Patient Admission Procedures PDF

Patient Admission – Deccan, Nagar Road, Hadapsar Walk-in or Planned Emergency Admissions IPD Casualty OPD IPD Counter Coun...

Patient Admission – Deccan, Nagar Road, Hadapsar Walk-in or Planned Emergency Admissions IPD Casualty OPD IPD Counter Counter Admission Wards Wards ICU The doctor who assesses the patient for the first time shall : Obtain History, Do Initial assessment, Inform to the Consultant, and Document and proceed with the Care plan. Patient Admission – Kothrud, Bibwewadi, Surya, Nashik, Karad All Patients IPD Casualty OPD Counter Admission Wards ICU  Lab Investigations Consultant / Resident orders the investigations Doctor shall note down in the IPD file and fill up the Lab requisition form Few Units – online requisition Sample can be collected by Phlebotomist. For new admissions, high priority, and urgent tests, sample shall be collected by Staff nurse and is sent to Lab/BCR. Doctors shall collect lab sample for ABG and Blood Culture & Sensitivity. Doctor shall ensure required preparation is done. e.g. 14 hrs NBM for Lipid profile Doctor shall follow up for the report (HMIS) Doctor shall note down the report in IPD file and inform to Consultant  Radio-Diagnostic Investigations Consultant / Resident orders the investigations Doctor shall note down in the IPD file and fill up the Radiology requisition form Few Units – online requisition Doctor shall contact Radiology / Diagnostics for appointment, give history and indication, take preparation instructions e.g. NBM status / Full Bladder etc. Doctor shall ensure required preparation is done. e.g. Creatinine before contrast, Rule out Metal implants before MRI etc. To send the patient to Radiology / Diagnostics Unstable patients shall be accompanied by the Nurse and Doctor Doctor shall follow up for the report Doctor shall note down the report in IPD file and inform to Consultant  HISTORY TAKING History Taking can be effective only if we listen patiently A good history can be elicited only if we establish a good rapport with the patient First introduce yourself, make the patient comfortable and then start Talk to the patient in his or her mother tongue or preferred language HISTORY TAKING IS AN ART…MASTER IT !!  Initial assessment The initial assessment of the ward patient shall be done within 30mins of the admission & within 10mins for critical care area. Once the assessment is done, the doctor shall document :- Complete history sheet with all columns. CMO shall fill History for patients routed through casualty, and ward/ICU doctors shall fill History for planned admissions directly coming to ward/ICU. Signature of the patient /relative who is narrating the history is obtained for verification of History. Admission shall be informed to the consultant/residents. Doctors shall receive orders, note down the Care plan & follow the same.  CHIEF COMPLAINTS Ask for information in the patient‘s own language. DO NOT use medical terms like burning micturition, hematuria while asking history Ask open questions ― tell me about your stomach pain‖ Ask leading questions ― Was the vomitus red, yellow or black, coffee ground‖ ? USE medical terms while documenting it on the case sheet RELEVANT QUESTIONS ABOUT PAIN Site Use numerical Pain score, Onset ask patient to rate his own Character pain from 0 (no pain) to 10 (worst possible pain) Radiation Document Pain Score and Act accordingly. Associations Timing Duration Exacerbating & Alleviating Factors Severity CARDIO RESPIRATORY SYMPTOMS Chest Pain Dyspnea ( breathlessness at rest ? ) Exertional dyspnea ( breathlessness on walking, climbing stairs) Orthopnea ( breathless in lying down position) Edema Palpitations Cough, wheeze Sputum, hemoptysis, weight loss  GI SYMPTOMS Pain in the abdomen Nausea Vomiting – colour, quantity, Frequency Hematemesis – blood in vomitus Diarrhoea Constipation Altered bowel movements Pain while defecation Blood in stools  GENITOURINA RY SYMPTOMS Incontinence ( urge to pass urine) Dysuria ( painful micturition) Hematuria ( bloody urine) Nocturia ( need to micturate at night) Polyuria ( frequent micturition) Hesistancy ( difficulty in starting urine) Terminal dribbling Pain in the flanks  NEUROLOGIC AL SYMPTOMS Senses – sight, hearing, smell, taste, touch Headache – location, type Numbness of limbs Weakness of limbs Higher mental function  MUSCULOSKELETAL SYMPTOMS Pain, stiffness, swelling of joints Diurnal variation Functional deficit  THYROID SYMPTOMS - HYPERTHYROIDISM Prefers cold weather Bad tempered Sweaty Diarrhoea Oligomennorhoea Weight loss, increased appetite Tremors Palpitations Visual Problems  THYROID SYMPTOMS - HYPOTHYROIDISM Depressed Slow, tired Thin hair Croaky voice Heavy periods Constipation Dry skin Prefers warm weather  ASSOCIATED COMPLAINTS Headache – h/o nausea, vomiting Chest pain – h/o jaw pain, shoulder pain Neck pain – h/o numbness in the arms Long standing productive cough – h/o night sweats, weight loss, anorexia  DRUG HISTORY Current medication – name, dose, route, frequency, duration Allergies to any medication in the past  PAST HISTORY Ask about HTN/ DM/TB/IHD If yes ask about the medication Ask about any previous surgical history  FAMILY HISTORY Ask details about family members Ask for social history Ask for H/o HTN/ DM/TB/Epilepsy/Cancer Ask for details about the age of onset of illness, the prognosis Tendency for hyperlipidemia, obesity, HTN  PERSONAL HISTORY Ask about smoking / alcohol/ drugs/ tobacco Ask details about diet habits Ask about the social life which will give an indication about the above parameters Ask about occupational history  MENSTRUAL HISTORY MC : 4/28 means … – bleeding for 4 days every 28days RMP means... – regular, moderate, painless Menorrhagia means – heavy bleeding Dysmenorrhea – painful menses Dyspareunia – painful intercourse LMP – last menstrual period (date-12.2.2016) Date of Menarchy – to be asked for in case of an adolescent girl  OBSTETRIC HISTORY Can you write the obstetric code for a patient who has two living children and has had one abortion ? G3 P2 A1 OBSTETRIC HISTORY Primigravida Gravida : : – One who – denotes is pregnant pregnant for state present andthe firstirrespective past time of the Primipara : period of gestation Parity : who has delivered – One one viable – Denotes child a state of ( parity does not previous increase even if pregnancy the children beyond areoftwins or the period triplets) Multipara: : viability Nulligravida – one – one whowho hashas nevercompleted been 2 or more pregnancies to a pregnant stage of viability Nullipara Grand :Multipara : – one who has never completed a – one whotohas pregnancy thecompleted stage of four viability or more pregnancies to the stage of viability  CONCLUDING THE HISTORY Ask about the patient‘s Ideas Concerns Expectations Summarize the history and ensure that the understanding has been correct and take the signature of the patient Don’t get disturbed / Irritated / Carried away. Confused patient / Arguing ? ? relatives patient / relatives Violent / Rowdy Weepy, patient / sentimenta relatives l patient / relatives  What is Pain? Pain is an unpleasant sensory and emotional experience associated with actual and potential tissue damage The body’s response to pain has both physiologic and psychological aspects. Pain management is an important factor in patient care. Pain management plays important role in Patient Satisfaction and overall experience with the Hospital.  Pain can cause... Pain may lead to develop physical signs also like tachycardia, sweating etc. ( sympathetic Nervous System) The person may hold his breath or have short, shallow breathing, which may produce atelectasis , lowers circulating oxygen and increase cardiac load. Pain interferes with sleep, affects appetite and lowers quality of life. Natural response is to stop activity, tense muscles, and withdraw from the pain-provoking activities which reduce mobility that may produce muscle atrophy and painful spasm.  If pain remains untreated... Acute pain may lead to : Chronic pain may lead to: – increase metabolic rate – fatigue, and blood clotting, – anxiety, – Uncontrolled pain – depression, impairs immune – confusion, function, which slows – increased falls, healing and increase susceptibility to – impaired sleep, and infections and dermal – decreased physical ulcers. functioning – induce negative emotions  Good Pain Management Pain Assessment Detailed pain history Pain score periodically monitored Pain Management : Drugs and other measures Response to treatment is monitored  Pain Assessment – common failures Neglect : – Commonly overlooked area Poor Documentation – Detailed assessment lacking. Unimportant : – Many a times, treatment is given but Pain assessment is not done. Confusion : – How to assess? How to measure? Myth : – Once treatment is given : assessment is not necessary.  Pain Assessment Pain Assessment is NOT…. Why Pain Relying on changes in Assessment is vital signs so difficult? Deciding a patient does not “look in pain” Pain is a Knowing how much a subjective procedure or disease symptom, not “should hurt” a sign. Assuming a sleeping patient does not have pain Perception of pain varies  Pain History Pain Characteristics – onset, duration, location, quality, intensity, associated symptoms, exacerbating and relieving factors Past and current management therapies Relevant medical and family history Psychosocial history Impact of pain on daily life – work, daily activities, personal relationships, sleep, appetite, emotional state Patient (and family’s) expected goals for treatment  Nonverbal Pain Indicators Facial expressions (grimacing) -Less obvious: slight frown, rapid blinking, sad/frightened, any distortion Vocalizations (crying, moaning, groaning) -Less obvious: grunting, chanting, calling out, noisy breathing, asking for help Body movements (guarding) -Less obvious: rigid, tense posture, fidgeting, pacing, rocking, limping, resistance to moving  Using Pain Scales Numerical Pain Scale Faces Pain scale – – 0 to 10 A series of human faces depicting Ask the patient to different facial expressions from rate his own pain on no pain to severe agonizing pain. the scale of 0 (no Patient has to correlate and pain) to 10(worst possible pain) choose the most appropriate face for his own pain. Doctors should Simple, easy to understand. not judge by the expressions. Less time consuming. Requires patient coopertion and more time.  Pain Management Document Pain Score on admission and daily. Next action should be appropriate according to the score – Score 0 to 2 Score 8 to 10 = “Pain – to be monitored and emergency” documented daily. – needs immediate intervention. Score 3 to 7 – Analgesia. – needs intervention. – Inform consultant. – Analgesia. – Reassess after 1 – 2 hrs. – inform consultant. – Reassess after 4 - 6 hrs See the Documented Pain Score in Earlier duty, and Follow up it appropriately.  Pain Management - Drugs Analgesic : drug used to achieve analgesia. Analgesia : relief from pain. Analgesics relieve pain without eliminating sensation. (different from Anaesthetics) Different Classes are : Systemic NSAID – Oral Cox 2 inhibitors – Intravenous Opioids – Intramuscular Combinations – Transdermal patch Atypical analgesics Topical – Cream, ointment, gel  NSA ID Non-Steroidal Anti-Inflammatory Drugs A class of drugs that provides : – Analgesic and – Antipyretic (fever-reducing) effects, and – Anti-inflammatory effects, in higher doses. Non-narcotic Non-addictive alternative to narcotics.  NSA Salicylates ID Acetic acid derivatives Aspirin (ASA) Indomethacin (Indocap) Ointments : Salicure, Etodolac (Etosafe, Proxym) Topisol, Salactin, Zytee etc. Ketorolac (Ketorol, Ketanov) Diclofenac (voveran, Dynapar, Propionic acid derivatives Enzoflam) Ibuprofen (Imol) Aceclofenac (Aceclo, Hifenac) Dexibuprofen (Sibet) Dexketoprofen (Infen) Enolic acid (Oxicam) derivatives Naproxen (Naprosyn, Piroxicam (Dolonex, Pirox) Xenobid) Meloxicam (M Cam) Lornoxicam (Lorsaid, Lorfit) Anthranilic acid derivatives Mefenamic acid (Meftal)  NSAID – Sulfonanilides Nimesulide (systemic preparations are banned by several countries for the potential risk of hepatotoxicity) The use of nimesulide in children under the age of 12 is contraindicated and banned. Continuous use of nimesulide (more than 15 days) can cause the following side effects : – Diarrhea, vomiting – Skin rash, Itching – Dizziness – Bitterness in mouth  Paraceta mol Paracetamol (acetaminophen) is not considered as NSAID because – It has only little anti-inflammatory activity. It mainly acts as Analgesic and Antipyretic. Maximum combinations with other analgesics. Dicyclomine + Paracetamol Cyclopam Mefenamic acid + Paracetamol Meftal forte Dextropropoxyphene + Paracetamol Proxyvon Caffeine + Paracetamol Saridon Nimesulide + Paracetamol Sumo Diclophenac + Paracetamol Dyanapar Ibuprofen + Paracetamol Combiflam  COX-2 inhibitors Controversial class of drugs due to risk of Cardiovascular adverse events. (Heart attack and stroke) Particularly, Rofecoxib and Valdecoxib are banned in India,too. Molecules Available in India Celecoxib (USA-FDA alert) – Celact Etoricoxib (not USA-FDA approved, licenced in the Europe) – Ezact, Etoshine,Lorfit  Adverse Effects Paracetamol NSAIDs Cox2 inhibitor s GIT Dyspepsia, Nausea, Dyspepsia vomiting, Gastric erosion and bleeding. Liver If overdose Rare failur e Renal In high doses, and failur prolonged use can cause renal e insufficiency. Vascular Rare Increased chances of Increased risk system bleeding of MI and Stroke.  Opioi ds Drugs which act on Opioid receptors are called Opioids. Opioids act on Nervous system to produce analgesia by : – decreased perception of pain, – decreased reaction to pain, and – increased pain tolerance.  Mild Opioids Tramadol – Injection – Cap/Tab/Suppository – 50mg / 100mg It is often combined with Paracetamol as this is known to improve the efficacy of tramadol in relieving pain. – Ultracet / Urgendol P Codeine Sulphate – Tab Codeine – Syp Phensedyl, – Mit’s Codeine Linctus  Strong Opioids Morphine and Fentanyl are Narcotic Drugs Morphine Sulphate Tab / Inj 10mg Double lock storage. Triplicate Prescription from Physician. Fentanyl citrate Inj / Patch  Opioids Adverse effects of opioids : – Nausea, vomiting, – Constipation, – sedation, – Respiratory depression, – Suppression of cough.  Strong Opioids Opioids produce sense of euphoria. Sudden discontinuation after prolonged use may lead to withdrawal syndrome. (Restlessness, Anxiety, Muscle aches, Sleeplessness, Sweating, Abdominal cramping, Nausea and vomiting) These drugs can cause physical dependence. This means that a person relies on the drug to prevent symptoms of withdrawal. Over time, greater amounts of the drug become necessary to produce the same effect (drug tolerance).  Atypical Analgesics Different class of drugs are used as Analgesics in patients with chronic or neuropathic pain (pain caused by damage/disease of Nervous system) Tricyclic antidepressants : especially Amitriptyline, is useful as analgesic in Migraine, Neuralgia. Anti-Epileptic Drugs : Carbamazepine, Gabapentin, and Pregabalin are used to treat neuropathic pain. WHO 3 step Pain Ladder for Cancer Pain  Choice of Analgesic Choice of Analgesic Severity of pain Cause / Type of pain Earlier drug treatment given for pain Patient’s age, co-morbidities  Non Pharmaceutical Pain Management Methods of non-pharmacological pain include – Rest / Immobilization (splints / collars) – Manipulation / Mobilization / Physiotherapy / Correction of posture – Traction – Local Heat application - helpful in diminishing pain and decreasing local muscle spasm – Cryotherapy (cold / icepack application) - reduces local metabolism, inflammation, and pain by decreasing nerve conduction velocity locally – Transcutaneous electrical nerve stimulation (TENS) - generally used in chronic pain conditions  Summary Each patient’s pain assessment is necessary because : – Pain is as important as of one of 5 vital signs. – Pain is a subjective symptom, cannot be measured by anyone else. – Pain can cause patient to be restless/dissatisfied. Doctor should use Faces Pain Scale or Numerical Pain Scale where patient has to rate his/her own pain in terms of Pain score 0 to 10. All Conscious and oriented patient’s pain assessment should be done at the time of admission (History sheet) and then Daily. Daily notes should include Pain score, wherever applicable. Required actions has to be taken as per the Pain score.  CLINICAL EXAMINATION Privacy & Dignity : The patient should be properly draped. Exposing only the area being examined at a time without undue exposure of the other areas. Accompanied by a female nurse / attendant when a male doctor examines a female patient. Sequential / Systematic approach : Vital Signs General examination Systemic examination  Patient Examination General Examination – Posture – Nutritional status – Consciousness & responsiveness – Pallor – Oedema – Lymphadenopathy – Icterus – Cyanosis – Skin – Dehydration.  Inspection – 1st step Observe Cleanliness & tidiness. Does he look acutely or chronically ill? sunken eyes loose, fragile skin Patient‘s look. Being ill doesn‘t mean that one looks sick. Appearance can be deceptive.  Inspection – 1st step Posture : the general way of holding the body may reveal significant information. Forced supine position: The patient lies down quietly on the back with two legs bending. -- Acute peritonitis Fetal position: Knee chest position with patient lying on sides. -- Acute Pancreatitis Forced lateral position (compulsive lying on the side): -- pleural disease (effusion/ pleurisy) forces the patient to lie down on the affected side to relieve pain or cough. Orthopnea : patient can not lie down, has to sit to ease breathing -- heart failure, pulmonary insufficiency.  Nutritional status One of the most important factors impacting an individual‘s health and disease. It can be evaluated mainly by skin, hair, muscle and subcutaneous fat. Parameters to measure : Body weight, height. Body mass index (BMI) Arm circumference Skinfold thickness Status : Normal / Average Nutrition or Malnutrition. Malnutrition : Under-nutrition or Over-nutrition - Protein / Protein+energy malnutrition - Overweight - Emaciation, Marasmus, Cachexia - Obese (?)  Cachexia Severe form of Malnutrition with loss of weight, muscle atrophy, fatigue, weakness, and significant loss of appetite. Observed in patients with malignancy, AIDS, chronic obstructive lung disease, tuberculosis, etc.  Consciousness & Responsiveness Disturbances can be noticed – Memory deficit. – Confusion. – Disorientation. – Language disturbance. – Delayed responses. – Emotional status. – Restlessness. – Aggressive, Rowdy, Delirious. – Depressed, indifferent. – Drowsy, stuporous, comatose.  Assess responses : AVPU scale Alert - a fully awake patient…… (although not necessarily well orientated) Voice - responds to voice Either in any of the 3 components - Eyes, Voice or Motor movement. Pain - responds when pain stimulus is given. Recognized methods for causing pain stimulus – a Sternal rub, Supraorbital pressure, Trapezius squeeze, pinching the patient's ear pinna, and Responses can be – through Eyes, Voice or Motor movement. Motor : locate the pain and push it away, : withdrawal from pain, or : involuntary flexion or extension of the limbs from the pain stimulus. Unresponsive - No Eye, Voice or Motor response to voice or pain.  Pallor Pallor = Paleness of the skin and mucous membranes. Pallor may be the result of reduced amount of oxyhaemoglobin in skin or mucous membrane due to -- 1. decreased blood supply to the skin (cold, fainting, shock, hypoglycemia) or 2. decreased number of red blood cells (anemia) Where to check it ? the face, lips, oral mucous membrane, tongue and palate, conjunctiva, palmer crease, nailbed. Good lighting is essential. It can develop suddenly or gradually, depending on the cause. Pallor Raynaud‘s Phenomenon  Possible causes - Pallor Acute Chronic Emotional response due Anemia, due to blood loss, poor nutrition, or to fear, embarrassment, underlying disease such grief, panic attack as sickle cell anemia frostbite vitamin D deficiency, reaction to ethanol and/or Osteoporosis other drugs scurvy migraine attack Hypothyroidism, hypopituitarism Shock Cancer, Leukemia hypoglycemia  Icterus Yellowish pigmentation of the skin and other mucous membranes (prominently the conjuctival membranes over the sclerae) caused by hyperbilirubinemia. Normal S. Bilirubin < 1 mg/dL. A concentration higher than 1.8 mg/dL leads to jaundice/icterus.  Icterus Type Prehepatic High rate of Hemolysis beyond liver's ability to conjugate causing Mechanism accumulation of unconjugated (indirect) bilirubin in blood. Causes Hemolytic anemia, Sickle cell anemia, Thalassemia, Malaria, HUS. Intrahepatic Extrahepatic A problem in Obstruction of conjugation and / biliary tree or transportation causing causing increased level increased level of of conjugated unconjugated (Direct) bilirubin. (indirect) bilirubin. Liver cirrhosis, Obstructive Alcoholic Gall stones liver disease. or Stricture Infection : Viral, obstructing CBD, Leptospirosis. Pancreatitis, Inflammation : cyst or Chemicals/drugs. cancer in head of pancreas  Cyanosis Bluish discoloration of skin & mucous membranes from lack of O2 in blood or increased quantities of Deoxygenated Hb in blood. Note : Anaemic patients require more severe hypoxia before cyanosis becomes clinically apparent. With a hemoglobin of 6 g/dL oxygen saturation would need to fall as low as 60% before cyanosis becomes clinically apparent  Cyanosis Central Peripheral Peripheral Mechanism circulatory or ventilatory problem Inadequate circulation. that leads to poor blood Cutaneous vasoconstriction. oxygenation. oxygenation. Sites Tongue, lips + extremities Extremities, fingers. Extremities Warm Cold On warming No change Disappears extremities warming Improvement on extremities Slight improvement No change O2 supplement Improvement on Slight improvement No change O2 supplement Causes : High altitude, Reduced cardiac output Causes : Congenital High heart disease, altitude, Cold exposure Reduced cardiac output Right to Leftheart Congenital shunt, Arterial Cold obstruction exposure ARDS, Pulmonary oedema Venous obstruction Arterial obstruction disease, Right to Left Sepsis Venous shunt, obstruction Sepsis ARDS, Pulmonary oedema  Oede ma Abnormal accumulation of fluid beneath the skin or in the tissues. Generalized oedema or localized swelling. Types : pitting oedema or non-pitting oedema. Pitting edema, is the more common type, resulting from water retention. 1. pregnancy 2. heart failure, or 3. local conditions such as varicose veins, thrombophlebitis, insect bites, and dermatitis. Non pitting oedema : 1. Lymphoedema : 2. Myxoedema : Seen in various forms of hypothyroidism and Graves‘ disease.  Lymphatic Drainage failure Obstruction due to a Pathophysiology : Oedema mass, nodule, Malignancy. Post-radiation, or Post-mastectomy. Infection : Filariasis. Reabsorption depends upon Filtration depends Oncotic pressure upon Hydrostatic (proteins) pressure (plasma) 1. Protein Loss Heart failure Increased Capillary permeability Nephrotic syndrome Water / Na Inflammation, Sepsis. 2. Reduced albumin retention Thrombophlebitis, Stings/Bites. synthesis Liver Cirrhosis Allergic reaction. Liver Cirrhosis Pregnancy, PMS Burn, Trauma. Malnutrition  Lymphadenopathy Types Localized lymphadenopathy : due to localized spot of infection. Generalized lymphadenopathy : due to generalized infection all over the body e.g. influenza. Causes Infection : acute or chronic (TB), Bacterial or Viral. Tumor : Primary (Hodgkin lymphoma and non-Hodgkin lymphoma) : Secondary : metastases Autoimmune : SLE, Rheumatoid arthritis. Immunocompromised status  Palpation : Lymphadenopathy Normal lymph nodes are not palpable. Note – Location, Size (in centimeters), Degree of Tenderness, Fixation to underlying tissue, and Texture (hard, soft, etc.). Clinical Presentation  Skin Erruptions Rash Erythema Pigmentation Scars Moisture Monitor time taken for Elasticity / Turgor Capillary Refill Indicates generalized health and nutritional status, including Hydration status. Dehydration Clinical Classification  EXAMINATION OF RESPIRATORY SYSTEM Respiratory Rate – 12-18breaths /min is normal SpO2 Pattern of respiration Movement of chest – equal on both sides Auscultation – check bilateral air entry – all the lobes – anteriorly and posteriorly. – Rule out : wheezes, rhonchi, crepts/ rales, – Check for decreased air entry – percussion note? Use of accessory muscles  EXAMINATION OF THE CARDIOVASCULAR SYSTEM Palpate the apex beat in the 5th intercostal space in midclavicular line Auscultate the heart sounds – at the apex or mitral area Turn to left lateral position and in expiration look for – – any murmur ( rumbling mid diastolic murmur indicates mitral stenosis/ pansystolic murmur – mitral regurgitation)  EXAMINATION OF ABDOMEN Each of the 9 abdominal areas should be examined in turn with light and deep palpation Light palpation – look for guarding, tenderness, rebound tenderness Deep palpation – look for masses Liver – Using the radial border of the index finger start palpating the RIF. Ask patient to take deep breaths. If the liver is not felt move towards the ribs Spleen – Start palpation below the umbilicus in the midline and move towards the left costal margin asking the patient to take a deep breaths and feel the movement of spleen EXAMINATION OF ABDOMEN  NEURO EXAMINATI ON 1. Walk – gait, Romberg‘s test, Heel walking, Tandem walking 2. Talk – content, articulation 3. Vision – visual acuity, check temporal fields, check eye movements, check fundus 4. Face – eye closure, check deviation of mouth, mouth opening against resistance, compare facial sensations on both sides of the face  NEURO EXAMINATION 5. Upper Limb – Pronator Drift, Check shoulder abduction against resistance, check deep tendon reflexes( biceps, triceps), finger nose test, fine movements of hand, sensation 6. Lower Limb – Hip flexion & knee extension against resistance, Deep Tendon reflexes( knee & ankle) , plantar reflex, sensation 7. Others –Neck Stiffness, check skull & spine  Objectives Today we will learn – Vital Signs, Significant variations in vital signs Basic Management of the ups/downs 4 vital signs Temperature Respiratory rate Pulse Rate Blood Pressure 5th vital sign : Pain  When to assess vital signs? On admission, and then every 4-6 hourly (wards) and continuous monitoring in Critical care area. Change in symptoms, appearance of new symptoms. Before, during & after surgery or any invasive procedure. Before & after the administration of a medication, specially a high risk medication. Before & after any nursing interventions e.g. ambulating a bed ridden or post-op patient. Before, during & after Blood transfusion. Vulnerable patients shall require frequent monitoring.  Vital signs linked to MEWS scoring Normal ranges of measurements of vital signs may change with age, sex, weight, exercise tolerance and clinical condition. By comparing patient’s vital signs and LOC with normal - MEWS scoring to be done for following patients : Patients shifted from ICU to wards. Immediate Post-operative patients in wards. Patients with GCS score < 13 Patients with more than 2 co-morbidities e.g. Known case of Diabetes, Hypertension and Ischemic Heart disease. Or Known case of Hypothyroidism, COPD and renal failure.  Temperat ure Body temperature reflects the balance between the heat produced and the heat lost from the body. Types : Core Temperature and Surface temperature Rectal Temp > Oral Temp > Axillary Temp (each in 0.50C) The variation may range within 10C Factors affecting Body Temperature Diurnal variation Environmental Temperature. Age (Infants and children respond faster and so temp. changes are rapid.) Basal metabolic rate Muscle activity Sympathetic stimulation / Response to Stress  Alterations in Body Hypothermia temperature < 35.0 °C Hypothermia < 95.0 °F Risk Factors : Normal 36.5–37.5 °C The extremes of age, Poor clothing, 97.7–99.5 °F Hypoglycemia, Fever / Pyrexia > 37.8 °C chronic medical conditions (such as > 100 °F hypothyroidism and sepsis), Hyperpyrexia > 40 °C Alcohol and drug users. > 104 °F Common reasons : Exposure to Cold ( winds, rain, or water for prolonged time e.g. diving), In Hospital setup like us : common Hypothermia occurs when your body situations of Hypothermia include : loses heat faster than it can be Intra-operative. produced. Immediate postoperative. It can be fatal if not treated Critically ill patients. properly. Sepsis.  Hypothermia Signs & Symptoms : Shivering (Note : in severe hypothermia, J wave shivering will cease ) (Osborn wave) Slurred speech, Memory loss, Confusion, Drowsiness. Cardiovascular Signs : Mild hypothermia : Tachycardia, rise in BP. Moderate to Severe hypothermia : Bradycardia, arrhythmias (AF), hypotension, VF to asystole. The J wave (Osborn wave) in ECG (prominent in Lead V3/V4) observed in 80% of hypothermic patients.  Hypother mia Treatment : Preventing further heat loss is important. 1. Protect from any cold / wet surface or wind. 2. Remove any wet clothing. 3. Warm the Patient. Warm the center of the body. Focus on the chest, neck, head, and groin. 4. Use an electric warmer blanket. Use dry layers of blankets, clothing, towels, or sheets. (Apply warm rather than hot) 5. Do not attempt to warm the arms and legs, as this will push cold blood back towards the heart, lungs & brain, making things worse. 6. If patient is alert and if allowed : warm drinks such as milk. 7. Unconscious patients / unable to or not allowed to drink /eat : warm gastric lavage through Ryle’s tube. 8. Monitor the victim. 9. CPR and Defibrillation as indicated.  Pyrexia Fever / Pyrexia > 37.8 °C or > 100 °F Hyperpyrexia Common causes : > 40 °C or > 104 °F Infections (acute, chronic, Sepsis) Causes : Inflammations e.g., boils, or abscess Intracranial hemorrhage Immunological diseases e.g. SLE, Infections : Cerebral inflammatory bowel disease. malaria, Tetanus, Pyogenic Tissue destruction e.g. Hemolysis, surgery, meningitis. infarction, trauma, cerebral hemorrhage etc. Sepsis, Reaction to Drug or incompatible blood Drug effects / Reactions, products Thyrotoxic crisis Cancers e.g. leukemia, lymphomas Metabolic disorders e.g., gout Thrombo-embolic processes e.g. PE or DVT Fever of unknown origin.  Fever /Hyperpyrexia Fever /Hyperpyrexia may cause - Symptomatic Treatment : Worsening of Level of sensorium Do not cover patient during Heat specially in Neurosurgical phase and minimum required for Neurological patients. shivering in Chill phase. Tachycardia, delirium, seizure. If continued, Dehydration. Tepid sponging. Daily Round – Covered Ice Packs in armpits / groin. Check Temperature graph / records. If Fever If patient has RT, Cold water lavage. – Note pattern / trend / spikes in last 24–48 hrs. Give fluid replacement (e.g. oral or IV) – possible causes, search Clinical to compensate for fluid loss from clues for source, sweating. – Investigations accordingly. Antipyretics  Respirati ons Patient’s Respiratory status to be defined in terms of following : Respiratory Rate = breaths per minute – Normal RR : 12 – 18 per minute. – Tachypnea : abnormally fast respirations. – Bradypnea : abnormally slow respirations. – Apnea : the absence of breathing Pattern / Rhythm : refers to the regularity of the expirations and the inspirations. A respiratory rhythm can be described as regular or irregular. Depth : normal, deep, or shallow. Hyperventilation; refers to very deep, rapid respiration. Hypoventilation; refers to very shallow and slow respirations Quality : Usually breathing does not require noticeable effort. Dyspnea / labored breathing. / Gasping respiration  Respirati Assessment : ons Factors Causing increased RR : Exercise Auscultation : Increase metabolism Bilaterally, posteriorly Stress covering all lung fields. Increased environmental Check Air entry, Normal temperature breath sounds, abnormal Lowered oxygen concentration in breath sounds if any. environment Note Accessory muscles use. Check SpO2 Factors Causing Decreased RR : Rule out cyanosis. Sleep Note associated complaints Decreased environmental temp. Arrange CXR, ABG, ECG. Certain medications such as narcotics Increased intra cranial pressure Dyspnoea - Symptomatic Treatment Propped up position. Oxygen supplementation. (Limited flow in COPD) Nebulization Bronchodilator : salbutamol, ipratopium. Steroid : Budesonide, Beclomethasone, Fluticasone Mucolytic : Acetylcysteine If COPD, Asthma : (Wheeze on auscultation) : if primary nebulisation is inadequate, Inj. Steroid can be given after confirming with Consultant. Inj. Dexamethasone / Inj. Hydrocortisone / Inj. Methyl Prednisolone. If LVF / CCF : Pulmonary oedema : Diuretic. Inform Senior and Consultant.  Oxygen Therapy Nasal prongs : 2–5 LPM, O2 concentration 24– 35%. Face Mask : 6 -12 LPM, Ventury mask : Rates above 5 L/min can O2 concentration 28– Can accurately deliver a result in discomfort to 50%. predetermined oxygen the patient, drying of concentration from 24 the nasal passages, and to 60%. possibly epistaxis.  Mask with Reservoir bag Rebreather mask : Non-rebreather mask : 5–15 LPM, With valve. concentration 40–70%. Non invasive method delivering highest oxygen concentration upto 90% Assisted Ventilation (Positive Pressure Ventilation) Mask with Ambu bag ventilation Non invasive ventilation Invasive ventilation  Identify Impending emergency : Need for Assisted Ventilation Tachypnea, Shallow and short breaths. Using accessory muscles, Gasping respiration. Respiratory distress, fatigue SpO2 < 85% Central cyanosis Mental status – confused, lethargic, drowsy. ABG : hypercapnia, hypoxia.  Pul se For an Adult, Normal Pulse rate = Normal heart rate = 60 – 100 /min. Rate – Tachycardia > 100 bpm and Bradycardia < 60 bpm Rhythm – the pattern of the beats (regular / irregular) Force or Volume – weak or thready (lacks fullness, hypovolemia) Full, bounding (volume higher than normal) Imperceptible (cannot be felt or heard, shock, arrest) 0 1+ 2+ 3+ 4+ Absent Weak NORMAL Full Bounding Sites to check pulse : Central or Peripheral Apical pulse : beat of the heart at it’s apex – 5th intercostal space, midclavicular line, just below left nipple  Central : Carotid Femoral Peripheral : Radial Brachial Peripheral: Popliteal Dorsalis Pedis Posterior Tibial  Factors affecting Pulse Age : as age increases, the pulse rate gradually decreases. Newbor Infant Childre children over 10-12 well-trained n (0 – 3 s (3 – n (1 – years & adults, adult athletes months) 12 10 months) years) 100–150 90–120 70–130 60–100 /min 40–60 /min /min /min /min Gender : male’s pulse rate is slightly lower than the female’s. Weight : More the weight, more may be the heart rate. Medications : some medications decrease the pulse rate, and others increase it such as digitalis decrease the heart rate.  Abnormal Pulse rate Check whether Sinus rhythm or Arrhythmia? For any abnormal Pulse rate : Check Regular or irregular? Temperature, Respiratory rate, pattern and SpO2. Blood pressure. Associated complaints (e.g. dyspnoea, chest pain etc.) ECG. Continue monitoring Treatment : depends on the cause.  Sinus Tachycardia Sinus tachycardia : Rate >100 beats per minute, regular. A normal physiological response to Exercise, stress, fright, anger, anxiety etc. Other Common causes include: Pain Hyperthyroidism Fever Sepsis Hypovolemia : blood loss, shock. Pulmonary embolism Dehydration ACS and MI Anemia Chronic pulmonary disease Heart failure Hypoxia Caffeine, nicotine, smoking.  Sinus Bradycardia Sinus Bradycardia : Rate 7 or any Red parameter Continue Rule out any Search cause for the Keep close watch / continuous all as per immediate cause of particular abnormal monitoring orders stress such as pain, score. Implement appropriate Clinical ambulation etc. interventions. Implement appropriate Bring Crash cart near Implement Clinical interventions the patient. appropriate Clinical Inform Consultant and Resident interventions Inform Consultant and to attend patient immediately. Resident immediately. If Consultant / Resident is not Recheck after able to attend patient every 1 hour for at immediately – inform ICU Recheck after half an least 4 hrs or unless consultant to see the patient. hour for at least 4 hrs or the score changes. unless the score SOS Code Blue to be announced changes.  Appropriate Clinical Interventions Temperature 96 or less 101 or more Remove any wet clothing. Do not cover patient during Heat Warm the Patient. Warm the center phase and minimum required for of the body. Focus on the chest, shivering in Chill phase. neck, head, and groin. Do not Antipyretics attempt to warm only the arms and Tepid sponging. legs. Covered Ice Packs in armpits / groin. Use an electric warmer blanket. Use Cold water lavage. dry layers of blankets. Give fluid replacement (e.g. oral or IV) If patient is alert and if allowed : to compensate for fluid loss from warm drinks such as milk. sweating. Warm gastric lavage through Ryle’s Monitor the patient. tube. Monitor the patient.  Appropriate Clinical Interventions SBP SBP < 80 mm Hg SBP > 180 mm Hg Check Peripheral and Check other vitals signs, and Central Pulsations. Rhythm. Check Rhythm. Check neurological status. Check responsiveness and other Check associated symptoms e.g. vital signs dysponoea, chest pain, sweating IV NS 250 – 500 ml fast drip – with etc. monitoring response in terms of Simultaneously search for cause. pulse volume / BP. Check Drug chart for doses Simultaneously search for cause. of antihypertensive drugs. Call for help. Counsel and pacify the patient. Inform Resident / Consultant / ICU. Do ECG. Monitor the patient.  Appropriate Clinical Interventions HR HR < 60 /min HR > 110/min Check Peripheral and Central Check Peripheral and Central Pulsations. Pulsations. Check Rhythm. Check Rhythm. Check responsiveness and other Check responsiveness and other vital signs. vital signs. Do ECG. Simultaneously search for cause Inform Resident/Consultant / ICU. such as fever, pain, anxiety, dehydration etc. Inform Resident/Consultant / ICU.  Appropriate Clinical Interventions RR SpO2 RR < 10 RR > 25 SpO2 < 90% Check other vital signs, SpO2 Check Responsiveness. Check pattern, quality, and depth of respiration. Check accessory muscle use, Cyanosis. Auscultate bilateral lung fields, all lobes and posteriorly. PUP and O2 by mask. SOS CXR, ABG, ECG. If wheeze on auscultation (c/o Asthma, COPD) : Salbutaomol, Ipratopium nebulization sos inj.Dexa/Hydrocortisone If crepts, rales bilateraally s/o pulmonary oedema : diuretic.  When to do it? MEWS scoring is to be done for following patients : 1. Patients shifted from ICU to wards. 2. Immediate Post-operative patients in wards. 3. Patients with GCS score < 13 4. Patients with more than 2 co-morbidities e.g. Known case of Diabetes, Hypertension and Ischemic Heart disease. Or Known case of Hypothyroidism, COPD and renal failure.  Advantages Composed of routinely recorded physiological parameters. Any deterioration in a patient’s condition will be recognised early with the help of the score. Use of MEWS in conjunction with rapid response team / Code Blue team has been associated with significant reductions in cardiac arrests and unplanned transfers to the ICU.  Patient transfer Within the facility : Stable patient can be transferred with PCA on wheelchair or stretcher. Unstable patients shall be accompanied by the Nurse and Doctor. Internal transfer note to be filled. ICU : detailed shift out summary to be written. Outside the facility : Stable patient can be transferred with patient’s relative. In such case a written consent shall be obtained in IPD file from patient and relative. Unstable patients shall be accompanied by the ACLS/BLS providers (Doctor and Nurse). A transfer note including the details of treatment & plan to be given with the patient.  Joint care / transfer to another consultant If a consultant requests for a joint care/transfer of patient, ward doctor shall give a note to IPD to change in HMIS and Face Sheet of IPD file, which must be authenticated by MCO. MCO shall confirm with both concerned consultants, shall ensure that joint care is not with the same speciality, and only then shall authenticate the note for joint care/transfer. Note shall be sent to IPD to do the required changes in HMIS and face sheet. Doctors shall give required information to both the Consultants for Patients who are under joint care of Consultants. BSL Management  Contents Introduction : Glucose Metabolism Hypoglycemia – causes, symptoms and treatment. Hyperglycemia – causes, symptoms and treatment. – Diabetic ketoacidosis Insulin – Types and commonly used preparations and monitoring  Introduction Blood sugar level or Plasma Glucose level is the amount of glucose (sugar) present in the blood. Glucose is the primary source of energy for the body's cells. There are two types of hormones affecting blood glucose levels : – catabolic hormones (such as glucagon, cortisol and catecholamines) which increase blood glucose; – anabolic hormone (insulin) which decreases blood glucose.  Glucose Metabolism Insulin is produced by the pancreas. Glucose available in blood can be absorbed by the Body cells with the help of the insulin. Thus insulin helps body cells to use glucose and lowers blood glucose level. Blood glucose level fluctuates throughout the day. Glucose levels are usually lowest in the morning (fasting level), and rise after meals temporarily.  Normal Sugar levels BSL Fasting : overnight or atleast 8hrs : < 100 mg/dL BSL PP (Post-Prandial) : 2hrs Post Meal : 30 Perfusion - Radial pulse present? – Yes, Mental status – Awake, doesn’t follow simple commands.  Example of RPM/ START Patient states he can’t move or feel his legs, his RR= 26, PR= 110 (Radial). He is awake and oriented. – Is he able to walk ? No – RR=? Rt LL, Cough with yellowish expectoration ++ Conscious, well oriented. Pain Score =0 CVS, CNS, PA = NAD Oral intake reduced, c/o nausea, but no vomiting Urine, motion passed. Today’s care plan – BSL monitoring premeals and Insulin accordingly. ? Add IV fluids w/f dyspnoea. ? Repeat CXR/Haemogram  Progress Notes Example e.g. Date-------- Time 12pm S/B Dr. XYZ 46 yr old male, Known HT on Rx, operated for Laparoscopic Inguinal hernia repair with mesh. POD 1, D2 Ciplox, No fever. Yesterday’s I/O = 2450/1900 Ambulated today morning. At present, afebrile, HR=70/min, BP=140/70 mm Hg, RR=14/min, PA= soft, Peristalsis +, Pain Score =2, Dressing in situ, Flatus passed, motion not passed, Tolerated soft diet today morning. Catheter removed at 10am, urine not passed since then. w/f urine output  Informed Consents Very Important medico-legal documents Different types of printed consent forms shall be used, written consents on progress sheet shall be avoided. Bilingual forms are available, Marathi / English side to be used as per Patient’s understandable language. Consent forms shall be filled completely and appropriately including patient details, name of Surgeon/Consultant, Procedure name, etc. All Consents are valid for 24hrs. So Blood Transfusion and Restraint consent should be obtained repeatedly/daily as per patient’s requirement. Do not leave any blank fields in the consent form. Do not use Short forms (TKR, TURP etc.)  Informed Consents Two signs to be obtained on each and every consent. 1st sign : person giving the consent or permission : – 1st choice – Patient – signature or LHTI. OR – If patient is unconscious / disoriented / unstable / less than 18yrs – then signature or Thumb impression of Next of kin. 2nd sign : Witness sign. – Witness should be preferably patient’s relative. – If second relative is not available, any other person can serve as witness. (other patient’s relatives / security / ward secretary / Nurse in charge /nurse as a last option) – Doctors shall not sign as witness. Surgeon / Consultant has to sign the consent form before the surgery / procedure.  Informed Consents HIV consent to be obtained in Duplicate copy, 1 copy to be attached with Lab form and 1 copy to be stored in file. DNR consents are not allowed by Law. Printed Forms available : HIV test, Surgery, Cathlab procedures, High Risk for Sx, Anesthesia, Procedure, Contrast administration, Chemotherapy, Critical status, DAMA, Restraints, BT, Liver Transplant consents etc. Following consents shall be documented in progress sheet till the printed forms are available : – Refusal of treatment, – Head shaving, – Sending pt outside the hospital (Stamp is available)  Consents – common non compliance Patient’s sign is not obtained though patient is conscious and oriented. Witness sign and / or Name is not written. Patient name, PRN not written. Alternative surgery/treatment not written. All blanks not filled in e.g. complications and risk factors in high risk consent. Type of Anesthesia is not marked in Anesthesia consent. Type of Restraint (physical /Chemical) is not marked in Restraint consent. Surgeon’s / Consultant Sign is not obtained.  Signs / Thumb impressions of Unconscious/Disoriented patients When the relatives of an unconscious/disoriented patient requests for permission to obtain the thumb impression/signature of their patient on any document, no such permission should be granted to obtain the thumb impression/signature of the unconscious/ disoriented patient (for whatever purpose). If bank officials/close relatives wish to perform any financial transaction on behalf of the unconscious/ disoriented patient, they should officially request and obtain a certificate from the hospital authorities that the patient is unconscious or disoriented and as such incapable of signing or voluntarily putting his thumb impression or understanding the details of the document on which s/he is putting his thumb impression. Based on this official certificate from the hospital, the bank officials can allow the nominee of such person to transact on behalf of the patient. Shift handover : Doctors shall give a file to file handover to the reliever which includes the status of the patient & further plan of action. Documents : handover book/form to be maintained in each shift as per the format provided.  Privileged health information Patient’s diagnosis, surgery etc. details are to be kept confidential and should not be disclosed to anyone unless patient permits. Seropositive patient and his medical records should not be demarkated with any kind of tags/stickers/bands etc. (no red star marks on patient file etc.) Communication with Consultants SBAR In Today’s Lecture : What is SBAR? What is the need of it? How to use it? Good Communication ? ??  Good Communication ?  Good Communication ?  Good Communication !  A Case Mr. Kale. 70 yr old Male. Study Known Hypertensive, IHD on Rx. (AWMI 3months back) Admitted for LVF in ICU, settled with diuretics and oxygen. 2D echo = EF 40%. Shifted out of ICU to wards on 3rd day of admission. Continued with antihypertensive drugs, anti-platelets, Aspirin, Digoxin, Diuretics. Adviced Coronary Angiography.  Day 6 of admission. 11am. In Ward. After passing motion, patient complained of dyspnea, sweating. Housedoctor examined patient to find – Heart Rate =98/minute. BP = 160/90 mm Hg. RS = Rales bilaterally, RR=24/minute. SpO2=92% on room air.  Day 6 of admission. 11am. In Ward. After passing motion, patient complained of dyspnea, sweating. Housedoctor examined patient to find – Heart Rate =98/minute. BP = 160/90 mm Hg. RS = Rales bilaterally, RR=24/minute. SpO2 = 92% on room air. Patient is not looking well. Shall I wait or Call the Consultant?  Hello Sir, Good Morning. There is a patient Mr. Kale. Kale …. His daughter came to me telling that he is complaining of Oh, LVF little breathlessness. patient. I checked him, SpO2 is 92%. BP=160/90 Give him Inj. Lasix …40mg. Start Oxygen. Good! Sir is coming It would take to see the patient. some more time I will tell him rest till I see the of the details in patient. But he round. should settle with Lasix. Also do an ECG. I will see him in the round. Nurse, Give Inj. Lasix 40mg to Bed. No. 217. Start O2 4lit/min and do ECG.  After half an hour, patient’s daughter called the doctor in panicky state, Housedoctor finds the Patient in gasping state. (Meanwhile Lasix was given, started on Oxygen, ECG not yet done) Code Blue announced. Patient resuscitated and shifted to ICU for further treatment. In ICU, investigations revealed – ECG changes s/o Ischemia. CXR s/o Pulmonary Oedema. Potassium of 2.9mEq/L. Was the Incident Preventable???  What went wrong? Housedoctor could not convey the seriousness of situation to the Consultant. (also to the nursing staff, as ECG was delayed) The communication was missing Important Details. (vital signs, and background) COMMUNICATION !!! Differences in the Perception Consultant knew that he would take some time to go and see the patient, but Housedoctor perceived that Consultant is coming to see the patient.  Multifaceted, Multilevel Communication (Apart from patients & relatives) Consultant Other doctors Staff nurse Other Healthcare Employees Med.Admin / MCO  (1995 – 2004) Mis-Communication – Major cause of Sentinel events  Challenges ! Challenges in Good Communication - Story telling : More narration and description may miss out important details. Physicians are busier and are trained to be problem solvers – “what do you want me to do?” Lack of assertiveness from the informer. Human factors : Hierarchy, prior experiences, interpersonal relations, anxiety etc. “What if I do a mistake?” Organizational culture.  What can we do? Understand What Do Physicians Want To Know? – Accurate concise information. – Complete Relevant information available. – Accurate Assessment of patient. – Possible solution or Recommendation. Use of a simple technique – SBAR – Promotes clear, effective and efficient communication. Standardized approach. (everyone is talking in the same line) Definite framework for communication. Efficient transfer of information.  SBA R Situation Background Assessment Recommendation  Before the Call.... ASK Yourself --- Have I seen and assessed the patient myself before calling? What do I want to happen as a result of this call? Gather all the information before you contact the physician.  Name, age, Diagnosis of the patient.  Medication list.  Most recent assessment of pt. – Vital signs.  Most recent Lab results  Current Problem.  SBAR S – SITUATION – State your name and unit / floor / ward. – I am calling about (pt name and bed no.) – The problem I am calling about is. – In Brief (5 -10 seconds) B – BACKGROUND – State the admission diagnosis – State the Relevant medical history – A brief, concise summary of events which lead to current scenario.  SBAR ASSESSMENT – What do you think the problem is? State current scenario and your assessment. Pulse BP Rhythm changes Respiration rate and quality, pattern Temperature Oxygen level Pain Mental status etc.  SBA R Recommendation – What do you want to happen and by when? What is your recommendation to solve the current problem? e.g. Do you want the consultant to come and see the patient? Do you want immediate help from a senior? Do you feel need to transfer the patient to the ICU? Do you feel need for some specific treatment? i.e. IV fluids, diuretic, nebulization, pain medication etc. Do you want somebody to counsel the patient / family? Express Concern : Use ‘I am concerned that …’ ‘ I am uncomfortable about ….’ Reassert if necessary. READ BACK.  After the Call Immediately – Note the important details, directives, decisions in the IPD file. Note the date and time. Complete the notes with due signature and name. Act upon the directives.  Where you can use SBAR ? Informing to Consultant – Reference – GC informing – Alert / Emergency call Transferring Patient – Shifting patient to another ward – Shifting to another hospital Handover to next shift. Administrative Reporting. (e.g. MCO)  DOCTOR - DOCTOR RELATIONSHIP Understand your superiors and colleagues Co-operate with them Good communication and rapport Work as a team Have a complete knowledge of the case before you communicate with your superiors Respond to criticism positively Own up your mistake and apologize Give negative feedbacks in a positive manner  DOCTOR – NURSE/ SUBORDINATE RELATIONSHIP Doctor is the Nucleus of the Health Team Team leader – demonstrate leadership qualities – Capable of getting work done – Monitor the work that is delegated Work in co-ordination with nurses and subordinates Respect the nursing staff and helpers Show understanding, be empathetic Prevent interpersonal conflicts GIVE RESPECT AND GET RESPECT!!  COMMUNICATION with Patient and Family  Learning Objectives In this session we will see: What is a good effective Communication ? Importance of communication for doctors What do patients expect from doctors? Complaint Handling Handling Difficult Patients Things we can do to improve doctor patient communication.  Communication Communication is the exchange and flow of information and ideas from one person to another; it involves a sender transmitting an idea, information, or feeling to a receiver Effective Communication occurs only if the receiver understands the exact information or idea that the sender intended to transmit.  It’s different … Communication with a patient is different from communication in general. The patient is in pain, he is mentally unstable, he wants immediate attention. He is emotionally, physically and sometimes even financially not prepared to face the situation He wants someone who would listen to him and understand his sufferings.  Empathize... “A physician is obligated to consider more than a diseased organ, more than the whole man - he must view the man in his world”. -Harvey Cushing  DOCTOR - PATIENT RELATIONSHIP CREATE A POSITIVE IMPRESSION Knock before you enter the room Introduce yourself respectfully Minimize the patient’s apprehension Be friendly and engage the patient into a conversation Explain to the patient what you plan to do DOCTOR - PATIENT RELATIONSHIP EFFECTIVE COMMUNICATION Non Verbal Communication – body language, gestures, posture, facial expression, Eye contact Verbal Communication – language, tone of voice, content of words, clarity, relevance, politeness Empathetic communication Active listening skills  DOCTOR - PATIENT RELATIONSH IP VULNERABLE PATIENTS Vulnerable patients are those who are unable to care of themselves, and so are more prone to physical injuries. They are emotionally unstable and so susceptible to mental distress, injuries. “TREAT WITH ZERO ERROR” !!  DOCTOR - PATIENT RELATIONSH IPcould be : Vulnerable patients Neonates Children, Adolescents. Elderly, geriatric patients. Mentally challenged patients. Physically challenged patients. Patients with critical illness. Patients with malignant diseases Patients volunteered for Research / clinical trials.  DOCTOR - PATIENT RELATIONSH GO THAT EXTRA MILE…. IP Assurance & Support Give preference to them Prompt response. Practice empathy Be mild / soft spoken Volunteer for help Better communication Honor the pain / distress Timely and correct intervention  Barriers of communication Perceptions and assumptions Being bias Thought process Know all attitude Routine and stagnant life style Interrupting Jumping to conclusions Pre occupied mind  Complaint handling... Listening is an art... The process of recognizing, understanding, accurately interpreting communicated messages and responding to spoken and/or nonverbal messages is called as empathetic/ active listening. Steps to Effective Listening Hearing Interpretation Evaluation Respond  Tips to become an empathetic listener Don’t only talk – also listen. Don’t interrupt or change the subject Don’t prepare to reply before hand Listen to the unspoken words. Ask relevant questions Don’t get distracted by the surroundings. Keep an open mind and body posture. Be willing to listen to someone else’s point of view and ideas Avoid giving advice or narrating your story Provide feedback. (“ha”, “hmm”, “ya”, “may be”,) Summarize : let the speaker know that you are listening  DOCTOR - PATIENT RELATIONSH HANDLING DIFFICULTIP PATIENTS Defusing Technique – agree with the grieved patient or relative & stay calm Understand the patient’s perspective and be empathetic Ask probing questions softly and try to explore the reason for the problem Using “I”statements – I feel that….. Address only medical issues Divert other issues to the concerned persons Try to resolve the issue if possible If not escalate the issue to the higher authorities  Things you can do to improve doctor patient communication. Observe empathetic listening. Build trust. Get rid of pre conceived notions. Give due respect. Demonstrate sense of responsibility. Be polite and courteous. Use body language Use figures, pictures, or models if required  What do patients expect from doctors? Trustworthy Quality treatment Confidentiality Assurance Time and Moral support attention Patient’s Expectations Guidance Comfort Co operation Approachable Help  DO NOT BE MECHANI Hello, How are you? Avoid This!! CALHad your Lunch? What did you eat? Avoid such situations ! What did the Consultant tell you? What about Discharge?  Nurse, I told you - Do not touch Avoid such that tube. You xxxxx. situations ! Don‘t get disturbed / Irritated / Carried away. Confused patient / Arguing ? ? relatives patient / relatives Violent / Rowdy Weepy, patient / sentimental relatives patient / relatives  Empathy in Patient Care To be used for Training purpose only within Units of Sahyadri Hospitals.  Empathy : What is it? Empathy is the ability to understand and share the feelings of another. Empathy is the capacity to understand or feel what another person is experiencing from within the other person's frame of reference, i.e., the capacity to place oneself in another's position. Empathy is seeing with the eyes of another, listening with the ears of another and feeling with the "heart" of another  Sympathy vs Empathy Sympathy Empathy Acknowledging another Understanding what others person's emotional are feeling hardships Understand from your own Put yourself into their shoes perspective. Example “I know it's not easy Example “Trying to lose to lose weight because I have weight can often feel like an faced the same problems uphill battle.” myself.”  Sympathy vs Empathy Sympathy Empathy Feeling sorrow or concern Feeling the same emotions as for the person the other person  Empathy Compass ion the feelings of another person. Empathy is the ability to experience It goes beyond sympathy, which is caring and understanding for the suffering of others.  Empathy in patient care The capacity to empathize is innate in all of us, and is vital for a person in Medical profession. We need to connect with patients first on an emotional level to gain their trust. After this process, then we seek / share the medical information. Emotional connections lead to trust. The greater the sense of trust, the more likely the patients will be compliant.  Empathy in patient care Empathy means understanding what it is like to be in other’s shoes, What are they experiencing? Health care professionals have empathy in the hearts, but this is not enough. They empathy needs to come out in words. Patients are not mind readers. Empathic Opportunities : From time to time, patient may signal an area of personal concern or worry. Doctor needs to identify these windows and react empathetically so that a strong connection is build with the patient.  Empathic Listening Empathic listening is when one listens with the intent to understand how the speaker feels in addition to understanding his thoughts/problems. Showing empathy involves Identifying with a person’s emotions and situation, even if not in agreement with them. Use empathic listening To discover another’s needs and concerns To show an interest in the other person Empathic listening is therapeutic in itself It leads to an increase in another’s satisfaction of you  Steps for Empathic Listening Listen carefully to the patient : both verbal & non-verbal Consider patient’s emotional status Maintain an Eye contact Show that you are actually “Listening” e.g. nodding head, smiling/ expressing at appropriate moment Show that you want to understand more about patient’s experience e.g. asking related and relevant questions to collect more information such as “can you tell me more about that?” Reflect back what you have perceived  Don’t s... Don’t overload information Avoid Extremes Do not judge / Criticize Do not interrupt / probe Do not start advising / lecturing Do not start your story Do not check your watch every 2 minutes or yawn Do not simultaneously engage in other work e.g. fill up the forms / enter in computer Elements of Empathy  Barriers Cultural Differences Don’t know how to be Gender empathic? Not viewing the other “If I show caring, the individual as an equal floodgates will open.” Your preconceived ideas and beliefs Your uncomfortableness with another’s emotions  Not enough time The Biggest Barrier ??? In recent years Medical profession is facing more challenges with – a growing population, – the acuity of patients, – Shortage of manpower, – Increasing Documentation, – Patients’ mindset ! Doctors often assume that empathy is a time-consuming exercise of drama and has little effect on ultimate health outcome. Researchers found that when discussing life-threatening diagnoses, patients do offer many empathic opportunities, and doctors respond to only 10% of these emotional needs.  Empathy does not require extra time Surprisingly, When empathy was provided, the responses from patients ranged from 1 to 2 words up to 1 sentence. On the other hand, when empathy was not provided, patients repeatedly attempted similar things, uttered similar problems repeatedly until the Doctor acknowledges it. In other words, empathic response may actually save time. Empathy is not about a particular set of words  Benefits Showing empathy to patients -- Reduces patient anxiety, Motivates patients to stick to their treatment plans Builds a strong Doctor – patient relationship Improves Patient’s satisfaction of care, Improves clinical outcomes Reduces malpractice claims.  Empathy for all… Not only for VIPs... E – Everyone needs someone M – Model and Mirror P – Put yourself in their shoes A – Acknowledge and understand T – Treat others the way you want to be treated H – Helpful Y – You both feel better MLC Protocols  Contents MLC admission Brought Dead Brought in Dying Non MLC consent condition Injury Certificate Samples, Evidence Thumb impression of MLC for cases not unconscious patient routed through casualty Unaccompanied / Delayed MLCs unidentified patients MLC for OPD cases MLC Discharge MLC Death Reports handover  What is a MLC ? A medico-legal case is one where besides the medical treatment; investigations by law enforcing agencies are essential to fix the responsibility regarding the present state / condition of the patient. The case therefore has both medical and legal implications.  Registering MLC is mandatory for … All injury cases, circumstances of which suggests commission of offence by someone. All burn injuries due to any cause. All vehicular, railway, aeroplane, ship, boat, factory, construction site or other unnatural accidents Electrocution Suspected or evident homicide, or suicide (including attempted.) Suspected or evident poisoning. Suspected or evident criminal abortion. Assault – domestic violence – Rape, sexual assault – Child abuse  Registering MLC is mandatory Chemical injuries for … Poisoning, Alcohol Intoxication Snake / animal bite Fire Arm injuries Cases of asphyxia as a result of hanging, strangulation, drowning, suffocation etc. Domestic fall / trauma with suspicious circumstances Suspicious history Deaths in the Operation Theatre during Medical Termination of Pregnancy, delivery, following sterilization or any other surgical procedure should also be reported to Police. Brought Dead to the Casualty Dept Deaths occurring within 24 hours of hospitalization without establishment of a diagnosis.  Non MLC consent – Not allowed It is purely the responsibility of an attending doctor in casualty to decide when to label a case as medico-legal. Request of the patient or the accompanying relative or friends etc. for not registering the case as medico legal shall not be entertained. The medical Officer has to base his decision on findings and the nature of circumstances. However, doctor should not act as a detective in such cases. Main duty of the doctor is to observe and record things correctly. It is important to remember that treatment of every medico-legal case takes precedence over medico-legal formalities.  Registering MLC CMO shall inform to the particular police station, where the incident has occurred and register MLC. CMO shall note down the Name and Buckle no. of information receiving Police Constable. If patient is transferred from another hospital where a MLC is registered already, even then a MLC should be registered again at the same police station. If patient is transferred from other city where a MLC is registered already, even then a MLC should be registered again at the police station nearest to the Hospital.  Registering MLC MLC no. to be generated as Serial no/Month/Year. (serial no. to be restarted from 1,2,3…. every new year) CMO shall put MLC stamp on face sheet (IPD/OPD) and Yellow activity sheet. Details should be written on Face sheet including name of police station (in the defined space) MLC Register has to be filled in with all relevant details.  Injury Certificate The injury certificate must be prepared by the CMO on duty at the time of admission The certificate must mention the details of the injury as were found during first assessment Two identification marks like scars, moles or tattoo marks preferably on the exposed parts of the body should always be recorded. The injury must be classified as grievous and non grievous injuries While describing an injury, its type (i.e. abrasion, contusion or laceration etc.), dimension i.e. length, breadth and depth (depth should be mentioned where possible, in case of stab injuries measuring for depth is not available) and location (along with position from a bony point) must be mentioned.  Injury Certificate Where possible opinion regarding the nature of injury (simple or grievous) should be mentioned but in case it is not possible, reasons should be given e.g. opinion reserved pending X-ray report, of the patient under observations. In such cases the opinion may be given at a later date. In case of fire-arm injuries, blackening, tattooing or scorching if present should be mentioned and wound of entry, wound of exit if present is also required to be mentioned. While interpreting the weapon of offence the opinion should be given in the form of hard blunt weapon, soft blunt weapon, cutting weapon, stabbing weapon or fire-arm etc. While mentioning the age of injuries, findings like fresh hemorrhage, clot formation, color of scab, color changes in bruise healing, findings of pus formation etc. should be taken into account.  Injury Certificate The reporting Officer must put signature at the end of injury Certificate along with his full name, official stamp, date and time. Consultant later on must sign the Injury certificate and authenticate. If Consultants wants to add any details, he shall mention them on the same certificate with his name, sign, date and time.  Samples, Evidence In suspected poisoning cases, (where required and indicated) gastric lavage should be done. Give details of symptoms and probable nature of poison used in the injury certificate. Where clothes are blood stained, these should also be taken possession of by the Medical officer and sent to Police station in sealed cover with a mention of it in the report. Any material (like bullets) gastric lavage fluid, weapons found on the body etc. should be mentioned in the report and handed over to the Police Investigating Officer under sealed cover. Forensic Science Lab form should be used to dispatch the sample to Forensic lab through police ( to be filled in Duplicate) One copy to be handed over to police, one to be retained in IPD file If the police does not collect the sample the CMO/ attending doctor should obtain sign of police on the same form with his reasoning for not collecting the sample. If the police does not claim the sample during patient stay, then the same must be communicated to them at the time of discharge.  Direct admissions If any patient is seen by the Consultant in OPD and advised admission, then in Hub units patient is directly admitted to ward (not routed through casualty) In such cases the Consultant / first doctor attending the patient in IPD has to identify the case as MLC and register a MLC in coordination with Casualty. OPD MLC Patients falling under the category of MLC but treated on OPD basis – also need to be registered as MLC.  Delayed MLCs If a case was not registered as MLC at the time of admission, but during the course of admission at any point of time if the Doctor discovers circumstances or findings that fall under category of MLC (e.g. Bruises at the back, suspected poisoning) then MLC is to be registered at that point of time immediately. In such case, details and reason for delay is to be mentioned in IPD sheet at that time The ward doctor shall register the MLC in coordination with Casualty. Injury certificate shall be filled at that point of time.  MLC Patient statement When Police official come to record MLC patient’s statement, if patient is not in a condition to give statement (unstable / unconscious / disoriented etc) then Doctor can give certificate of the same.  MLC Discharge All MLCs are to be informed at the time of discharge also. The attending doctor (ward / ICU from where patient is discharged), shall inform CMO about MLC discharge and shall document same in IPD file with SNDT. (e.g. MLC discharge informed to CMO Dr. XYZ). On receiving information form ward, CMO shall inform the police and shall document same in MLC register with his sign, name, date, time, name of police station and name & buckle no. of police receiving information. Note – MLC cases who are discharged and readmitted for administrative reasons (e.g. change of schedule) – In such cases attending doctor must ensure that the second file is stamped as MLC while readmitting. And discharge shall be informed to police when patient is actually physically discharged.  Reports handover All the original reports and imaging films shall be retained with the Hospital for all MLC patients. If patient wants the copies, they can request in writing and get duplicate copies /films. – Exception : At SSH Deccan, monthly backup of all imaging and reports of MLC cases is obtained on a separate Hard disk, so original reports are handed over to patients after obtaining a Separate consent for the same. All MLC patients’ records shall be stored in MRD under lock and key for 30 years.  MLC Death In case of Death of a MLC patient, Death certificate shall not be issued and death has to be informed to police. Dead body is to be handed over to police and the same shall be documented in patient’s file with name & sign of receiving Police officer. Police shall also ask for photocopies of all the IPD record in MLC deaths.  Deaths occurring within 24 hrs of hospitalization without establishment of a diagnosis In such cases the Consultant in charge shall counsel the patient’s relatives, shall explain that a Diagnosis is not established from the patient’s Clinical condition, history and available investigations. Consultant in charge shall counsel the patient’s relatives about inability to certify Cause of Death, and need of Postmortem examination to establish the Cause of death.  Absconded patient Absconded patient situation may be due to … If any admitted patient is found absconding /missing If a patient has been permitted to go out for a particular reason and he/she has not returned as per the agreed time period In such cases, following steps to be taken :  Contact the patient, relatives, next of kin, then…  Inform the incidence to Unit Head, CMS/MCO, Nursing supervisor and Security Supervisor, then …  Perform a local search within hospital premises, then …  Inform nearest Police station  Note all details in the IPD file and Incidence report.  Missing Record If a patient’s IPD/OPD record or part of record is misplaced, and if not retrieved after diligent search – Medical admin should register FIR at the nearest police station. FIR copy needs to be preserved.  Signs / Thumb impressions of Unconscious/Disoriented patients When the relatives of an unconscious/disoriented patient requests for permission to obtain the thumb impression/signature of their patient on any document, no such permission should be granted to obtain the thumb impression/signature of the unconscious/ disoriented patient (for whatever purpose). If bank officials/close relatives wish to perform any financial transaction on behalf of the unconscious/ disoriented patient, they should officially request and obtain a certificate from the hospital authorities that the patient is unconscious or disoriented and as such incapable of signing or voluntarily putting his thumb impression or understanding the details of the document on which s/he is putting his thumb impression. Based on this official certificate from the hospital, the bank officials can allow the nominee of such person to transact on behalf of the patient.  Unaccompanied/Unidentified Patients In case patient is unidentified and incapable of giving consent and is unaccompanied, and condition of patient warrants life saving emergency procedure/surgery then Clinician In charge & another independent Clinician and administrator and a Police official shall give consent for such a procedure/ surgery. Unclaimed/unaccompanied dead body is to be handed over to police. Other situations where you need to inform police : Deaths occurring within 24 hrs of hospitalization without establishment of a diagnosis Absconded patients Missing Record Brought Dead Protocols  Brought Dead patients Any patient who is brought dead in casualty, CMO shall first examine and Confirm Death. If patient is already Dead before coming to Casualty, Resuscitation should not be attempted. Death shall be declared to family / accompanying relatives. If not already registered, PRN shall be generated. (PRN to be generated for CMO visit) All the clinical details with date and time shall be noted in OPD paper. Photocopy of Straight line ECG authenticated by the attending doctor shall be attached to OPD paper. Brought Dead register shall be filled with all the details and copy of ECG.  Brought Dead patients Death Certificate shall not be issued to Brought dead patients. Exception : Chronic illnesses, malignancy or other medical/surgical illness patient who has received treatment in the same Hospital, and if brought dead then CMO should examine the patient thoroughly and rule out unnatural cause of death and shall communicate the same to Consultant. Then DC can be issued on Form 4A on Consultant’s discretion only. (Non-institutional death certificate form 4A to be signed by Consultant with his Name and Registration No.) Do not issue a Death Certificate. – Even if patient was taking treatment in one Sahyadri Unit but now brought dead to another unit of Sahyadri, and if treating doctor is not the Panel Consultant for the particular unit, then Hospital shall not issue a DC. If Consultant wants to give DC, Arrange to give DC from the original unit where patient was taking treatment earlier.  Brought Dead patients While proceeding further, various