Physical Assessment Class

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Physical Assessment Class
Case Scenarios
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Objectives

• State common Approaches to Priorities in
  Assessment to Action
• Adapt assessment to focus on common medical
  diagnosis their complications

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Objectives

• Individualize assessment to incorporate common
  treatments and diagnostic procedures and their
  complications
• State areas to focus assessment on for a changing
  patient case scenario

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Common Approaches

• First Level
• ABCS
• Second level
• MPULOR
• Third level
• KARR

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1st Level - ABCS
Emergent, Life threatening and Immediate - Things
you HAVE TO DO NOW!

• Airway
• Breathing
• Cardiac and Circulation
• Signs - Vital Signs

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2nd Level - MPUOLR
Next in Urgency, may stop further
deterioration -Things you NEED to take care of.

• Mental
• Pain
• Urinary
• Other Medical Problems
• Labs
• Risks

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3rd Level - KARR
Important to health but can be approached more
slowly and deliberately -Things you WANT to do

• Knowledge
• Activities
• Rest
• Relations

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Adapt Assessment to Focus

• Treatments for 1st and 2nd are usually rapid in
  succession or simultaneous.
• At time priorities will change - depending on
  seriousness of the problem - ie abnormal labs can
  be life threatening
• Important to consider the relationship between
  the problems - one causing or worsening another

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Common Diagnosis and their Potential Complications

• Angina / MI
• Asthma / COPD
• Diabetes
• Fractures
• Head Trauma
• Hypertension

• Pneumonia
• Pulmonary Embolus
• Renal Failure
• Trauma
• UTI

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Angina / MI

• Dysrhythmia
• Congestive Heart Failure
• Shock - cardiogenic, hypovolemic
• Infarction / Infarction Extension
• Thrombi/emboli formation
• Hypoxemia
• Electrolyte imbalance
• Acid Base Balance
• Pericarditis
• Cardiac Tamponade
• Cardiac Arrest

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TREATMENT

• Aspirin. You may be instructed to take aspirin by
  the 911 operator, or you may be given aspirin by
  emergency medical personnel soon after they
  arrive. Aspirin reduces blood clotting, thus
  helping maintain blood flow through a narrowed
  artery.
• Enteric Coating? (Chew IT UP)

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Treatment

• Thrombolytics. These drugs, also called
  clotbusters, help dissolve a blood clot that's
  blocking blood flow to your heart. The earlier
  you receive a thrombolytic drug after a heart
  attack, the greater the chance you will survive
  and lessen the damage to your heart. However, if
  you are close to a hospital with a cardiac
  catheterization laboratory, you'll usually be
  treated with emergency angioplasty and stenting
  instead of thrombolytics. Clotbuster medications
  are generally used when it will take too long to
  get to a cardiac catheterization laboratory, such
  as in rural communities.

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THROMBOLITICS

• Alteplase
• Reteplase
• Tenecteplase

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TREATMENT

• Other blood-thinning medications. You'll likely
  be given other medications, such as heparin, to
  make your blood less "sticky" and less likely to
  form more dangerous clots. Heparin is given
  intravenously or by an injection under your skin
  after a heart attack.

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Blood Thinners

• Heparin
• Lovenox
• Coumadin
• Xarelto
• Plavix

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Treatment

• Pain relievers. If your chest pain or associated
  pain is great, you may receive a pain reliever,
  such as morphine, to reduce your discomfort.

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Treatment

• STATINS
• Lipitor
• Crestor

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Treatment

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

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Treatment

• Beta blockers. These medications help relax your
  heart muscle, slow your heartbeat and decrease
  blood pressure, making your heart's job easier.
  Beta blockers can limit the amount of heart
  muscle damage and prevent future heart attacks

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Beta Blockers

• Coreg
• Lopressor
• Toprol
• Tenormin

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Treatment

• ACE inhibitors. These drugs lower blood pressure
  and reduce stress on the heart.
• Vasotec, Prinivil, Altace, Mavik, Lotensin,
  Monopril, and Accupril.

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Surgical Interventions

• Coronary angioplasty and stenting
• http//www.youtube.com/watch?vfL3Aak_PI-I
• Coronary artery bypass surgery.
• http//www.youtube.com/watch?vnZNQ0uliqHI

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Tests for MI

• ECG-Arrythmia
• Blood- CKMB (Creatine Kinase) elevated in first
  4-6 hours
• Chest Xray- Size and Fluid (See Pic)
• Angiogram Dye to show narrowing or blockage
  (See Pic)
• STRESS TEST http//www.youtube.com/watch?voIPaRAf
  6sQ0
• CT or MRI

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Asthma / COPD

• Hypoxemia
• Acid Base / electrolyte imbalance
• Respiratory Failure
• Cardiac Failure
• Infection

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Treatment

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

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Lung Sounds

• Asthma
• http//www.youtube.com/watch?vYG0-ukhU1xE
• COPD (Chronic Obstructive Pulmonary Disease)
• http//www.youtube.com/watch?v5JA6D1Mguh0
• Listen for the Difference

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Documentation

• SOB- Shortness of Breath
• Now get out your Bottle and grab a pair of
  scissors and wait for my instructions
• Next Get with a Partner and Clean your
  stethescope (men with men and ladies with ladies)

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Where to Listen
Anterior
Posterior
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Diabetes

• Type I (Insulin Dependent)
• Type II (Non-Insulin Dependent)
• Type 1.5 LADA (Latent Autoimmune Diabetes in
  Adults)
• Gestational Diabetes
• If left uncontrolled long enough, all four have
  the same set of complications

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Diabetes Complications

• Hyper-/Hypoglycemia
• Delayed Wound Healing-Amputation
• Hypertension
• Eye Problems - retinal hemorrhage
• See also Angina / MI / CVA

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Type I

• Type 1 diabetes, once known as juvenile diabetes
  or insulin-dependent diabetes, is a chronic
  condition in which the pancreas produces little
  or no insulin, a hormone needed to allow sugar
  (glucose) to enter cells to produce energy.

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Type I S/S

• Increased thirst and frequent urination
  (nocturia)
• Extreme hunger
• Weight loss
• Fatigue
• Blurred vision
• Yeast Infections

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Test A1C
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Tests

• FBS- Fasting Blood Sugar
• (70-110)_
• RBS- Random Blood Sugar
• (70-120)
• PPG- Post Prandial Glucose 2-3 hours after eating
• (lt140)

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Tests URINE

• Microalbumin
• A microalbumin test checks urine for the presence
  of a protein called albumin. Albumin is normally
  found in the blood and filtered by the kidneys.
  When the kidneys are working properly, albumin is
  not present in the urine. But when the kidneys
  are damaged, small amounts of albumin leak into
  the urine. This condition is called
  microalbuminuria.

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Tests URINE

• Ketones
• Ketones build up when there is insufficient
  insulin to help fuel the bodys cells.
• High levels of ketones are therefore more common
  in people with type 1 diabetes or people with
  advanced type 2 diabetes.

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Type I Drugs

• Insulin lispro (Humalog)
• Insulin aspart (Novolog)
• Insulin glargine (Lantus)
• Insulin detemir (Levemir)
• Insulin isophane (Humulin N, Novolin N)
• can be used with Type II drugs

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Type II

• Type 2 diabetes, once known as adult-onset or
  noninsulin-dependent diabetes, is a chronic
  condition that affects the way your body
  metabolizes sugar (glucose), your body's main
  source of fuel.

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Type II S/S

• Increased thirst and urination mainly nocturia
• Increased hunger
• Weight loss
• Fatigue
• Blurred vision
• Slow-healing sores or frequent infections
• Patches of Darkened skin (acanthosis nigricans)
• Yeast Infections (thrush)

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Type II Testing

• Glycated hemoglobin (A1C) test
• An A1C level of 6.5 percent or higher on two
  separate tests indicates you have diabetes. A
  result between 5.7 and 6.4 percent is considered
  prediabetes, which indicates a high risk of
  developing diabetes. Normal levels are below 5.7
  percent.

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A1C Flowchart
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Type II Drugs

• Glucophage (metformin)
• Glucotrol, Diabeta, Glynase, Amaryl
• Actos

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Standards for DM

• BS everyday(More Frequent when ill)
• Treat Hyper/Hypo quickly
• Know Your ABCs (A1C, BP, Cholesterol)
• Constant Oral Hygiene (Dentist 2xyr)
• Always have your Meds!
• Diet (ADA) and Exercise is a must!
• Frequent Eye Exams
• Know your TEAM MD/Dietician/Pharmacist/Trainer/e
  tc..

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Fractures

• Bleeding
• Fracture Displacement
• Thrombus/embolus formation
• Compromised circulation
• Nerve Compression
• Infection
• see also Skeletal traction/casts

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Types of FX

• Breaking of the Bone
• Closed or Simple No open wound present
• Compound or Open Open wound watch for
  hemorrhaging and infection

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• Deformity, limited motion or loss motion, pain
  and tenderness at the site, swelling and
  discoloration, and the protrusion of the bone
  through the skin
• The victim may hear the bone snap, feel
  crepitation (grinding), and have abnormal
  movement of the parts

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Spiral FX- Abuse?
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TX of FX

• Keep the broken bone from moving and prevent
  further injury
• Using Splints, Slings, and Air Splints, you can
  prevent the injured body part from moving
• When Splinting, splint above and below the break
• You must get EMS and medical help ASAP

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Dislocation

• When the end bone moves out of place or is out of
  normal position in the joint
• Frequently accompanied by tearing or stretching
  of ligaments, muscles, and other soft tissue

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TX of Dislocation

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

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TX for Dislocation

• Same as Fractures
• Ensure the patients body extremity is immobilized
  until it can be set.

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Sprain/Strain

• Swelling, pain, discoloration, and sometimes
  impaired movement
• Frequently resemble fractures and dislocations
• If in doubt, treat it as a fracture

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TX for Sprain/Strain

• Application of cold (ice with barrier 15 on 15
  off) to decrease swelling and pain, elevation of
  the affected part and rest
• An elastic bandage can be applied for support and
  if swelling is severe or there is a question of
  fracture/dislocation treat it as a fracture

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Splints pg 421

• Used to immobilize fractures, dislocations, and
  other similar injuries that are present or
  suspected
• Splints can be created using anything that
  provides support and does not further injure the
  patient

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• Splints should immobilize the injury above and
  below the site while preventing movement or
  further injury
• Splints should be padded especially over boney
  areas
• Strips of cloth, roller gauze, triangular
  bandages can be folded, or any other object that
  can be stretched and tied
• Splints must be applied in a manner that does not
  put pressure directly over the site of injury
• If an open wound exists, use sterile dressing and
  apply pressure

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• You must monitor circulation and nerve endings
  when the splint is in place.
• Skin should be warm to touch and watch for any
  edema, cyanosis, numbness or tingling, and always
  check the pulse
• IF any S/S of changes in circulation occurs or
  numbness occurs, loosen the splint while still
  supporting the area

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Neck and Spine

• Neck and Spine injuries can be life threatening
  and my result in permanent paralysis so avoid
  moving the patient at all cost until EMS arrives
• Watch for SHOCK since most bone injuries can
  result in shock
• Always watch for HALO Effect!!

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Head Trauma

• Increased Intracranial Pressure - bleeding or
  swelling
• Respiration Depression
• Shock
• Hyper-/Hypothermia
• Coma

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Diuresis and brain edema

• Diuretics are powerful in their ability to
  decrease brain volume and, therefore, to decrease
  ICP. Mannitol, an osmotic diuretic, is the most
  common diuretic used. Mannitol is a sugar alcohol
  that draws water out from the brain into the
  intravascular compartment. It has a rapid onset
  of action and a duration of action of 2-8 hours.
  Mannitol is usually administered as a bolus
  because it is much more effective when given in
  intermittent boluses than when used as a
  continuous infusion. The standard dose ranges
  from 0.25-1 g/kg, administered every 4-6 hours.

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Neuro cks

• Watch Again Tonight!!
• http//www.youtube.com/watch?vV2MBiS1kc_0

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Craniotomy for Aneurysm

• http//www.youtube.com/watch?vjySbT86tJqM

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Hypertension

• Cerebral Vascular Accident
• Transient Ischemic Attack
• Renal Failure
• Hypertensive crisis
• see also Angina / MI

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Pneumonia

• Pulmonary Embolus
• See Angina / MI

• Respiratory Failure
• Sepsis
• Septic Shock

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Pulmonary Embolus

• See Angina Myocardial Infarction

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Renal Failure

• Fluid Overload
• Hyperkalemia
• Electrolyte / Acid-base imbalance
• Anemia
• See also Hypertension

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Trauma

• See Anesthesia/ Surgical or Invasive procedures

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UTI

• Urinary Tract Infection
• SEPSIS??

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Individualize Assessment for Common Treatments
Procedures

• Anesthesia/ Surgical or Invasive Procedure
• Cardiac Catherterization
• Chest Tubes
• Foley Catherter
• Intravenous Therapy
• Medications
• Nasogastric Suction
• Skeletal Traction/Casts

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Anesthesia/ Surgical or Invasive Procedure

• Bleeding / hypovolemia / Shock
• Respiratory Depression / Atelectasis
• Urinary Retension
• Fluid / Electrolyte imbalances
• Thrombus/ embolus formation
• Paralytis Ileus
• Incisional Complication - infection, poor
  healing, dehisence, eviseration
• Sepsis / Septic Shock

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Cardiac Catheterization

• Bleeding
• Thrombus / embolus formation

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Chest Tubes

• Hemo / Pneumothorax
• Bleeding
• Atelectasis
• Chest tube malfunction / blockage
• Infection / sepsis

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Foley Catheter

• Infection / Sepsis
• Catheter Malfunction / Blockage

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Intravenous Therapy

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

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Medications

• Adverse Reactions
• Allergic Response
• Exaggerated Effect
• Side Effects
• Drug Interaction
• Incomplete effect
• Overdose / Toxicity

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Nasogastric Suction

• Electrolyte Imbalance
• Tube Malfunction or blockage
• Aspiration

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Skeletal Traction / Casts

• Poor Bone Alignment
• Bleeding / Swelling
• Compromised circulation
• Nerve Compression
• See also Fractures