Basic Clinical Skills Final

Principles of Assessment

• scene size-up

• primary assessment

• secondary assessment

• working diagnosis

scene size up

done while approaching patient

• body substance isolation

• number of patients

primary assessment

identify immediate life-threats to your patient

• general impression

• mechanism of injury/nature of illness

• responsiveness

• ABC’s

ABC’s

• airway

• breathing

• circulation

• skin

secondary assessment

related to specific problems with your patient

• patient history

• physical examination

• vital signs

• diagnostic tests

working diagnosis

what your assessment leads you to believe is wrong with the patient

chief complain

what is bothering the patient the most

OPQRST

• Onset

  • “how did your symptoms begin?” 

  • “did it start rapidly or were the symptoms gradual?”

• Provocation/Palliation

  • “does anything make the symptoms better or worse?”

• Quality

  • “can you describe the type of pain you are feeling, for example is it sharp, dull…?”

• Region/radiation

  • “where do you feel your pain, does it radiate anywhere else?”

• Severity

  • “on a scale of 1 -10, 1 being no pain at all and 10 being the worst pain of your life, where would you rate your pain”

• Time

  • “when did the pain first begin and how long did it last?”

SAMPLE

• Signs and Symptoms

• Allergies

  • “do you have any allergies”

• Medications

  • “what medications are you currently taking?”

• Past Medical History

  • “what medical problems have you been diagnosed with?”

• Last Oral Intake

  • “what was the last thing you ate or drank?”

• Events leading up to injury/illness

  • “what were you doing before or during the injury?”

Physical examination techniques

• observe

• auscultate

• palpate

Physical Exam

• Body systems approach

  • focus questioning and exam on the particular body system that is most likely involved

• observe for discoloration, swelling, deformities

• auscultate for abnormal body sounds

• palpate for rigidity, masses, crepitus

Reassessment

subsequent sets of vital signs

• unstable patient: every 5 min

• stable patient: every 15 min

Diagnosis

label for condition based on your assessment, patient history, physical exam, and vital signs

differential diagnosis

working diagnosis

• small list of potential diagnoses

traditional approach to diagnosis

• assess patient

• list of conditions or diagnoses

• further evaluation

• final diagnosis

secondary assessment - unresponsive medical patient

• scene size up and primary assessment

• begin with physical exam and baseline vital signs

• obtain patient history from bystanders

• look for thins like medical alert bracelets and medication bottles to help guide assessments

trauma patient assessment

• c spine precautions

• rapid trauma assessment

trauma assessment

• D- Deformities

• C- Contusions

• A- Abrasions

• P- Punctures

• B- Burns

• T- Tenderness

• L- Lacerations

• S- Swelling/Symmetry

Myocardial Infarction

• caused by fatty deposits in the artery that limit blood flow

• complete loss of blood flow to area of cardiac muscle that causes pain and eventually cell death

Left sided heart failure

left ventricle is responsible for pumping oxygenated blood to the body

• when L ventricle has trouble pumping, blood backs up into lungs causing pulmonary edema

Right sided heart failure

right ventricle is responsible for pumping deoxygenated blood to the lungs

• when R ventricle has trouble pumping, blood backs up into the tissues of the body, causing peripheral edema

• gravity dependent, legs are most common site

diabetes type 1

• pancreatic cells do not produce or secrete insulin appropriately

• glucose cannot enter blood cells

• requires lifelong management and cannot be reversed

diabetes type 2

• cells become less receptive to insulin

• often seen with sedentary lifestyle and high sugar diets

• often reversible in early stages

• can require oral diabetic medications or even insulin administration for treatment

CVA

• death of injury of brain tissue from oxygen deprivation

• causes

  • ischemic

    • blockage of artery supplying blood to part of the brain

  • hemorrhagic

    • bleeding from a ruptured blood vessel in the brain

P wave - impulse initiated in the sinus node

P wave - beginning of atrial excitation

P wave - atrial excitation

P wave - completion atrial excitation

P-R interval

QRS complex

T wave

Einthoven’s Triangle

12 Lead ECG

ECG Elements

Normal ranges

• PR interval

  • 0.12 - 0.20 s

• QRS interval

  • <0.12 s

• QT interval

  • 0.33-0.42 s

Five Step Rhythm Analysis

1. Analyze rate

   1. atrial

   2. ventricular

2. Analyze rhythm

3. Analyze P wave morphology

4. Analyze PR interval

5. Analyze QRS morphology

Six second method

• count 30 large boxes

• count # of QRS in 6s

• multiply by 10

• time consuming and least accurate

R-R interval #1

• count # of small boxes between R waves

• divide 1500 by #

• only works on regular rhythms

triplicate method

• count # of large boxes between R waves

• reference table

• fast and reliable

• only works on regular rhythms

Point of Care Testing

• Purpose: Perform laboratory testing at the patient’s bedside

• saves time to obtain important information

• not as accurate and often does not replace obtaining actual lab results

Urine Dipstick Test

urine dip analysis

• leukocytes - white blood cells? infection?

• nitrites - uti?

• protein - kidney disfunction?

• pH - problems with kidney?

• Blood - problems with kidney or urinary tract?

• Specific gravity - more “stuff” in urine?

• Ketones - body burning fat instead of sugar for energy?

• Bilirubin - liver problems"?

• glucose - diabetes?

bleeding

• follow blood-borne pathogen precautions

• protect wound from contamination

• seek medical attention if bleeding is excessive and/or stitches are required

bleeding procedures

1. apply direct pressure with a sterile dressing or clean pad over the site to stop the bleeding

2. apply more pressure if bleeding does not stop

3. if dressing becomes saturated, apply a 2nd dressing over the first

4. apply pressure

5. if bleeding still does not stop and multiple dressings have been applied, apply tourniquet

types of dressings

• gauze pads

• adhesive strips

• trauma dressings

• improvised dressing

purpose of dressing

• cover an open wound

• control bleeding

• prevent infection and contamination

• absorb blood and wound drainage

• protect wound from further injury

RICES

• R- Rest

  • prevents further injury and allows for initiation of bleeding

• I - Ice

  • reduce swelling, bleeding, inflammation, and pain

• C - Compression

  • reduces swelling and bleeding

• E - Elevation

  • decrease blood flow and controls edema

• S - Stabilization

  • reduces muscle spasm in the injured are by assisting in relaxation of associated muscles

Acromioclavicular separation

• clavicle is higher on one side

• limited mobility

• extreme pain in shoulder

• loss of function

Shoulder dislocation

• shoulder appears squared off

• complete loss of function

• previous history of dislocations

Sling and swathe

• support and protect the upper extremities

• used to support an injury to shoulder and arm

signs of extremity fracture

• pain and tenderness

• deformity

• swelling

• inability to move extremity

• potential for broken skin surface

general care for fractures

• reduces pain

• prevents damage to muscle, nerves, and blood vessels

• prevents a closed fracture from becoming an open fracture

• reduces bleeding and swelling

hyperthermia

• heat cramps

• heat exhaustion

• heat stroke

Hypothermia

• shivering

• loss of muscle function, LOC, vitals

• slurred speech

• disoriented

• dehydrated

hypoglycemia

low blood glucose

hyperglycemia

high blood glucose

HbA1c test

• measures a patient’s average blood glucose level over a 3 moth period

• measures percentage of RBC that have glucose attached to hemoglobin

• assists in the diagnosis of prediabetes and diabetes

• also assists with diabetic patient management

allergic reactions

• may cause anaphylactic shock causing respiratory arrest

• seek immediate medical attention

• consider assisting patient with epi-pen

S&S of shock

• increased HR

• rapid, weak pulse

• hypotension

• irritability

• difficulty maintaining body temp

• skin becomes pale and cyanotic

seizure

• do not restrain the person during convulsions

• attempt to assure safety by ensuring that the person does not injure themselves

• seek medical attention

• when seizure is over, complete physical exam

• place in recovery position

low flow oxygen devices

• nasal cannula

• simple mask

high flow oxygen devices

• partial-rebreathing mask

• nonrebreathing mask

• bag-valve-mask

• air-entrainment masks

• CPAP

Nasal cannula

• nasal prongs

• various sizes

• use pressure-compensated Thorpe tube flow meter

• adults: 1-6 L/min

• infants: 0-2 L/min

Simple mask

• flow rate 5-10 L/min

nonrebreathing mask

• PRM with one-way valves

  • bag and mask

  • side ports

• exhaled gasses cannot enter reservoir

• flow rate: 10-15 L/min

Bag-Valve Mask

• Inhalation

  • squeeze the BVM

  • created positive pressure

  • airway structures and lungs get distended

  • increases size of chest

  • pushes air into lungs

• exhalation

  • release the BV<

  • releases positive pressure

  • allow structures and lungs to return to resting position

  • decreases size of chest

  • pushes air out

CPAP

Continuous Positive Airway Pressure

• uses continuous positive pressure to open alveoli for gas exchange

bronchospasm

oxygen enclosures

• hoods (over head)

• tents (over bed)

• isolettes (enclose infant)

Different gases

• oxygen

• air

• nitrogen

• carbon dioxide

• helium

hazards of oxygen therapy

• if the tank is punctured or a valve breaks off, the supply tank can become a missile

• oxygen supports combustion

• oxygen and oil do not mix under pressure

Safety Indexed connection systems

• american standard compresses gas cylinder outlet

• inlet connections (American Safety System) (ASSS)

• Pin-indexed safety system (PISS)

• Diameter-indexed safety system (DISS)

challenges of telehealth

• less stable and sanitary environment

• no access to immediate help

• requires active patient involvement in their own care

• privacy

• insurance coverage

• more difficult to do a proper exam

advantages of telehealth

• increased access of healthcare providers/easier access of healthcare

• reduces ED/Hospital/EMS overcrowding

• patient comfort

tech used in telehealth

• EKG monitoring patch

• blood glucose monitoring patch

• portable ultrasound

• in hospital telehealth robot

• point-of-care blood analyzer