxygenshouldneverbegiventopeoplewithCOPD

Diabeticketoacidosisistheresultofhypoglycaemia

Diabeticketoacidosiscanresultinalteredlevelsofconsciousness

Hypoglycaemiamaybetheresultofheavyalcoholintake

Hypoglycaemiacancausefitting

Asilentchestinapatientsufferingfromacuteasthmameanstheyaregettingbetter



ScenarioYouworkinthereasonablewellequippedlocalclinicandaretheleaderofanemergencyresponseteambasedinaruralseasidecommunity.TheclosestMedicalOfficerisbasedinalargerinlandruralcommunity which is 45 minutes away by road, and the nearest regional hospital, which provides an emergencyaero-retrievalserviceusinghelicopters,isanhourawaybyair.

At10amonaFridaymorningyoureceiveanemergencycallfromthelocalbeachabout23yearoldMichaelwhohasexperiencedasaltwatersubmersion.HehassufferedarespiratoryarrestandhasbeenmanagedwithCPRbybystanderswhohavepulledhimfromthewater.Youhavearrivedatthesitewithin5minutesofreceivingthecall.Michaelisunconscious,hypothermicandhypotensive.Healsohasanaudiblewheezeandiscyanotic.

1. What immediate management is required?

Answer

• GivehighflowO2vianon-rebreathingmask.AHudsonmaskisnotsufficient• ContinueCPR.Donotstop,unlessadvisedbytheMOandMichael’sbodytemperatureisabove32°C.• RemoveallwetclothinganddryMichael• KeepMichaelwarmwithblanketsandspaceblankets• Transfer to clinic and consult MO as soon as possible

2. What clinical assessment needs to be conducted?

Answer

• Obtain a complete history including circumstances of submersion• Perform standard clinical observations +• O2 saturation• Coretemperature(ifpossible)• Consciousstate.SeeGlasgowComaScale/AVPU• Listentochestforaddedsounds-cracklesorwheezes• Takechestx-rayifavailableforotherinjuries• ExposeandexamineMichaelsystematicallyforotherinjuries,startingattheheadandprogressingdownwardstothetoes.Donotlethimgetcold,coverwithablanketafterexamination


Michael’s has been transferred to the clinic where you and your team have continued to provideemergencycare.Michael’sconditionhasbeguntoimprove.Heisnowconsciousandtalking,hiscoretemphasrisento35degreesCelsiusandhisbloodpressurehasstabilised.Hestillhasaslightwheezebut he is not distressed.

3. What is now required?

Answer

• ConsultMedicalOfficer• ContinueOxygentherapy• EncourageMichaeltocoughandtakedeepbreaths• Ensureheremainswarm

Michael’s had been in the clinic for three hours and is now stable. He is breathing normally, andmaintaininghiscoretemperatureandbloodpressure.HenolongerrequiresOxygentherapy,butawheezecanstillbeheardonauscultation.

4. What further management is required?

Answer

Michael needs to be evacuated to the regional hospital as he has lost consciousness and has had chest symptoms.

Hewillneedmonitoringbecauseoftheriskofdevelopingadultrespiratorydistresssyndrome,orcerebral oedema.



1. Asystoleisashockablerhythm

Tick Choice

True

False

2. Which of the following emergencies has a Clinical Care Guideline?

Tick Choice


Intraosseousinfusion

Anaphylaxis


Hypoglycaemia

3. Matchthelevelofseverityofanacuteasthmaattackinanadultwithoneofitssignsandor symptom and one of its management strategies

Severity Choice

Mild Central cyanosis absent Consider oral corticosteroids

Moderate Abletospeakinphrasesonly Ipratropiumbromideoptional

Severe O2saturation<90% IVhydrocortisone100mg6hourly


4. Capillarybloodglucoselevelsshouldbecheckedinallpatientswithalteredconsciousness

Tick Choice

True

False

5. Which of the following emergency presentations always requires referral or consultation with a MedicalOfficer

Tick Choice



Minorchoking


Mildasthmaattack


PD3500 Post-Session Survey

Nowthatyouhavecompletedthissessionweaskyoutotakeafewmomentstocompletethepost-session survey for this topic. This will give us some indication about how well we have met your learning needs. Oncesubmittedyouwillbeeligibletoreceiveyourcertificate.

Please indicate the degree to which you agree to the following, bytickingtheboxmostrelevant.

Iunderstandandamabletodiscussthescope,benefitsandprocesses around the development of the PCCMIamabletodiscussthedevelopmentanduseofthePCCM

Icandescribethestructuresandpracticeprecedingandfollowing the development and implementation of the PCCM

What, if anything could have been added to this session?

StronglyAgree

Agree

Neu

tral

Disagree

StronglyDisagree


PCCM Course - Part 1 References

primary clinical care manual - part 1 manual...the primary clinical care manual (pccm) is now in its...

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