2006 CHAM User Orientation

1
2006 CHAMUser Orientation
2
2006 CHAM User Orientation

• Welcome and Introductions
• Introduce yourselves to the books
• Philosophy of the CHAM revision project
• Major changes from previous edition
• Introduction to the 2006 CHAM
• Medicine practice
• More scenarios

3
Philosophy CHAM revision project

• Make a book that is user-friendly for the CHA/P
• Also usable by physicians, trainers, supervisors
• Compatible with Basic Training Curriculum

4
Philosophy CHAM revision project

• Additional information in CHAM, not included in
  the current Curriculum, such as
• End of Life Comfort Care
• HIV patient care
• Intraosseous infusion
• Female cancer screening

5
Philosophy CHAM revision project

• Up-to-date standards of care
• Looked at national, state, and Native health
  service guidelines
• Cautious approach to practice
• BP cutoff is 105 for Nitro
• Orthostatic VS conservative
• Extensive review by
• Rural Tribal Health Organization doctors who work
  with CHA/Ps
• Medical specialists

6
Philosophy CHAM revision project

• How to Use this Book and CHAP Overview chapters
  contain valuable information
• Explain many of the things that are new
• Helpful for all users of the book
• Homework assignment handout in your folder

7
Major Changes in CHAM

• Problem or chief complaint based, rather than
  assessment based, except chronic care.
• Approach to Sick Child younger than 8 years.
• Recheck section.
• Emergency chapter and how it is used.
• Inside Front Covercontent and clarity.

8
Color for Navigation

• Blue text
• Assessment names
• Section titles and breaks
• Patient Ed boxes Blue
• Procedure boxes Gray
• Information for CHA/P boxes White

9
Telehealth

• Reminder to CHA/P to use telehealth
• If available
• You think it will help doctor
• Used in appropriate problem exam sections
• Skin
• Ear
• Musculoskeletal
• Etc.

10
Overview of 2006 CHAM

• Emergency Field Handbook
• CHAM Patient Care Visit book
• CHAM Medicine Handbook
• Combined VMR and 1998 CHAM Medicine Chart
• No more VMR
• CHAM Reference and Procedure book
• Laminated sheet with exams
• CD ROM

11
CD ROM

• Contains all 4 volumes in PDF format
• Can print any page
• Click-on patient ed information that will print
  for CHA/P to give to patient.
• Problem patient ed
• Medicine patient ed

12
CD ROM

• Read the instructions carefully
• Can navigate to anyplace in the 4 volumes by
  entering the desired page number
• Does NOT contain any audio or video clips in this
  version

13
How to Use the CD

• Insert the disk.
• Menu will pop up.
• Install Adobe Reader as needed.
• Do not need internet connection to do this
• Takes 5 to 10 minutes to install
• Will not work for Windows 98. Call your IT
  department.

14
How to Use the CD

• Click on Instructions and read them carefully.
• Click on CHAM 4 volume set.
• Inside front cover comes up first.
• May take a few minutes, depending on your
  computer.
• To change pages
• Click on page number at bottom of screen
• Enter a new page number, example p. 290
• Press enter
• P. 290 will appear

15
How to Use the CD

• To go to other books
• Reference type in R-40. Must have R and dash
• Medicine handbook type in M-114.
• Emergency handbook type in E-36
• Now install the disk and try these steps

16
Use the Emergency Field Handbook
17
Scenario 1

• You are health aides in a village 250 miles from
  the nearest hospital.
• You get a call in the middle of the night about a
  4-wheeler accident with someone hurt bad. It is
  summer, not raining.
• You arrive at the scene with your emergency kit
  and Emergency Field Handbook.

18
Scenario 1

• Where do you start?
• Start on p. E-1.
• Scene is safe. 4-wheeler rolled over on its side
  several feet away from patient. One patient
  wearing a helmet, moaning but not moving much.
  Witness says he had been drinking and the
  4-wheeler rolled over him.
• What kind of problem Trauma? Medical? Young
  child?

19
Scenario 1

• Trauma patient. Go to p. E-5.
• GA Moaning, says stomach hurts.
• Stabilize neck?
• Airway and breathing Open, breathing a little
  fast.
• If open chest wound, would bump out here to p.
  E-25. Not for this patient.
• Start Oxygen.
• Circulation pulse fast, weak.
• No major bleeding.
• Skin normal color, cool, dry.

20
Scenario 1

• Remove helmet no
• Rapid trauma exam Abdomen, tender RUQ.
• Weather OK.
• VS P 120, R 20, BP 98/85.
• SAMPLE history Not cooperative to answer
  questions.
• Treat for shock?
• Experienced CHA/P might.
• New CHA/P might or might not.

21
Scenario 1

• Serious injuries May start at
• Shock p. E-11.
• E-12 sends you back to E-9, then p. E-35
  Assessment chart.
• Abdominal Injury p. E-35.
• Assessment Chart
• What is Assessment?
• Other Severe Abdominal Injury.
• Go to p. E-41.

22
Scenario 1

• Then go to CHAM, p. 57.
• CHAM p. 66.
• Back to p. E-122 for care during medevac.
• The only time CHA/P is sent back to Emergency
  Handbook.

23
Scenario 2

• Phone call Says cannot wake up grandmother. Go
  to home with emergency kit and Handbook.
• Where to start?
• Start on p. E-1.
• Scene is safe.
• 60 year old woman lying in bed.
• What kind of problem Trauma? Medical? Young
  child?

24
Scenario 2

• Medical. Go to p. E-60.
• GA Patient looks sick. Responds only to pain by
  moaning and moving a little.
• Airway open, breathing slow and deep.
• Start Oxygen.
• Not exposed to cold.
• Pulse slow, strong.
• Skin Pink, warm, dry.

25
Scenario 2

• SAMPLE history woke up during the night with a
  headache, but went back to sleep. Unable to wake
  her up this morning. No allergies or meds. High
  blood pressure for 2 years, didnt want to take
  the medicine.
• Is this Severe Allergic Reaction?
• Is this a Seizure?
• What next?

26
Scenario 2

• Do blood sugar.
• Blood sugar is 92.
• Do vital signs.
• T 97.4 P 60 R 12 BP 160/90 SpO2 92
• Vital signs OK
• Is this Poisoning, Chest Pain, Severe Shortness
  of Breath, Stroke, Mental Health Emergency?

27
Scenario 2

• What next?
• Rapid exam Pupils, right larger than left, slow
  to respond to light.
• Transport to clinic.
• Report.
• Go to CHAM p. 74, Additional History
• Negative except for headache and hypertension.

28
Scenario 2

• Additional Exam neck a little stiff when flexed.
  Reflexes cant tell if they are equal.
• Hgb 12.2 No urine
• What is your Assessment?
• Other Cause Decreased Level of Consciousness.
• Plan p. 102, Emergency 38, Other Medical
  Emergency

29
Scenario 3

• A mom calls, saying her 2 month old baby is very
  sick. Please come to the house. 
• You go with emergency kit and EFH.
• Where do you start?
• Start on p. E-1.
• Scene is safe.
• Wont eat, very sleepy.
• What kind of problem Trauma? Medical? Young
  child?

30
Scenario 3

• Go to p. E-55.
• GA pale, limp, sweaty, not moving.
• LOC difficult to wake up.
• Airway open, breathing fast, shallow, grunting.
• Start Oxygen.
• If wheezing, could give Albuterol.
• No cold exposure.

31
Scenario 3

• Pulse 180, hard to feel.
• No bleeding.
• Skin feels cold, cap refill 4 seconds.
• SAMPLE History
• Getting sick over 2 days, wont breastfeed or
  take a bottle now, was fussy and irritable, now
  just hard to wake up. Maybe had a fever, but now
  feels cold. No other symptoms.

32
Scenario 3

• Vital signs
• T 96.6 P 180 R 60, irregular SpO2 88
• Is this Severe Allergic Reaction?
• Is this Seizure?
• What next?
• Check blood sugar
• Blood sugar 68
• Examine quickly
• Eyes sunken, mouth dry
• Chest clear. Abdomen soft.Arms/legs floppy,
  limp

33
Scenario 3

• Is this Poisoning?
• Is this child very sick?
• Yes
• Very sleepy, will not drink
• Looks very sick, pale
• Vital signs T 96.6 P 180 SpO2 88
• Eyes sunken, mouth dry
• Floppy, limp
• Skin cold cap refill 4 seconds

34
Scenario 3

• Transport to clinic
• What next?
• Very sick child. Go to CHAM p. 149
• Follow Plan 1 while trying to contact doctor

35
Look through Emergency Handbook

• New volume. For use by health aide who has
  completed Session I and ETT.
• Designed to be used outside the village clinic.
  All plans send CHA/P to CHAM for continued care
  in clinic.
• Layout and content are similar to emergency
  chapter in CHAM.
• Tabs for major sections.

36
Emergency Handbook

• Information for giving emergency medicines is in
  this book.
• p. E-74, 75
• Section for Emergency Childbirth.
• Skills summary.
• Plan Care of Patient During Medevac, p. E-122
  written plan to follow during transport.

37
CHAM Patient Care Book

• Look at Dedication
• Look at Table of Contents, p. 10 and 11
• Chapters organization
• Emergency
• Emergency Childbirth
• Child
• Elders
• Head Chest Abdomen Musculoskeletal, Skin/Soft
  Tissue
• Urinary, Male, Female, Pregnancy
• Nervous Endocrine Immune
• Mental Health Alcohol/Drug Other Topics.

38
CHAM Patient Care Book

• Always try to go forward in the book, not
  backwards. Less skipping here andthere. Plans
  may be repetitive to avoid going to another
  section.

39
CHAM Patient Care Book

• Children In order to identify early and as often
  as possible the very sick child, CHAM is designed
  to catch the very sick child at a number of
  places in the patient visit.

40
CHAM Patient Care Book

• Look at Digestive Chapter, p. 359
• Do Not begin here, Begin Here
• Problem sections in order
• Injury, Acute, Chronic
• History Most Other History is gone, was
  incorporated into HPI.
• If not already done
• Standard questions for child younger than 3
  years.
• Exam Sick Child box if problem may involve a
  child. To eliminate the need for multiple chapter
  histories and exam.
• If not already done

41
CHAM Patient Care Book

• Assessments
• Some chapters have 2 assessment charts. Look at
  Assessment step for instructions.
• Female, p.
• Musculoskeletal, p.
• Skin/Soft Tissue, p.
• Possible vs definite. Medicaid issues.
• Assessment charts or lists of assessments for
  that problem.
• Example Breast problems Assessment, p. 512. A
  list rather than a chart
• May or may not definition

42
CHAM Patient Care Book

• Assessment charts and lists try to cover the most
  common findings for the problems.
• Definitive assessments are those that a health
  aide can make using the CHAM and lab tests
  available in the village.
• There is extensive use of the word possible
• In order of most common or most urgent

43
CHAM Patient Care Book

• Plans
• Plan names Eye, Eyelid Child, Teen Mouth, Jaw,
  Teeth
• Definitions after plan name
• Generally follow a standard format.
• May have immediate or emergency care. Any change
  in order of steps was deliberate.
• New sections While or If waiting to transport

44
CHAM Patient Care Book

• Standing Orders Many changes. Old ones gone, new
  ones possible. All marked p. 624
• Employer may issue other standing orders, but are
  responsible for testing, etc.
• Medicines NOT part of standing order p. 304
• Special Topics and Procedure Summaries mostly
  gone.
• Most procedures are in Reference/Procedure book.

45
Inside Front Cover

• There are 7 different places to go from Inside
  Front Cover.

46
Scenario 4 Emergency

• Adult male walks into clinic. Looks pale, says he
  feels very sick and needs to lie down.
• As you start to get him onto exam table, he
  faints.
• Where to start in CHAM?
• Inside Front Cover Emergency, go to p. 40.
• Scene Size-up
• No apparent injury. He said he felt sick.
• What kind of problem Trauma? Medical?

47
Scenario 4 Emergency

• Medical Emergency Adult go to p. 72.
• Looks like emergency field handbook
• Differences from handbook
• References to cold weather care
• Transport to clinic
• Plans are expanded to include medicines and more
  detailed care in clinic while waiting to talk to
  doctor.

48
Scenario 4 Emergency

• Patient wakes up enough to tell you he has had
  chest pain and felt faint for about 2 hours.
• Follow steps to Chest Pain listing on p. 73.
• Go to p. 90.
• Emergency care, if not already done.
• Get history, exam.
• You decide Assessment is Chest Pain, Possible
  Heart Attack.
• Go to p. 95, Plan Emergency 33 while trying to
  contact doctor.

49
Scenario 4 Emergency

• What medicine should you give?
• ASA and Nitroglycerin
• Morphine, ONLY after talking to doctor
• What additional care?
• Start an IV
• While waiting to transport
• Recheck vital signs
• Continue this plan
• Go to p. 102, Emergency 38, Care of Patient While
  Waiting for Medevac

50
Scenario 5 Sick Child Younger than 8 Years

• 2 year old comes in fussy, fever, pulling at left
  ear, runny nose, cough.
• Inside front cover to p. 1.
• Box Young Child Who May be Very Sick
• Child has none of those findings.
• Back to Inside Front Cover Begin History

51
Scenario 5 Sick Child Younger than 8 Years

• Mom brings 2 month old into clinic, says baby is
  sick
• Inside front cover to p. 1, Sick Child Box
• Baby looks very sick, pale, sweating, breathing
  very fast and grunting
• Go to p. 68
• Very similar to Emergency Field Handbook

52
Scenario 6 Recheck Visit

• 3 1/2 year old brought to clinic by mom 3 days
  after being treated for Strep throat. Mom wants
  to be sure he is better.
• Where do you start?
• Recheck visit, inside back cover.
• Child is better, eating some. Playing. Still
  taking Amoxicillin
• Where do you go now? 
• Index Strep throat or look at old PEF
• p. 300, Strep throat Plan, recheck section.

53
Scenario 6 Recheck Visit

• Taking fluids well.
• Exam GA looks well. Running around clinic room.
• T 98 rectally
• Throat A little red, swollen tonsils. No white
  patches or bad breath.
• Is patient better?
• When should this patient be reported?
• Only if not getting better.

54
Scenario 7 Follow-up After Hospital or Regional
Clinic Visit

• Patient just came home from hospital after an
  operation.
• Where do you start?
• Inside Front Cover sends you to p. 737
• Information you need for this visit
• Try to get this information before you see the
  patient
• Otherwise do history and exam, then contact
  doctor to complete visit

55
Scenario 7 Follow-up After Hospital or Regional
Clinic Visit

• Patient had gall bladder surgery one week ago
• History
• What do you examine?
• GA, VS, Wt, Abdomen
• Telehealth?
• Lab?

56
Scenario 7 Follow-up After Hospital or Regional
Clinic Visit

• Assessment
• Follow-up after Gall Bladder Surgery (date)
• Plan how much can you do?
• Report
• Tell patient to come back to clinic after you
  talk to doctor

57
Scenario 8 Chronic Care Visit

• Patient needs refill of blood pressure medicine.
• Where do you start?
• Inside Front Cover sends you to Inside back cover
• Find High Blood Pressure
• p. 348

58
Scenario 8 Chronic Care Visit

• Do not begin here, Begin here
• Information you need for this visit
• Things to remember
• History
• Exam
• Assessment
• Plan
• Look at each patient ed info
• Next visit depends on regional pharmacy
  guidelines

59
Scenario 8 Chronic Care Visit

• Patient has chronic toe fungus and needs med
  refill
• Where to start?
• Inside front cover to Inside back cover
• Problem not listed, so use General Chronic Care,
  p. 734
• For use with chronic problems not in the CHAM
• Colostomy, boils, amputee stump check, etc

60
Scenario 9 Preventive Care Visit

• 2 year old needs a well child check-up
• Where to start?
• Inside front cover to Inside back cover
• Find Well Child Care in the list
• Go to p. 156

61
Scenario 9 Preventive Care Visit

• Patient wants to lose weight
• Where to start?
• This is preventive care
• Inside front cover to Inside back cover
• Go to p. R-29

62
Scenario 9 Preventive Care Visit

• Define Preventive Care
• Some of these things may seems like acute care
  visit
• Wanting to get pregnant
• Prenatal care
• Review the list on inside back cover

63
Scenario 10 New Problem

• 2 year old comes in fussy, fever, pulling at left
  ear, runny nose, cough.
• Inside front cover to p. 1.
• Box Young Child Who May be Very Sick
• Child has none of those findings.
• Back to Inside Front Cover Begin History
• Problem started 2 days ago, seems to be getting
  worse
• Mom gave him Tylenol last night

64
Scenario 10 New Problem

• Had an ear infection 6 months ago, treated with
  antibiotics
• Past health history/Other history
• No chronic illness
• No meds/No allergies
• Dad smokes at home
• Alcohol/Drugs N/A
• Never had a TB test

65
Scenario 10 New Problem

• Female questions N/A
• High Risk?
• Look at p. 1, High Risk Health Conditions box
• Patient with any of these problems MUST always be
  reported, even if CHA/P has a current standing
  order for an assessment

66
Scenario 10 New ProblemHigh Risk Health
Conditions

• These conditions may be affected by something the
  CHA/P does to patient or fetus
• Medicines not used correctly by a sick liver
• Medicines not eliminated properly by sick kidney
• Medicine may affect the fetus
• Immune system does not work well in many of these
  conditions

67
Scenario 10 New Problem

• Child does not have any high risk health
  condition
• Go to Index
• Ear
• problems, 235
• Plan for .. Only to be used for Recheck Visit
• Go to p. 235 Ear Problem
• Do history Look at 5, child questions.
• These questions are in every problem section that
  applies to a young child.

68
Scenario 10 New Problem

• Notice that respiratory questions are included so
  CHA/P does not have to also use Respiratory
  Illness section for mixed problems
• If you decided he had a respiratory problem,
  there are ear questions in that section

69
Scenario 10 New Problem

• Exam Child does not look sick, temp is 102.
• What exam should you do?
• Continue with exam on p. 236
• Weight is 30 pounds
• Assessment chart assessment is Acute Otitis
  Media
• Plan p. 240, Ear 3
• You have a current standing order for this
  assessment

70
Scenario 10 New Problem

• Review Report statements
• Child has none of these problems
• What medicine do you give?
• Amoxicillin
• p. M-90. Turn to this page

71
Scenario 10 New Problem

• All medicines have this information
• Name, strength, common brand names
• Brief description and uses
• Warnings
• Always read box carefully before you give the
  medicine
• Dosing for CHAM plans Find your patients
  assessment

72
Scenario 10 New Problem

• What dose of Amoxicillin do you give?
• 12 ml (600 mg) by mouth
• How often?
• 2 times a day
• For how long?
• 10 days

73
Scenario 10 New Problem

• Information on p. M-91 is for the CHA/P
• Serious side effects
• Minor side effects
• Storage and Preparation
• Patient education is found on the next page
• Xerox or print this page for patient.
• Explain pertinent information to patient.
• Child has an infection now. Do not explain to
  prevent an infection or if a woman info to
  parent.
• Fill in any blanks

74
Scenario 10 New Problem

• Medicine for pain/fever?
• Acetaminophen
• p. M-243
• Find plan name and number
• Dose
• How often
• How much in one day

75
Scenario 10 New Problem

• Go back to CHAM p. 240, Recheck
• When does this patient need a Recheck?
• In 3 days if fever over 101
• One month after finishing antibiotic
• Where would you start Recheck Visit?
• Inside front cover to Inside back cover

76
Scenario 11 New Problem

• 9 month old with vomiting and diarrhea for 12
  hours
• Where to start?
• Inside front cover
• Child younger than 8 years, p. 1
• Does not have any of these things
• Back to Inside front cover questions
• Index
• Vomiting, p. 369 or Diarrhea, p. 369

77
Scenario 11 New Problem

• Do not begin here, Begin here
• History, is you do not already know
• Child younger than 3 questions
• Exam
• Child looks sick, T 101.6 rectal
• What exam should you do?
• Sick Child Screening Exam
• Laminated sheet
• p. 147

78
Scenario 11 New Problem

• Where to next?
• p. 371, Lab tests
• From instructions in child box
• Assessment
• Amount of Dehydration
• Chart p. 372
• Assessment for Vomiting/Diarrhea
• Chart p. 373

79
Scenario 11 New Problem

• Assessment is Gastroenteritis with mild
  dehydration
• Plan Digestive 6, p. 375
• You have a current standing order for this
  problem
• Do you need to report?
• Yes
• When?

80
Scenario 11 New Problem

• Report NOW
• Child looks sick
• Do you need to report if child did NOT look sick?
• Yes
• Why?
• Child is younger than 3 years
• Child has mild dehydration

81
Scenario 11 New Problem

• What should you do while waiting to report?
  (doctor is delivering a baby)
• Patient Ed
• Diet for Child Younger Than 2
• Preventing Spread of Communicable Disease, p. 379
• What meds can you give?
• None this med is NOT part of standing order

82
Scenario 11 New Problem

• Look at p. M-178, Promethazine
• Would the doctor ever order this medicine for
  this patient?
• No.
• Warnings book says NOT to give to child younger
  than 2 years

83
Scenario 11 New Problem

• Go back to p. 376.
• What next?
• Recheck when?
• In one day, then every day until better

84
Scenario 11 New Problem

• If your assessment was Other Cause of Vomiting
  and Diarrhea, go to Digestive 9, p. 378
• Look at Report statement
• Look at plan
• Most assessment charts have an Other Cause
  assessment.
• Plan for these is similar to plan on p. 378

85
Summary of Changes

• Look at handout, CHAM, table of contents at
  beginning of each chapter
• Emergency Chapter
• Emergency Childbirth
• Child/Teen

86
Summary of Changes Child Scenario

• Mom brings in 1 year old who has fever and is
  fussy.
• Where to start?
• Inside front cover to p.1
• Child has none of these
• Back to Inside front cover
• Problem is fever
• Index

87
Summary of Changes Child Scenario

• Fever
• Child younger than 8 years, p. 145
• Fussy index, p. 145
• Just sick, no specific problem
• Inside front cover right hand column, sends to p.
  145
• Go to p. 145, Young child who may be sick
• Review at all pages in this section

88
Summary of Changes

• Look at rest of Child/Teen chapter
• Elders, p. 189
• Look at table of contents
• Flip through chapter
• History and plan are arranged by body system
• All should have a screening elder exam
• Eye
• Ear
• Mouth/Teeth

89
Summary of Changes

• Respiratory
• Circulatory
• Digestive
• Musculoskeletal
• History, p. 397
• Exams, p. 400

90
Summary of Changes

• Skin/Soft Tissue
• One chapter
• Wounds
• Infection Cellulitis, p. 454
• Look at medicines for type of injury and
  resistant bacteria (MRSA)
• Burns, p. 467
• Starts the same way as Emergency chapter and
  Emergency Field Handbook

91
Summary of Changes

• Urinary
• Male Reproductive
• Female Reproductive
• Pregnancy
• Look at table of contents, p. 563

92
Scenario 12 Pregnancy chapter

• 30 year old pregnant woman here for 32 weeks
  check-up. First pregnancy.
• Where to start?
• Inside front cover to inside back cover,
  Preventive Care
• Return Prenatal Visit, p. 574
• Look at Things to Remember and Information for
  CHA/P charts

93
Scenario 12 Pregnancy chapter

• What next?
• Weight 158, up 5 ½ pounds. Urine dip ok. BP
  144/92.
• Calculate birth/due date
• History
• Feels well, but a little tired. Was diagnosed
  with high blood sugar 4 weeks ago, seen at
  hospital and sent home with diet and exercise.

94
Scenario 12 Pregnancy chapter

• No signs of problem in pregnancy (danger signs).
  No contractions. Blood sugars at home 100-200. No
  signs of preeclampsia. Never had high blood
  pressure, but problem runs in the family.
• Exam
• 34 cm, head down, FHTs 140. Ankles a little
  swollen. Hands ok. Reflexes ok.

95
Scenario 12 Pregnancy chapter

• Assessments
• For BP, go to p. 592.
• High Blood Pressure in Pregnancy section can be
  used as part of prenatal visit, or by itself for
  BP check-up in a pregnant woman
• Skip the things you have already done
• Assessment chart, p. 591
• Gestational Hypertension
• Plan Pregnancy 5, p. 580
• Return Prenatal Visit

96
Scenario 12 Pregnancy chapter

• You have a current standing order
• Do you need to report this patient?
• Always report.
• She has high blood pressure and diabetes
• What should you do while waiting to report?
• Special Care and Patient Ed
• Look at Additional Care does she need any of
  this?

97
Scenario 12 Pregnancy chapter

• Also do 6 on p. 581
• When to recheck?
• Every 2 weeks, plus any extra visits for high
  blood pressure or diabetes

98
Scenario 13 Pregnancy chapter

• 14 weeks pregnant, had normal prenatal check-up 2
  weeks ago
• Today comes to clinic with spotting bright red
  blood from vagina. No cramping
• Is this a preventive care visit?
• No
• Where to begin?

99
Scenario 13 Pregnancy chapter

• Inside front cover
• Vaginal bleeding in pregnancy
• Index
• Vaginal bleeding
• p. 600
• Notice plans listed in index for recheck only
• If CHA/P comes here directly, only questions
  missed will be Past Health Hx, which she/he
  should already have.
• Briefly look through this section

100
Scenario 13 Pregnancy chapter

• Same patient came to clinic for routine prenatal
  check-up, and had started spotting that morning
• p. 577 would bump her out to p. 600
• Plan Pregnancy 12, p. 601

101
Pregnancy chapter

• All of the Prenatal Problems sections are
  designed to be stand-alone, or used with the
  Return Prenatal Visit
• CHA/P would look for if not already done
  statement in history and exam
• Major change in Preeclampsia assessment
• High BP is defined as 140/90 or higher
• Prenatal Glucose Tolerance Test patient visit

102
Summary of Changes

• Nervous
• 4 seizure sections
• Emergency Having a Seizure Now
• Seizure nervous system problem section
• Seizure Disorder, Chronic Care
• Pregnancy Seizure in a Pregnant Woman
• Endocrine
• Look at table of contents, p. 653
• Steroid-dependent patient Includes adrenogenital
  syndrome

103
Summary of Changes

• Immune System new chapter
• 30 year old man comes to clinic feeling bum.
• Where do you start?
• Inside Front Cover
• Started a few days ago feeling sick, tired, weak,
  hot and cold. Getting worse.
• No allergies, no meds, smokes 5 sticks a day, no
  alcohol.

104
Scenario Immune System

• What next?
• Index
• Look up fever
• Look up feeling
• Look up tired
• Look up fatigue
• All take you to p. 673
• Do not begin here, begin here

105
Scenario Immune System

• This history and exam may help you find a
  specific problem
• You know him pretty well, and he finally tells
  you he used IV drugs the last 2 trips he made to
  town
• His temp is 103.8 and he has swollen lymph nodes
  everywhere
• Assessment?
• Fever and swollen lymph nodes

106
Scenario Immune System

• When to report?
• Could report now if you think patient looks sick
• Does he have high risk behavior for HIV?
• p. 682
• Notice there is patient ed box for fever

107
Immune System

• Look at table of contents, p. 673
• Patient getting cancer treatment
• Section for any patient who has had treatment for
  cancer in the last 3 month
• Look at High Risk Health Conditions, p.l, Cancer

108
Summary of Changes Immune Chapter

• HIV or AIDS
• General Information
• Testing
• Advanced HIV or AIDS patient visit

109
Summary of Changes

• Mental Health table of contents, p. 693
• Alcohol/Drug table of contents, p. 717
• Look at Assessment chart, p. 720 to 723
• Inhalant abuse assessment and plan
• Chronic Alcohol/Drug Abuse section is primarily
  used when patient wants to get treatment for
  addiction
• Designed to provide information for detox center
  to determine admission

110
Summary of Changes

• Other Topics
• Table of contents, p. 733
• Summaries
• Alcohol and Drug Use and Injury Prevention
• Referred to frequently from problem-specific
  sections
• More detailed information can be found in Alcohol
  chapter and Wellness
• Recognizing and Reporting Abuse and Neglect
• Summary more detail found in age-specific or
  problem-specific chapters
• Internet Resources
• Here and at the end of many chapters

111
CHAM Medicine Handbook

• Inside front cover
• Look at Table of Contents, p. M-3
• Contains only meds listed in CHAM and stocked in
  village clinics
• How to use chapter
• Medicine skills
• Injections chart, p. M-24
• Controlled medicines, p. M-14
• Medicine errors, p. M-16

112
CHAM Medicine Handbook

• Immunizations
• Look at charts
• What are side effects of DTaP?
• p. M-50
• What is the minimum age you can give IPV?
• p. M-54
• What vaccines should a 6 month old get?
• p. M-55
• What is the dose of Hepatitis B vaccine for an
  adult?
• p. M-57

113
CHAM Medicine Handbook

• Where can you find information about vaccination
  catch-up?
• p. M-58, 59
• What is the dose of flu vaccine for a 12 month
  old?
• p. M-59
• What vaccines are required for a child entering
  school in Alaska?
• p. M-60
• Refrigerator logs

114
CHAM Medicine Handbook

• Medicines in CHAM, p. M-65
• P. M-67, table of contents for chapter
• P. M-153, table of contents for chapter
• P. M-431, Index
• Contains only contents of Medicine Handbook

115
CHAM Medicine Changes

• Dextrose 50 M-71
• Epinephrine M-73 IM vs SQ
• Naloxone M-822 strengths
• Cefpodoxime M-103
• Notice differences in plans
• Ceftriaxone M-1063 dose schedules
• Meds for status seizures M-225-232
• Ibuprofen M-259

116
CHAM Reference and Procedures Book

• Table of Contents
• Wellness
• Find information about stress management
• P. R-55
• Find information about Stopping Tobacco
• P. R-50

117
CHAM Reference and Procedures Book

• Lab Tests
• Table of contents, p. R-59
• Some are not in basic training
• Included because some corporations what their
  CHA/Ps to do them
• PAP smear
• Find information about doing a urine dipstick
• P. R-81. Review these pages
• All tests are explained the same way

118
CHAM Reference and Procedures Book

• Procedures and Equipment
• Table of contents, p. R-97
• Moved most of procedures out of main CHAM
• Only ones left in main CHAM are procedures CHA/P
  may need to review with doctor before doing
• Opening an abscess
• Packing a dry socket

119
CHAM Reference and Procedures Book

• Anatomy and Function
• Use these simple drawing for patient ed
• History and Exam
• Very complete history
• Info about recording and reporting
• Screening exams for adult, child age 6-11
• Complete exam for each body system
• Medical Words and Abbreviations
• Good reference section

120
CHAM Reference and Procedures Book

• Clinic Management, p. R-273
• General information
• Your region may have more specific guidelines
• Needle-stick procedure
• Forms, p. R-291
• End of Life Comfort Care
• For patient who comes home to die
• Not usually scope of practice for CHA/P

121
Scenario 14 End of Life Comfort Care

• 70 year old woman has terminal lung cancer. Has
  come home to die.
• Death expected within 2 months.
• Family asks for a home visit to help make patient
  comfortable, as she is too ill to get to clinic
  easily.
• Where do you start?

122
Scenario 14 Comfort Care

• Inside front cover
• P. R-307, Comfort care chapter
• Introduction and information for this visit
• History
• Do not need to ask all questions
• Exam
• Only do starred items if death is near
• Assessment chart with various problems for
  terminally ill patients

123
Scenario 14 Comfort Care

• Plans
• Everyone gets Comfort Care 1, p. R-311
• Use other plans as needed
• Plan Comfort Care 11, p. R-318 is for the family
  or other caregiver
• Their health is very important to maintain

124
CHAM Reference and Procedures Book

• Death and Grief
• Table of contents, p. R-319
• Index
• Same as CHAM patient care visit book

125
Medicine Practice

• Fix problem on p. M-330
• Under If for Scabies, should say Do NOT take a
  shower before using this medicine.
• Fix problem on p. 96 in CHAM
• Morphine 0.8 mg should be 8 mg
• Give 8 mg (0.8 ml)
• Doses in charts were calculated and rounded off
  to make measuring easier

126
Medicine Practice

• CHAM p. 354, To prevent infection of heart lining
  or valves
• What medicine?
• Patient is allergic to Amoxicillin
• What medicine
• Clindamycin. Look up dose on p. M-114
• CHAM p.463, Tetanus shot
• What is a dirty wound?
• Look on p. M-428

127
Medicine Practice

• CHAM p. 514, Breast 4, Breast Infection
• Doctor orders the IM medicine
• Which one is it?
• Meds in CHAM that are not by mouth will list the
  route.
• IM shot
• Skin ointment, on skin
• Rectally
• Vaginally

128
Medicine Practice

• Cefazolin
• Look up dose, p. M-99
• Doctor may also order this medicine for other
  infections
• CHAM p. 462, Wounds 1
• Wound in a pregnant woman who was cutting up a
  seal
• What medicine to prevent infection?
• Erythromycin. Look up dose on p. M-122

129
Medicine Practice

• CHAM p. 580, Pregnancy 5, Return Prenatal Visit
• Patient has a hemoglobin of 10
• What medicine does she need?
• Ferrous Sulfate. Look up dose on p. M-354
• Notice the separate dose chart for Anemia from
  Not Enough Iron in Diet.

130
Scenario 15

• 2 year old brought to clinic by mom with a bad
  cough
• Inside front cover
• Sick for 2 days, got worse last night. Felt a
  little hot. Never had before.
• No allergies, no meds, no smokers in house.
• No high risk health condition.
• Index cough

131
Scenario 15

• p. 290, Respiratory Illness
• History
• Cough worse during night and naps. Sounds like a
  seal.
• No appetite but takes fluids well. Normal wet
  diapers. Normal BM. Tired, cranky.

132
Scenario 15

• Exam
• GA does not look very sick.
• T 100.8 rectally P 130 R 32 SpO2 95
• Has barky cough, sounds a little wet. Sounds
  hoarse and has high-pitched sound (stridor) when
  crying.
• Chest clear, some retractions.
• Assessment?

133
Scenario 15

• Chart p. 292
• Croup
• Plan Respiratory 10, p. 302
• When should this patient be reported?
• Special Care Medicines Patient Education
• Recheck When?

134
Scenario 16

• 60 year old complaining of chest cold and
  cough.
• Sick for 10 days, getting worse. Cough worse in
  the morning. Had bronchitis 2 times before in
  the last year.
• No allergies, no meds. Smokes 2 packs/day. No
  interested in stopping.
• No high risk health condition.
• Where to now? 

135
Scenario 16

• p. 290, Respiratory Illness
• Coughing up a lot of yellow sputum. Worse in
  morning, and when he goes out into cold air.
  Feels a little more tired. Sweating some.
• Has not had a flu shot this year. Never had a
  pneumonia shot

136
Scenario 16

• Exam GA looks a little tired.
• T 99.8 P 88 R 20 SpO2 97
• Chest Rhonchi all over, get better after
  coughing. Percussion sounds the same everywhere.
• Assessment?
• Bronchitis
• Plan p. 304, Respiratory 11.

137
Scenario 16

• You have a current standing order for this
  problem
• Does this patient need to be reported?
• Yes, if you think patient has an infection
• Coughing for 10 days, getting worse
• Frequent episodes of bronchitis, he may have
  chronic lung disease
• Patient Education Medicines What Meds?
• Recheck When?

138
Scenario 17

• 50 year old complaining of bad stomach pain.
• Pain started 8 hours ago, getting worse. 7 on
  scale of 10. Started in upper left, moved to
  middle, now hurts everywhere.
• No allergies, no meds. No tobacco or alcohol.
• No high risk health condition.

139
Scenario 17

• Index Abdominal Pain stomach pain
•  p. 362, Abdominal Pain
• Watching TV when pain started. Started as
  cramping, but getting worse and worse. Hasnt
  eaten, feels nauseated. Hasnt passed any gas,
  would feel better if she could. Last BM yesterday
  morning.
• Had hysterectomy 10 years ago.

140
Scenario 17

• Exam GA Looks sick, pale.
• T 98.8 P 92 R 20
• Abdomen no bowel sounds heard after 2 minutes.
  Tender everywhere, muscles feel tight. No rebound
  tenderness.
• Assessment?
• Acute Abdomen
• Plan p. 366, Digestive 2

141
Scenario 17

• When should this patient be reported?
• Special Care
• Medicine What Meds?
• Additional Care
• Recheck When?

142
Any Questions