1. Focused History and Physical Exam: Critically Ill Patients Nelia B. Perez RN MSN PCU Mary Johnston College of Nursing

2. Focused History and Physical Exam Pt Hx Pt story of significant events related to current problem Usually begins with pt C/C Many disease conditions are 1st suspected by symptomology MI Diabetics Allergic rxn OD

3. Focused History and Physical Exam: Medical Patients What: Rapid assessment of medical conditions that may require emergency care OR early hospital tx. Who: Non traumatically injured pt with medical c/c How: Focus C/C Signs/Symptoms SAMPLE history Medical PAST OPQRST history Medical PRESENT Baseline vitals Plan of FUTURE treatment

4. SAMPLE HISTORY S= Signs and Symptoms A = Allergies M = Medications P = Past pertinent medical hx L = Last oral intake E = Events prior to the condition

5. OPQRST HISTORY OPQRST Hx Branch of SAMPLE Hx Focuses on Signs and Symptoms Gives a clearer picture of pt C/C and its severity

6. OPQRST Hx Onset O = Onset When the complaint first started. The pt activities at the time of onset/immediately before What were you doing when this started Chest pain pt mowing lawn Anaphylaxis pt stung by bee Diabetic pt Working in hot day without food

7. OPQRST Hx Provocation P = Provocation What actions make the symptoms better/worse Is there anything that makes it better? Anything that makes it worse? Chest pains Worse with activity Better with rest SOB Better when sitting Worse when lying flat Etc

8. OPQRST Hx Quality Q = Quality Subjective description of complaint in pt own words Would you please describe the pain. What does it feel like Chest pains Crushing, vice-like, elephant Crushing Stabbing Burning

9. OPQRST Hx Radiation R= Radiation Is the pain local or does it travel to another part of the body Is the pain in one place or does it spread to other parts of your body? Chest pains L shoulder, arm, jaw, neck ,back

10. OPQRST Hx Severity Severity 1-10 scale gauging pain On a scale of 1-10, 1 being the least pain youve felt and 10 being the worst pain youve ever felt can you rate the pain?

11. OPQRST Hx Time T = Time Duration of the C/C and assoc complaints How long has this been going on? Chest pains Woke pt from sleep that night Allergic rxn- 15-20 min

12. Problem Focused Medical Assessment Responsive Medical Pt Problem Focused Medical Assessment SAMPLE Hx OPQRST Hx Focused Physical Exam Chest/neck- chest pains Pharynx/chest- SOB Etc Baseline Vitals

13. Rapid Medical Assessment Unresponsive/AMS Medical Pt Rapid Medical Assessment Rapid assessment of ALL body regions (DCAP-BTLS) Try to define C/C or ID trauma Rule in/out trauma Medical ID tags Baseline Vitals SAMPLE & OPQRST Hx when/if possible Tx in recovery position

14. Focused History and Physical Exam: Medical Pt Recap S Signs/Symptoms A - Allergies M - Medications P Past pertinent medical hx L Last oral intake E Events leading to condition O - Onset P - Provocation Q - Quality R Radiation S - Severity T Time BASELINE VITALS

15. INITIAL ASSESSMENT OF THE CRITICALLY ILL PATIENT

16. A critically ill patient is one at imminent risk of death; the severity of illness must be recognized early and appropriate measures taken promptly to assess, diagnose and manage the illness.

17. The approach required in managing the critically ill patient differs from that required in less severely ill patients with immediate resuscitation and stabilization of the patient s condition taking precedence: patients PHILOSOPHY OF MANAGEMENT

18. 1. Prompt resuscitation & adhering to advanced life support guidelines 2. Urgent treatment of life threatening emergencies such as hypotension, hypoxaemia , hyperkalaemia , hypoglycaemia and dysrhythmias life-hypoxaemia, hyperkalaemia, PRIORITIES

19. cont.; 3. Analysis of the deranged physiology 4. Establish a complete diagnosis as history & further diagnostic results are available 5. Careful monitoring of the patient s condition and response to treatment patients PRIORITIES

20. CARDIOVASCULAR SIGNS 1. HR 2. BP 3. PERFUSION 4. OLIGURIA 5. ARREST How To Recognize?

21. 1. RATE 2. DISTRESS 3. THREATENED OBSTRUCTION/OBSTRUCTION 4. RISING PaCO2 5. DECREASING SPO2 6. ARREST RESPIRATOY SIGNS

22. 1. THREATENED AIRWAY OBSTRUCTION/OBSTRUCTION 2. SUDDEN DETERIORATION IN CONSCIOUSNESS 3. GCS 4. ABSENT GAG/COUGH 5. FAILURE TO OBEY COMMANDS 6. REPEATED SEIZURES NEUROLOGICAL SIGNS

23. 1. Initial assessment 2. Immediate management 3. Monitoring 4. Initial investigations What are the steps to be followed?

24. Basic hemodynamic monitoring ECG, BP, CVP, PAP, CO ABGs, lactate, H ion, Urine output Fluid balance Lung mechanics, capnography Peripheral skin temp O2 transport MONITORING

25. FLUID MANAGEMENT

26. Failure to supply sufficient oxygen to meet the metabolic requirements of the tissues is the cardinal feature of circulatory failure or shock. SHOCK & LOW CO

27. ALGORITH OF SHOCK

28. Level of consciousness Level of consciousness should also be assessed upon initial contact with your patient and continuously monitored for changes throughout your contact with the patient. THE COMMON VITAL SIGNS

29. a. AVPU. The AVPU scale is a rapid method of assessing LOC. The patient's LOC is reported as A, V, P, or U. Level of Consciousness

30. b. Glasgow Coma Scale. The Glasgow Coma Scale is an assessment based on numeric scoring of a patients responses based on the patient's best response to eye opening, verbal response, and motor response. The patient's score (3 to 15) is determined by adding his highest eye opening, verbal response, and motor response scores. Level of Consciousness (CONT)

31. c. PEARRL. Use the guide PEARRL when assessing the pupillary response of the patient's eyes. Level of Consciousness (CONT)

32. BLOOD PRESSURE several factors that can affect a patient's blood pressure. a. Condition of Cardiovascular System. b. Age. c. Gender. d. Physical Fitness. e. Obesity. f. Pain. VITAL SIGNS

33. g. Emotion. h. Gravity. i. Exercise. j. Disease. k. Drugs. l. Eating. m. Bleeding.

34. FACTORS NOTED WHEN TAKING A PATIENT'S BREATHING RATE AND QUALITY a. Rate. b. Depth. c. Rhythm. d. Quality. e. Unusual Position. RESPIRATORY RATE

35. f. Coughing. g. Sputum.

36. FACTORS NOTED WHEN TAKING A PATIENT'S PULSE a. Pulse Rate. b. Strength. c. Rhythm. PULSE RATE

37. A Regular. B Tachycardia. C Bradycardia, D Bounding. E Weak (thready). F Irregular. G Intermittent (irregular).

38. WHAT CAUSES ABNORMAL TEMPERATURES? a. Infection. b. Environmental Conditions. BODY TEMPERATURE

39. PQRST PAIN

40. Thank You for Bearing with me!