PAR3619 - Theory of Patient Care - Lecture 1B NOTE PDF

PAR3619 – Theory of Patient Care 1 Lecture 1A – Professionalism Wednesday, September 4, 2024 MPDS: Medical Priority Dispatch Purple - Emergent and life-threatening conditions. - Time critical response required. Red - Emergent and pote...

PAR3619 – Theory of Patient Care 1 Lecture 1A – Professionalism Wednesday, September 4, 2024 MPDS: Medical Priority Dispatch Purple - Emergent and life-threatening conditions. - Time critical response required. Red - Emergent and potentially life-threatening conditions. - Time sensitive response required. Orange - Urgent/potentially serious, but no immediate threat to life. Yellow - Non-urgent (not serious, and no immediate threat to life). Green - Non-urgent (not serious, and no immediate threat to life). - May be deferred. Age and Vital Signs – Expected Normal Ranges Adults Normotension (arterial blood pressure is within the normal range) - SBP ≥ 100 mmHg Hypotension (decrease in systemic blood pressure below accepted low values) - SBP < 90 mmHg Heart rate Bradycardia (abnormal heart rhythm – the heart beats very slowly) - HR < 50 BPM Tachycardia (a heart rate over 100 beats a minute) - HR ≥ 100 BPM Tachypnea (a breathing rate that is higher than normal) - RR ≥ 28 breaths/min Pump – Container – Fluid – Exchange → Circulatory System Pump - Heart Pipes - Arteries  - Capillaries - Veins Fluid - Blood Paramedic Assessment Triangle PAT: General Impression Triangle = appearance (right), work of breathing (left), circulation to skin (bottom) Stable = none Respiratory Distress = work of breathing Respiratory Failure = appearance and respiratory failure Shock = circulation to skin, circulation to skin and appearance CNS/Metabolic = appearance Cardio-Pulmonary Failure = appearance, work of breathing, circulation to skin Paramedic Handshake: no fancy gear needed … - Incorporate this into all your patient interactions - Something you can do during a reassessment or a change (not just at the start) Paramedic Handshake Vitals Pupils - Opioid crisis - Head Injury - GCS /LOA / Oriented Pulse - Atrial Fibrillation - Need for a Pacemaker - Need for Cardioversion / Adenosine Skin - Diaphoresis is a very significant finding (If your patient is sweating you should be too..............) - Mottled - Distal Circulation Breath - Alcohol  - Ketones - Feces - Airway ? Body Odors - Seizure ??? - General Health / Hygiene - Dead tissue Temperature - COVID - SEPSIS - Infection - Influenza Blood Pressure - Estimated Systolic Blood Pressure Blood Sugar - Hyperglycemia (ketones) - Hypoglycemia (diaphoresis & altered) Palpable Pulse Site Systolic Blood Pressure Radial >80 mmHg Femoral >70 mmHg Carotid >60 mmHg Equipment Orientation: Tools of the Trade Shears/scissors Penlight Stethoscope Safety eyewear Gloves 2 pens (clean / dirty) Blood pressure cuff Basic Vital Signs For every patient call:  1. Skin condition assessment 2. Level of Consciousness (LOC) – using AVPU 3. Glasgow Coma Scale (GCS) 4. Breathing assessment (RR, quality, depth & pattern) 5. Pulse assessment (HR, rhythm, quality) 6. Blood Pressure (BP) – ausc, palpated or Non-invasive BP (NIBP) 7. Temperature (oral, tympanic, rectal) 8. Pupils 9. Pulse Oximetry (SPO2) – “Sat” Patient/Complaint Specific Blood sugar Cardiac monitoring Capnography (EtCO2) Cranial Nerve assessment Key Points When Taking Vital Signs 1. Make sure they are accurate and reflect true values a) Never “guesstimate” (don’t make them up) 2. They are minimally invasive and minimally uncomfortable 3. They are done and repeated at regular intervals 4. Need to be analyzed and interpreted 5. Compare them to the patients “normal” values if known 6. Compared to baseline findings as well a) Have they changed? Improved / worsened? 1. Skin Condition Assessment When assessing the skin, look at: Colour (Pink, Pale, Jaundice, Flushed, Mottled, Cyanosis (Blue-purplish, gray, ashen)...) Temperature (Warm (Normal), Hot, Cool, Cold...) Humidity (Dry, Moist, Diaphoretic...) Turgor (hydration level) Edema (None, Non-Pitting, Pitting [remains after 2 seconds], weeping EXAMPLE Cyanosis - blue tinged lips/tongue/mouth, fingernails, feet/toes Diaphoretic/Diaphoresis - excessive sweating due to an underlying health condition or a medication  2. Level of Awareness (LOA or LOC) Level of Awareness (LOA) Level of Consciousness (LOC) … (LOC can also mean loss of consciousness) AVPU Alert Verbal Pain Unresponsive Glasgow coma scale (GCS) Origins with trauma patients but now commonly used with all patients *** Do not do a sternal rub. - This is an outdated technique and is no longer acceptable. - INSTEAD: pinch fingernail, push pressure point in neck, rub eyelashes 3. Glasgow Coma Scale (GCS) Assign a score for the patient’s best response in the 3 categories Lowest score possible is 3 Highest score possible is 15 1. Assess 2. Add up points 3. Note the time or any issues with the GCS (like pt is nonverbal according to family) Glasgow Coma Scale Eye Opening Response Spontaneous-open with blinking at baseline = 4 To verbal stimuli, command, speech =3 To pain only (not applied to face) =2 No response =1 Verbal Response Oriented = 5 Confused = 4 Words =3  Sounds =2 None =1 Motor Response Obey commands =6 Localising =5 Normal Flexion =4 Abnormal Flexion =3 Extension =2 None =1 Best Eye Opening Response (Total of 4 points possible) Rating Criterion GCS Score Spontaneous Patient's eyes open 4 spontaneously with no prompting from the nurse as he or she approaches the patient To sound Patient’s eyes do not open 3 spontaneously but they do open to an auditory (usually verbal) stimulus. Speak in a normal voice initially, and then in a louder voice as needed to consider hearing impairments/medications/ status fluctuations. To pressure Patient’s eyes do not open 2 spontaneously or with auditory stipulation, but they do not open to peripheral or central stimuli. Central stimulation for testing eye opening may cause the patient to grimace and confound the examination; if so, use peripheral stimulation. None/Non-testable There is no eye opening to 1 any stimuli or it is non-testable due to local factors (e.g. eye swelling). Best Verbal Response (Total of 5 points possible) Rating Criterion GCS Score Orientated The patient answers all of the following 5 correctly: Person (their name) Place where he or she is (e.g. hospital) Time (the month and year) When testing orientation, change the order of the questions as the patient may memorize the answers. If the patient is oriented but exhibits inappropriate behaviour, score the patient as oriented in that section and expand in the nursing or interdisciplinary notes, describing the behaviour as clearly as possible. Confused Unable to correctly answer all of “person,” 4 “place,” and “time.” Words The patient clearly articulates words, but 3 his/her verbal responses bear no relation to the context of the orientation questions (previously referred to as inappropriate words.) Sounds The patient fails to articulate words, but 2 does utter sounds, e.g. moans or groans (previously referred to as incomprehensible sounds.) None/Non-testable There is no eye opening to any stimuli or it 1 is non-testable due to local factors (e.g. eye swelling.)  If the patient has a language or communication barrier and there is no interpreter or family present at the time of the assessment, document the language barrier across the “none/non-testable” Best Motor Response (usually best arm response:) If a patient is obeying commands or clearly localizing spontaneously (e.g. he or she is purposefully attempting to remove oxygen mask, nasogastric tube or when being suctioned), further stimulation is not needed to assess motor response. If further stimulation is needed: a. A central stimuli is preferred over peripheral stimuli to avoid mistaking simple spinal reflex for normal flexion response. b. If there is a difference in response to central versus peripheral stimuli, response to central stimuli is a more sensitive indication of neural function and should be recorded. c. Use trapezius pinch first. If no response to this, try supraorbital pressure. d. If there is a difference in motor response between left and right side, document the best response. Best Motor Response Rating Criterion GCS Score Obeys Commands The patient is able to understand and obey 6 verbal/written/gestured commands. Acceptable commands include: “show me a thumb/two fingers;” “stick out your tongue.” Note: It is not acceptable to ask a patient to squeeze one’s hand unless he or she is also asked to release it. Hand grasping, without a release may be merely a reflex. If the patient is unable to obey commands, place the patient in a supine position with hands positioned at the groin area if possible. Proceed through the assessment by applying a central stimulus. Localizing The patient purposefully moves a limb in an 5 attempt to locate and remove the source of  the applied central stimulus. If stimuli is applied to head or neck, the patients must be able to move hand above the clavicle towards the applied stimulus. Normal Flexion The patient flexes the limb at the elbow, with 4 the limb drawn away from the trunk in response to a central stimulus. There is no direct attempt to remove the source of the stimulus. Abnormal Flexion The patient flexes the limb at the elbow in 3 response to a central stimulus. Accompanying this movement is shoulder adduction, wrist flexion, and the making of a fist. Abnormal flexion is usually a slow movement, with no attempt to remove the stimulus. Extension The patient extends the limb at the elbow in 2 response to a central stimulus. Accompanying this movement is abduction of the shoulder, flexion of the wrist while the fingers either make a fist or extend. None/Non-Testable No movement of the limbs occurs in 1 response to a central stimulus or it is non-testable due to local factors. “Grip my finger,” “Make a fist” → M6 – Obeys Commands Trapezius squeeze, Supraorbital pressure → M5 – Localises pain Flexion of limbs → M4 – Flexion/withdrawal to pain Adduction and internal rotation of upper limbs, Extension of lower limbs → M3 – abnormal flexion to pain Extension of upper and lower limbs → M2 – extension to pain No motor response → M1 – no response 4. Breathing Assessment Vital – Respiratory Status Respirations Depth Rate Pattern Is the body actually getting oxygen to the tissues ? Is the body actually getting rid of CO2 ? Limitations to your equipment / techniques / assessments ??? Acid Base Balance Respiratory Status Visual Assessment Stethoscope Assessment Pulse Oximetry : SpO2 Capnography : EtCO2 Respiration Rate, effort, Quality and Pattern Rate = Number of times the patient breathes in 1 minute (normal adult 12-20 breaths per minute) OR (if regular count for 30 seconds and multiply by 2) Effort = How hard they are working to breathe Quality = Depth (volume of air) and pattern Pattern = regular, irregular, disease pattern like Kussmaul breathing Breathing Patterns Eupnea (normal breathing pattern and rate) Causes: balance diet and healthy life Bradypnea (slow and shallow breaths) Causes: sleep drugs, metabolic disorder Tachypnea (fast and shallow breath) Causes: fever, anxiety, exercise, shock Sighing (frequently interspersed sighs) Cause: anxiety, dyspnea, and dizziness Biot (deep breath with periods of apnea) Causes: spinal meningitis, head injury) Cheyne-Stokes (varying periods of breaths) Cause: brain tumors and injuries Kussmaul (fast and deep breaths) Cause: renal failure, diabetic ketoacidosis Central Sleep Apnea (breathing with apnea) Causes: heart and kidney failure Respiration Rate, Effort, Quality Rate = Number of times the patient breathes in 1 minute Effort = How hard they are working to breathe Quality = Depth (volume of air) and Pattern = regular, irregular, disease pattern like Kussmaul breathing Breathing Reporting Note - If outside normal Respiratory Rates Report as bradycardic (slow) or tachycardic (fast) Reporting Examples: Pt has bradypneic breathing at 8 regular and deep, irregular pattern Pt is breathing at 16, regular and non-laboured Tachypneic breathing at 30, irregular and shallow 5. Pulse Assessment Pulse Assessment: Rate, Rhythm, and Quality Pulse rate = number of pulsations felt in 1 minute (bpm) (OR 30 sec multiply by 2) (normal adult 60-100 bpm) Rhythm = pattern and the intervals between beats (regular, irregular & regularly irregular) Volume/Quality = refers to the pulse’s strength (weak, regular, strong/bounding) Pulse Assessment ECG- 4 Lead 12 – Lead Sp02 Monitor (waveform ?) Apical (Pediatrics / Neonates) Carotid Femoral Radial Brachial Popliteal Pedal Posterior Tibial Heart Rate/Pulse, Rhythm, and Quality Image of peripheral pulse sites in Bledsoe textbook How many can you find on yourself? What is the difference between radial and carotid Elements of Consent The following are the elements required for consent to treatment:  1. The consent must relate to the treatment. 2. The consent must be informed. 3. The consent must be given voluntarily. 4. The consent must not be obtained through misrepresentation or fraud. 6. Blood Pressure (3 common ways: Auscultated, Palpated and Non-invasive BP (NIBP)) Manual Blood Pressure (BP) The Sphygmomanometer (Sfig-mow-muh-naa-muh-tr) Used for manual Blood pressure readings Bulb, cuff (various sizes), and a manometer Must be properly fitted to the patient to give accurate reading Considerations with Blood Pressure → Want to avoid using arms with AV fistulas (for dialysis) ALWAYS Mastectomy/Lymph - Sometimes a person with a mastectomy will prefer a certain arm or state a fear of BP post surgery - Can still be performed with discussion of side effects/concerns but cuff should not remain inflated more than briefly Auscultated Manual BP Procedure 1. To begin BP measurement, use a properly sized blood pressure cuff. The width of the cuff's bladder should be at least equal to 80% of the diameter of the upper arm. 2. Wrap the cuff around the upper arm with the cuff's lower edge one inch above the antecubital fossa. 3. Lightly press the stethoscope's bell or diaphragm over the brachial artery just below the cuff's edge to measure the blood pressure. 4. Rapidly inflate the cuff to 180mmHg. Release air from the cuff at a moderate rate (3mm/sec). 5. Listen with the stethoscope and simultaneously observe the sphygmomanometer. 6. The first knocking sound (Korotkoff) is the subject's systolic pressure. When the knocking sound disappears, that is the diastolic pressure (such as 120/80). 7. Record the pressure in both arms and note the difference; also record the subject's position (supine), which arm was used, and the cuff size (small, standard or large). Palpated Manual BP Procedure (highlights show differences to auscultated BP) 1. To begin BP measurement, use a properly sized blood pressure cuff. The width of the cuff's bladder should be at least equal to 80% of the diameter of the upper arm. 2. Wrap the cuff around the upper arm with the cuff's lower edge one inch above the antecubital fossa. 3. Check radial pulse 4. Rapidly inflate the cuff to 180mmHg or where you no longer feel the radial pulse. Release air from the cuff at a moderate rate (3mm/sec). 5. Feel the radial pulse and simultaneously observe the sphygmomanometer. 6. The first return of radial pulse is the subject's systolic pressure. Palpated BP do not allow for a diastolic pressure reading. 7. Record the pressure in both arms and note the difference; also record the subject's position (supine), which arm was used, and the cuff size (small, standard or large). Blood Pressure (palpation/auscultation) Practice sizing different BP cuffs Practice taking BP on volunteers 2 learners / volunteer write on paper Compare BP reading Non-Invasive Blood Pressure (NIBP) (class machine) Select appropriate cuff size Connect the cuff via hose Lining up the artery marker, place cuff on patient (not loose) Press “NIBP” – have patient keep still Correlations: Pulse and Systolic BP Radial = > 80 mmHg Femoral = > 70 mmHg Carotid = > 60 mmHg Some studies (small) have found these to be over estimations (up to 50%) Study linked below noted 25% accuracy. Lower the BP the greater the over estimation. MAP >65 mmHg (ave.age retired) What is MAP? MAP = Mean Arterial Pressure Used to measure adequacy of blood getting to vital tissues and organs Calculated by following formula: (Systolic pressure + 2(Diastolic pressure))/3 Why is MAP important? Perfusion Kidney MAP = 65-75 Heart MAP >65 Brain MAP >50-55 → A MAP greater than 65 will keep all these organs perfused 7. Temperature - Body temperature measured usually with battery operated thermometer - Oral, rectal or axillary temperatures Fever - Body temperatures vary slightly from person to person and at different times of day. - The average temperature has traditionally been defined as 98.6 F (37 C). - A temperature taken using a mouth thermometer (oral temperature) that's 100 F (37.8 C) or higher is generally considered to be a fever. 8. Pupil Assessment Pupils (size, shape, symmetry and reactivity to light) Observe size, shape and symmetry (similarity, anisocoria) Shine light into one eye and observe that eye’s reaction Also watch the other eye – that pupil should constrict as well – called consensual constriction Repeat for other eye Assess baseline pupil size (without light stimulus), equality between left and right, and reaction to light 1. Check pupils in ambient light prior to assessing reaction, The pupil size adjusted to ambient light is the size recorded. 2. Since not every person has equal pupils, assess and document a baseline for each individual patient.  3. Check the patient’s baseline history for any cataracts, surgeries, medications, or dilating drops that will affect the assessment. 4. Instruct the patient to look forward. If unconscious, open the patient's eyes by lifting the eyelids looking for midline status. 5. Use a concentrated light source (e.g. penlight) in a dim room (turn off ambient light to attain a response) and assess for: a. Direct constriction: Move the light from the outer aspect of the eye inward toward the pupil. The pupil should constrict. Repeat for the other eye. b. Consensual constriction: Shine the light into one pupil and observe the other pupil for constriction. Repeat for the other eye. The pupil you are shining the light in should constrict; also the other pupil should also constrict at the same time – this is a Normal finding. 6. Record the size and reactivity - ex. Pupils are 4 mm equal and reactive to light; 4 mm PEARL (or PERL) 7. May test accommodation - pupils should also constrict - get smaller - when they’re focusing on an object very close to the eye. Typically, your pupils change size as you switch from looking at something far away to something very near you. Then you would document PEARLA or PERLA 9. Pulse Oximetry Pulse Oximetry (SPO2) Pulse oximetry: Assesses oxygen saturation This Device Transmits Light Through a Vascular Bed, Such as in the Finger, and Can Determine the Oxygen Saturation of Red Blood Cells. Indirect method to monitor Oxygen Saturation of patient’s hemoglobin Probe sensor attached on a fingertip (but can be an earlobe or toe) To Use the Pulse Oximeter, It Is Only Necessary to Turn the Device on and Attach the Sensor to a Finger. The Oxygen Saturation and Pulse Rate Can Be Continuously Monitored Road tip: Place the SPO2 on the hand that does not have the BP cuff (so that you don’t interrupt your SPO2 readings when a BP is being taken The Order Vital Signs – Collection vs Reporting Typical order vital signs are collected on a call (Paramedic Handshake gets 1-5) 1. Level of Consciousness (LOC) – using AVPU (alert, verbal, pain, unresponsive) 2. Skin condition assessment 3. Breathing assessment (RR, quality, depth & pattern)  4. Pulse assessment (HR, rhythm, quality) 5. Glasgow Coma Scale (GCS) 6. Pulse Oximetry (SPO2) – “Sat” 7. Blood Pressure (BP) – ausc, palpated or Non- invasive BP (NIBP) 8. Temperature (oral, tympanic, rectal) 9. Pupils Order of vital sign reporting varies 1. Order of most significance – like you start with what is most serious first: - Pt who is bradycardic at 30 reg and weak, Breathing at 8 irregular and shallow etc.... 2. In groups: {LOC & GCS} {pulse & BP}, {Breathing & SPO2}, {skin, temp & pupils} - Pt who is alert and oriented x 4, GCS 15; Pulse 80 reg/strong; BP 110/80, Breathing 16 reg, full, non- laboured, SPO2 100% RA, Skin Pink, warm, dry; Temp 37 deg Celsius; Pupils 4+ PEARLA SpO2 Options