Chief Compaint/HPI History
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Advanced Interpretation of Adult Vital Signs in Trauma William D
Advanced Interpretation of Adult Vital Signs in Trauma William D. Hampton, DO Emergency Physician 26 March 2015 Learning Objectives 1. Better understand vital signs for what they can tell you (and what they can’t) in the assessment of a trauma patient. 2. Appreciate best practices in obtaining accurate vital signs in trauma patients. 3. Learn what teaching about vital signs is evidence-based and what is not. 4. Explain the importance of vital signs to more accurately triage, diagnose, and confidently disposition our trauma patients. 5. Apply the monitoring (and manipulation of) vital signs to better resuscitate trauma patients. Disclosure Statement • Faculty/Presenters/Authors/Content Reviewers/Planners disclose no conflict of interest relative to this educational activity. Successful Completion • To successfully complete this course, participants must attend the entire event and complete/submit the evaluation at the end of the session. • Society of Trauma Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. Vital Signs Vital Signs Philosophy: “View vital signs as compensatory to the illness/complaint as opposed to primary.” Crowe, Donald MD. “Vital Sign Rant.” EMRAP: Emergency Medicine Reviews and Perspectives. February, 2010. Vital Signs Truth over Accuracy: • Document the true status of the patient: sick or not? • Complete vital signs on every patient, every time, regardless of the chief complaint. • If vital signs seem misleading or inaccurate, repeat them! • Beware sending a patient home with abnormal vitals (especially tachycardia)! •Treat vital signs the same as any other diagnostics— review them carefully prior to disposition. The Mother’s Vital Sign: Temperature Case #1 - 76-y/o homeless ♂ CC: 76-y/o homeless ♂ brought to the ED by police for eval. -
Cardiovascular Assessment
Cardiovascular Assessment A Home study Course Offered by Nurses Research Publications P.O. Box 480 Hayward CA 94543-0480 Office: 510-888-9070 Fax: 510-537-3434 No unauthorized duplication photocopying of this course is permitted Editor: Nurses Research 1 HOW TO USE THIS COURSE Thank you for choosing Nurses Research Publication home study for your continuing education. This course may be completed as rapidly as you desire. However there is a one-year maximum time limit. If you have downloaded this course from our website you will need to log back on to pay and complete your test. After you submit your test for grading you will be asked to complete a course evaluation and then your certificate of completion will appear on your screen for you to print and keep for your records. Satisfactory completion of the examination requires a passing score of at least 70%. No part of this course may be copied or circulated under copyright law. Instructions: 1. Read the course objectives. 2. Read and study the course. 3. Log back onto our website to pay and take the test. If you have already paid for the course you will be asked to login using the username and password you selected when you registered for the course. 4. When you are satisfied that the answers are correct click grade test. 5. Complete the evaluation. 6. Print your certificate of completion. If you have a procedural question or “nursing” question regarding the materials, call (510) 888-9070 for assistance. Only instructors or our director may answer a nursing question about the test. -
(June 2000) I. INTRODUCTION WHAT IS DOCUMENTATION and WHY
DRAFT EVALUATION & MANAGEMENT DOCUMENTATION GUIDELINES (June 2000) I. INTRODUCTION WHAT IS DOCUMENTATION AND WHY IS IT IMPORTANT? Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. The medical record facilitates: · the ability of the physician and other health care professionals to evaluate and plan the patient's immediate treatment, and to monitor his/her health care over time. · communication and continuity of care among physicians and other health care professionals involved in the patient's care; · accurate and timely claims review and payment; · appropriate utilization review and quality of care evaluations; and · collection of data that may be useful for research and education. An appropriately documented medical record can reduce many of the "hassles" associated with claims processing and may serve as a legal document to verify the care provided, if necessary. WHAT DO PAYERS WANT AND WHY? Because payers have a contractual obligation to enrollees, they may require reasonable documentation that services are consistent with the insurance coverage provided. They may request information to validate: · the site of service; · the medical necessity and appropriateness of the diagnostic and/or therapeutic services provided; and/or · that services provided have been accurately reported. II. GENERAL PRINCIPLES OF MEDICAL RECORD DOCUMENTATION The principles of documentation listed below are applicable to all types of medical and surgical Pg. 1 services in all settings. For Evaluation and Management (E/M) services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient's status. -
Chest Pain and Non-Respiratory Symptoms in Acute Asthma
Postgrad Med J 2000;76:413–414 413 Chest pain and non-respiratory symptoms in Postgrad Med J: first published as 10.1136/pmj.76.897.413 on 1 July 2000. Downloaded from acute asthma W M Edmondstone Abstract textbooks. Occasionally the combination of The frequency and characteristics of chest dyspnoea and chest pain results in diagnostic pain and non-respiratory symptoms were confusion. This study was prompted by the investigated in patients admitted with observation that a number of patients admitted acute asthma. One hundred patients with with asthmatic chest pain had been suspected a mean admission peak flow rate of 38% of having cardiac ischaemia, pleurisy, pericardi- normal or predicted were interviewed tis, or pulmonary embolism. It had also been using a questionnaire. Chest pain oc- observed that many patients admitted with curred in 76% and was characteristically a asthma complained of a range of non- dull ache or sharp, stabbing pain in the respiratory symptoms, something which has sternal/parasternal or subcostal areas, been noted previously in children1 and in adult worsened by coughing, deep inspiration, asthmatics in outpatients.2 The aim of this or movement and improved by sitting study was to examine the frequency and char- upright. It was rated at or greater than acteristics of chest pain and other symptoms in 5/10 in severity by 67% of the patients. A patients admitted with acute asthma. wide variety of upper respiratory and sys- temic symptoms were described both Patients and methods before and during the attack. One hundred patients (66 females, mean (SD) Non-respiratory symptoms occur com- age 45.0 (19.7) years) admitted with acute monly in the prodrome before asthma asthma were studied. -
GUIDELINES for WRITING SOAP NOTES and HISTORY and PHYSICALS
GUIDELINES FOR WRITING SOAP NOTES and HISTORY AND PHYSICALS by Lois E. Brenneman, M.S.N, C.S., A.N.P, F.N.P. © 2001 NPCEU Inc. all rights reserved NPCEU INC. PO Box 246 Glen Gardner, NJ 08826 908-537-9767 - FAX 908-537-6409 www.npceu.com Copyright © 2001 NPCEU Inc. All rights reserved No part of this book may be reproduced in any manner whatever, including information storage, or retrieval, in whole or in part (except for brief quotations in critical articles or reviews), without written permission of the publisher: NPCEU, Inc. PO Box 246, Glen Gardner, NJ 08826 908-527-9767, Fax 908-527-6409. Bulk Purchase Discounts. For discounts on orders of 20 copies or more, please fax the number above or write the address above. Please state if you are a non-profit organization and the number of copies you are interested in purchasing. 2 GUIDELINES FOR WRITING SOAP NOTES and HISTORY AND PHYSICALS Lois E. Brenneman, M.S.N., C.S., A.N.P., F.N.P. Written documentation for clinical management of patients within health care settings usually include one or more of the following components. - Problem Statement (Chief Complaint) - Subjective (History) - Objective (Physical Exam/Diagnostics) - Assessment (Diagnoses) - Plan (Orders) - Rationale (Clinical Decision Making) Expertise and quality in clinical write-ups is somewhat of an art-form which develops over time as the student/practitioner gains practice and professional experience. In general, students are encouraged to review patient charts, reading as many H/Ps, progress notes and consult reports, as possible. In so doing, one gains insight into a variety of writing styles and methods of conveying clinical information. -
Chief Complaint: "Swelling of Tongue and Difficulty Breathing and Swallowing"
Chief Complaint: "swelling of tongue and difficulty breathing and swallowing" History of Present Illness: 77 y o woman in NAD with a h/o CAD, DM2, asthma and HTN on altace for 8 years awoke from sleep around 2:30 am this morning of a sore throat and swelling of tongue. She came immediately to the ED b/c she was having difficulty swallowing and some trouble breathing due to obstruction caused by the swelling. She has never had a similar reaction ever before and she did not have any associated SOB, chest pain, itching, or nausea. She has not noticed any rashes, and has been afebrile. She says that she feels like it is swollen down in her esophagus as well. In the ED she was given 25mg benadryl IV, 125 mg solumedrol IV and pepcid 20 mg IV. This has helped the swelling some but her throat still hurts and it hurts to swallow. Nothing else was able to relieve the pain and nothing make it worse though she has not tried to drink any fluids because of trouble swallowing. She denies any recent travel, recent exposure to unusual plants or animals or other allergens. She has not started any new medications, has not used any new lotions or perfumes and has not eaten any unusual foods. Patient has not taken any of her oral medications today. Surgical History: s/p vaginal wall operation for prolapse 2006 s/p Cardiac stent in 1999 s/p hystarectomy in 1970s s/p kidney stone retrieval 1960s Medical History: +CAD w/ Left heart cath in 2005 showing 40% LAD, 50% small D2, 40% RCA and 30% large OM; 2006 TTE showing LVEF 60-65% with diastolic dysfunction, LVH, mild LA dilation +Hyperlipidemia +HTN +DM 2, last A1c 6.7 in 9/2005 +Asthma/COPD +GERD +h/o iron deficiency anemia Social History: Patient lives in _______ with daughter _____ (919) _______. -
Management of Wheeze and Cough in Infants and Pre-Schoo L Children In
nPersonal opinio lManagement of wheeze and cough in infants and pre-schoo echildren in primary car Pauln Stephenso nIntroductio is, well established in adults 2thoughs there remain somer controversy about its diagnosis in children eve Managementa of wheeze and cough in children is sinceh Spelman's uncontrolled study of children wit commonm problem in primary care. In this paper I ai nchronic cough successfully treated according to a tod provide a few useful management tools with regar .asthma protocol 3gWithout the ability to perform lun toe diagnosis, the role of a trial of treatment, and th functione tests in pre-school children, care must b rationalee for referral. For an in-depth review see th takent to exclude other diagnoses. A persisten article. in this journal two years ago by Bush 1 eproductiv coughc may be due solely to chroni catarrhe with postnasal drip, but early referral may b sPresentation of Symptom needed. A persistent dry cough,n worse at night and o exercise,s and without evidence of other diagnose Ity is always worth asking parents what they mean b warrants. a trial of asthma treatment thed term 'wheeze' or 'cough'. The high-pitche musicaln noise of a wheeze usually on expiratio Thef younger the child, the longer the list o shouldy not be confused with the sound of inspirator differentialo diagnoses and the more one has t sstridor. The sound of airflow through secretions i econsider possibilities other than 'asthma'. Thes ddifferent again, and parents may describe their chil linclude upper airways disease, congenital structura 'vomiting'g when, in fact, the child has been coughin diseasel of the bronchi, bronchial or trachea severely and bringing up phlegm or mucus. -
Emergency Department Chief Complaint and Diagnosis Data to Detect Influenza-Like Illness with an Electronic Medical Record
UC Irvine Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health Title Emergency Department Chief Complaint and Diagnosis Data to Detect Influenza-Like Illness with an Electronic Medical Record Permalink https://escholarship.org/uc/item/9gq782tz Journal Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, 11(1) ISSN 1936-900X Authors May, Larissa S Griffin, Beth Ann Bauers, Nicole Maier et al. Publication Date 2010 License https://creativecommons.org/licenses/by-nc/4.0/ 4.0 Peer reviewed eScholarship.org Powered by the California Digital Library University of California Original research Emergency Department Chief Complaint and Diagnosis Data to Detect Influenza-Like Illness with an Electronic Medical Record Larissa S. May, MD, MS* * The George Washington University, Department of Emergency Medicine, Beth Ann Griffin, PhD† Washington, D.C Nicole Maier Bauers, MS‡ † RAND Corporation, Center for Domestic and International Health Security, Arvind Jain, MS† Arlington VA Marsha Mitchum, MS, MPHҰ ‡ The George Washington University School of Public Health, Washington, D.C. Neal Sikka, MD* Ұ The George Washington University School of Medicine, Washington, D.C. Marianne Carim, MDҰ € Georgetown University School of Nursing and Health Studies Michael A. Stoto, PhD€ Supervising Section Editor: Scott E. Rudkin, MD, MBA Submission history: Submitted August 28, 2009; Revision Received July 22, 2009; Accepted July 22, 2009 Reprints available through open access at http://escholarship.org/uc/uciem_westjem Background: The purpose of syndromic surveillance is early detection of a disease outbreak. Such systems rely on the earliest data, usually chief complaint. The growing use of electronic medical records (EMR) raises the possibility that other data, such as emergency department (ED) diagnosis, may provide more specific information without significant delay, and might be more effective in detecting outbreaks if mechanisms are in place to monitor and report these data. -
Gas Exchange and Respiratory Function
LWBK330-4183G-c21_p484-516.qxd 23/07/2009 02:09 PM Page 484 Aptara Gas Exchange and 5 Respiratory Function Applying Concepts From NANDA, NIC, • Case Study and NOC A Patient With Impaired Cough Reflex Mrs. Lewis, age 77 years, is admitted to the hospital for left lower lobe pneumonia. Her vital signs are: Temp 100.6°F; HR 90 and regular; B/P: 142/74; Resp. 28. She has a weak cough, diminished breath sounds over the lower left lung field, and coarse rhonchi over the midtracheal area. She can expectorate some sputum, which is thick and grayish green. She has a history of stroke. Secondary to the stroke she has impaired gag and cough reflexes and mild weakness of her left side. She is allowed food and fluids because she can swallow safely if she uses the chin-tuck maneuver. Visit thePoint to view a concept map that illustrates the relationships that exist between the nursing diagnoses, interventions, and outcomes for the patient’s clinical problems. LWBK330-4183G-c21_p484-516.qxd 23/07/2009 02:09 PM Page 485 Aptara Nursing Classifications and Languages NANDA NIC NOC NURSING DIAGNOSES NURSING INTERVENTIONS NURSING OUTCOMES INEFFECTIVE AIRWAY CLEARANCE— RESPIRATORY MONITORING— Return to functional baseline sta- Inability to clear secretions or ob- Collection and analysis of patient tus, stabilization of, or structions from the respiratory data to ensure airway patency improvement in: tract to maintain a clear airway and adequate gas exchange RESPIRATORY STATUS: AIRWAY PATENCY—Extent to which the tracheobronchial passages remain open IMPAIRED GAS -
Medical Terminology Information Sheet
Medical Terminology Information Sheet: Medical Chart Organization: • Demographics and insurance • Flow sheets • Physician Orders Medical History Terms: • Visit notes • CC Chief Complaint of Patient • Laboratory results • HPI History of Present Illness • Radiology results • ROS Review of Systems • Consultant notes • PMHx Past Medical History • Other communications • PSHx Past Surgical History • SHx & FHx Social & Family History Types of Patient Encounter Notes: • Medications and medication allergies • History and Physical • NKDA = no known drug allergies o PE Physical Exam o Lab Laboratory Studies Physical Examination Terms: o Radiology • PE= Physical Exam y x-rays • (+) = present y CT and MRI scans • (-) = Ф = negative or absent y ultrasounds • nl = normal o Assessment- Dx (diagnosis) or • wnl = within normal limits DDx (differential diagnosis) if diagnosis is unclear o R/O = rule out (if diagnosis is Laboratory Terminology: unclear) • CBC = complete blood count o Plan- Further tests, • Chem 7 (or Chem 8, 14, 20) = consultations, treatment, chemistry panels of 7,8,14,or 20 recommendations chemistry tests • The “SOAP” Note • BMP = basic Metabolic Panel o S = Subjective (what the • CMP = complete Metabolic Panel patient tells you) • LFTs = liver function tests o O = Objective (info from PE, • ABG = arterial blood gas labs, radiology) • UA = urine analysis o A = Assessment (Dx and DDx) • HbA1C= diabetes blood test o P = Plan (treatment, further tests, etc.) • Discharge Summary o Narrative in format o Summarizes the events of a hospital stay -
Approach to Type 2 Respiratory Failure Changing Nature of NIV
Approach to type 2 Respiratory Failure Changing Nature of NIV • Not longer just the traditional COPD patients • Increasingly – Obesity – Neuromuscular – Pneumonias • 3 fold increase in patients with Ph 7.25 and below Impact • Changing guidelines • Increased complexity • Increased number of patients • Decreased threshold for initiation • Lower capacity for ITU to help • Higher demands on nursing staff Resp Failure • Type 1 Failure of Oxygenation • Type 2 Failure of Ventilation • Hypoventilation • Po2 <8 • Pco2 >6 • PH low or bicarbonate high Ventilation • Adequate Ventilation – Breathe in deeply enough to hit a certain volume – Breathe out leaving a reasonable residual volume – Breath quick enough – Tidal volume and minute ventilation Response to demand • Increase depth of respiration • Use Reserve volume • Increase rate of breathing • General increase in minute ventilation • More gas exchange Failure to match demand • Hypoventilation • Multifactorial • Can't breathe to a high enough volume • Can't breath quick enough • Pco2 rises • Po2 falls Those at risk • COPD • Thoracic restriction • Central • Neuromuscular • Acute aspects – Over oxygenation – Pulmonary oedema Exhaustion • Complicates all forms of resp failure • Type one will become type two • Needs urgent action • Excessive demand • Unable to keep up • Resp muscle hypoxia Exhaustion • Muscles weaken • Depth of inspiration drops • Residual volume drops • Work to breath becomes harder • Spiral of exhaustion • Pco2 rises, Po2 drops Type 2 Respiratory Failure Management Identifying Those -
Respiratory System Diseases & Disorders
Respiratory System Diseases & Disorders HS1, DHO8, 7.10, pg 206 Objectives Discuss the diseases and disorders of the respiratory system and related signs, symptoms, and treatment methods Identify diseases and disorders that affect the respiratory system, including the following: asthma, pleurisy, bronchitis, pneumonia, COPD, rhinitis, emphysema, sinusitis, epistaxis, sleep apnea, influenza, TB, laryngitis, URI, and lung cancer Day 1 Respiratory Diseases and Disorders Upper Respiratory Tract The major passages and structures of the upper respiratory tract include the nose, nasal cavity, pharynx, and larynx. Asthma Bronchospasms with increase in mucous, and edema in mucosal lining Caused by sensitivity to allergen such as dust, pollen, animal, medications, or food Stress, overexertion, and infection can cause asthma attack Prevent asthma attacks by eliminating or desensitizing to allergens Symptoms: dyspnea, wheezing, coughing, and chest tightness Treatment: bronchodilators, anti-inflammatory med, epinephrine, and O2 therapy Test Your Knowledge Barbara has asthma and uses an inhaler when she starts to wheeze. The purpose of the device is to: a) Dissolve mucus b) Contract blood vessels c) Liquify secretions in the lungs d) Enlarge the bronchioles Correct answer: D Acute Bronchitis Chronic Bronchitis ◦ Caused by infection ◦ Caused by frequent attacks of ◦ S/S: productive cough, acute bronchitis or long-term exposure to smoking dyspnea, rales (bubbly breath sounds), chest ◦ Has chronic inflammation, pain, and fever damaged cilia, &