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Focused History and Physical Exam:
Critically Ill Patients
Nelia B. Perez RN MSN
PCU Mary Johnston College of Nursing
Focused History and Physical Exam
• Pt Hx
• Pt story of significant events related to current
problem
• Usually begins with pt C/C
• Many disease conditions are 1st suspected by
symptomology
• MI
• Diabetics
• Allergic rxn
• OD
Focused History and Physical Exam:
Medical Patients
• What:
• Rapid assessment of medical conditions that may require
emergency care OR early hospital tx.
• Who:
• Non traumatically injured pt with medical c/c
• How:
• Focus
• C/C
• Signs/Symptoms
• SAMPLE history
• Medical PAST
• OPQRST history
• Medical PRESENT
• Baseline vitals
• Plan of FUTURE treatment
SAMPLE HISTORY
• S= Signs and Symptoms
• A = Allergies
• M = Medications
• P = Past pertinent medical hx
• L = Last oral intake
• E = Events prior to the condition
OPQRST HISTORY
• OPQRST Hx
• Branch of SAMPLE Hx
• Focuses on Signs and Symptoms
• Gives a clearer picture of pt C/C and its severity
OPQRST Hx
Onset
• O = Onset
• When the complaint first started.
• The pt activities at the time of onset/immediately
before
• “What were you doing when this started”
• Chest pain pt – mowing lawn
• Anaphylaxis pt – stung by bee
• Diabetic pt – Working in hot day without food
OPQRST Hx
Provocation
• P = Provocation
• What actions make the symptoms better/worse
• “Is there anything that makes it better?
Anything that makes it worse?”
• Chest pains – Worse with activity Better
with rest
• SOB – Better when sitting Worse when
lying flat
• Etc…
OPQRST Hx
Quality
• Q = Quality
• Subjective description of
complaint in pt own words
• “Would you please
describe the pain. What
does it feel like”
• Chest pains –
Crushing, vice-like,
elephant
Crushing
Stabbing
Burning
OPQRST Hx
Radiation
• R= Radiation
• Is the pain local or does it travel
to another part of the body
• “Is the pain in one place or
does it spread to other parts
of your body?”
• Chest pains
• L shoulder, arm, jaw,
neck ,back
OPQRST Hx
Severity
• Severity
• 1-10 scale gauging pain
• “On a scale of 1-10, 1
being the least pain
you’ve felt and 10
being the worst pain
you’ve ever felt can
you rate the pain?”
OPQRST Hx
Time
• T = Time
• Duration of the C/C and assoc complaints
• “How long has this been going on?”
• Chest pains – Woke pt from sleep that night
• Allergic rxn- 15-20 min
Problem Focused Medical
Assessment
• Responsive Medical Pt
• Problem Focused Medical Assessment
• SAMPLE Hx
• OPQRST Hx
• Focused Physical Exam
• Chest/neck- chest pains
• Pharynx/chest- SOB
• Etc…
• Baseline Vitals
Rapid Medical Assessment
• Unresponsive/AMS Medical Pt
• Rapid Medical Assessment
• Rapid assessment of ALL body regions (DCAP-BTLS)
• Try to define C/C or ID trauma
• Rule in/out trauma
• Medical ID tags
• Baseline Vitals
• SAMPLE & OPQRST Hx when/if possible
• Tx in recovery position
Focused History and Physical Exam:
Medical Pt Recap
• S – Signs/Symptoms
• A - Allergies
• M - Medications
• P – Past pertinent medical hx
• L – Last oral intake
• E – Events leading to condition
• O - Onset
• P - Provocation
• Q - Quality
• R – Radiation
• S - Severity
• T – Time
• BASELINE VITALS
Critical care 1
INITIAL ASSESSMENT OF THE
CRITICALLY ILL PATIENT
A critically ill patient is one at
imminent risk of death; the severity
of illness must be recognized early
and appropriate measures taken
promptly to assess, diagnose and
manage the illness.
 The approach required in managing the critically ill
patient differs from that required in less severely ill
patients with immediate resuscitation and
stabilization of the patient s condition taking
precedence: patient’s
PHILOSOPHY OF MANAGEMENT
1. Prompt resuscitation & adhering to advanced life
support guidelines
2. Urgent treatment of life threatening emergencies
such as hypotension, hypoxaemia , hyperkalaemia ,
hypoglycaemia and dysrhythmias life-hypoxaemia,
hyperkalaemia,
PRIORITIES
cont.;
3. Analysis of the deranged physiology
4. Establish a complete diagnosis as history & further
diagnostic results are available
5. Careful monitoring of the patient s condition and
response to treatment patient’s
PRIORITIES
CARDIOVASCULAR SIGNS
1. HR
2. BP
3. PERFUSION
4. OLIGURIA
5. ARREST
How To Recognize?
1. RATE
2. DISTRESS
3. THREATENED OBSTRUCTION/OBSTRUCTION
4. RISING PaCO2
5. DECREASING SPO2
6. ARREST
RESPIRATOY SIGNS
1. THREATENED AIRWAY OBSTRUCTION/OBSTRUCTION
2. SUDDEN DETERIORATION IN CONSCIOUSNESS
3. GCS
4. ABSENT GAG/COUGH
5. FAILURE TO OBEY COMMANDS
6. REPEATED SEIZURES
NEUROLOGICAL SIGNS
1. Initial assessment
2. Immediate management
3. Monitoring
4. Initial investigations
What are the steps to be followed?
Critical care 1
 Basic hemodynamic monitoring
ECG, BP, CVP, PAP, CO
 ABGs, lactate, H ion,
 Urine output
 Fluid balance
 Lung mechanics, capnography
 Peripheral skin temp
 O2 transport
MONITORING
Critical care 1
Critical care 1
FLUID MANAGEMENT
 Failure to supply sufficient oxygen to meet the
metabolic requirements of the tissues is the cardinal
feature of circulatory failure or ‘shock’.
SHOCK & LOW CO
Critical care 1
ALGORITH OF SHOCK
Level of consciousness
Level of consciousness should also be assessed upon
initial contact with your patient and continuously
monitored for changes throughout your contact with
the patient.
THE COMMON VITAL SIGNS
 a. AVPU. The AVPU scale is a rapid method of
assessing LOC. The patient's LOC is reported as A, V,
P, or U.
Level of Consciousness
 b. Glasgow Coma Scale. The Glasgow Coma Scale is
an assessment based on numeric scoring of a
patient’s responses based on the patient's best
response to eye opening, verbal response, and motor
response. The patient's score (3 to 15) is determined
by adding his highest eye opening, verbal response,
and motor response scores.
Level of Consciousness (CONT)
Critical care 1
 c. PEARRL. Use the guide PEARRL when assessing the
pupillary response of the patient's eyes.
Level of Consciousness (CONT)
BLOOD PRESSURE
several factors that can affect a patient's blood pressure.
a. Condition of Cardiovascular System.
b. Age.
c. Gender.
d. Physical Fitness.
e. Obesity.
f. Pain.
VITAL SIGNS
g. Emotion.
h. Gravity.
i. Exercise.
j. Disease.
k. Drugs.
l. Eating.
m. Bleeding.
FACTORS NOTED WHEN TAKING A PATIENT'S
BREATHING RATE AND QUALITY
a. Rate.
b. Depth.
c. Rhythm.
d. Quality.
e. Unusual Position.
RESPIRATORY RATE
f. Coughing.
g. Sputum.
FACTORS NOTED WHEN TAKING A PATIENT'S
PULSE
a. Pulse Rate.
b. Strength.
c. Rhythm.
PULSE RATE
A Regular.
B Tachycardia.
C Bradycardia,
D Bounding.
E Weak (thready).
F Irregular.
G Intermittent (irregular).
WHAT CAUSES ABNORMAL TEMPERATURES?
a. Infection.
b. Environmental Conditions.
BODY TEMPERATURE
PQRST
PAIN
Thank You for
Bearing with
me!

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Critical care 1

  • 1. Focused History and Physical Exam: Critically Ill Patients Nelia B. Perez RN MSN PCU Mary Johnston College of Nursing
  • 2. Focused History and Physical Exam • Pt Hx • Pt story of significant events related to current problem • Usually begins with pt C/C • Many disease conditions are 1st suspected by symptomology • MI • Diabetics • Allergic rxn • OD
  • 3. Focused History and Physical Exam: Medical Patients • What: • Rapid assessment of medical conditions that may require emergency care OR early hospital tx. • Who: • Non traumatically injured pt with medical c/c • How: • Focus • C/C • Signs/Symptoms • SAMPLE history • Medical PAST • OPQRST history • Medical PRESENT • Baseline vitals • Plan of FUTURE treatment
  • 4. SAMPLE HISTORY • S= Signs and Symptoms • A = Allergies • M = Medications • P = Past pertinent medical hx • L = Last oral intake • E = Events prior to the condition
  • 5. OPQRST HISTORY • OPQRST Hx • Branch of SAMPLE Hx • Focuses on Signs and Symptoms • Gives a clearer picture of pt C/C and its severity
  • 6. OPQRST Hx Onset • O = Onset • When the complaint first started. • The pt activities at the time of onset/immediately before • “What were you doing when this started” • Chest pain pt – mowing lawn • Anaphylaxis pt – stung by bee • Diabetic pt – Working in hot day without food
  • 7. OPQRST Hx Provocation • P = Provocation • What actions make the symptoms better/worse • “Is there anything that makes it better? Anything that makes it worse?” • Chest pains – Worse with activity Better with rest • SOB – Better when sitting Worse when lying flat • Etc…
  • 8. OPQRST Hx Quality • Q = Quality • Subjective description of complaint in pt own words • “Would you please describe the pain. What does it feel like” • Chest pains – Crushing, vice-like, elephant Crushing Stabbing Burning
  • 9. OPQRST Hx Radiation • R= Radiation • Is the pain local or does it travel to another part of the body • “Is the pain in one place or does it spread to other parts of your body?” • Chest pains • L shoulder, arm, jaw, neck ,back
  • 10. OPQRST Hx Severity • Severity • 1-10 scale gauging pain • “On a scale of 1-10, 1 being the least pain you’ve felt and 10 being the worst pain you’ve ever felt can you rate the pain?”
  • 11. OPQRST Hx Time • T = Time • Duration of the C/C and assoc complaints • “How long has this been going on?” • Chest pains – Woke pt from sleep that night • Allergic rxn- 15-20 min
  • 12. Problem Focused Medical Assessment • Responsive Medical Pt • Problem Focused Medical Assessment • SAMPLE Hx • OPQRST Hx • Focused Physical Exam • Chest/neck- chest pains • Pharynx/chest- SOB • Etc… • Baseline Vitals
  • 13. Rapid Medical Assessment • Unresponsive/AMS Medical Pt • Rapid Medical Assessment • Rapid assessment of ALL body regions (DCAP-BTLS) • Try to define C/C or ID trauma • Rule in/out trauma • Medical ID tags • Baseline Vitals • SAMPLE & OPQRST Hx when/if possible • Tx in recovery position
  • 14. Focused History and Physical Exam: Medical Pt Recap • S – Signs/Symptoms • A - Allergies • M - Medications • P – Past pertinent medical hx • L – Last oral intake • E – Events leading to condition • O - Onset • P - Provocation • Q - Quality • R – Radiation • S - Severity • T – Time • BASELINE VITALS
  • 16. INITIAL ASSESSMENT OF THE CRITICALLY ILL PATIENT
  • 17. A critically ill patient is one at imminent risk of death; the severity of illness must be recognized early and appropriate measures taken promptly to assess, diagnose and manage the illness.
  • 18.  The approach required in managing the critically ill patient differs from that required in less severely ill patients with immediate resuscitation and stabilization of the patient s condition taking precedence: patient’s PHILOSOPHY OF MANAGEMENT
  • 19. 1. Prompt resuscitation & adhering to advanced life support guidelines 2. Urgent treatment of life threatening emergencies such as hypotension, hypoxaemia , hyperkalaemia , hypoglycaemia and dysrhythmias life-hypoxaemia, hyperkalaemia, PRIORITIES
  • 20. cont.; 3. Analysis of the deranged physiology 4. Establish a complete diagnosis as history & further diagnostic results are available 5. Careful monitoring of the patient s condition and response to treatment patient’s PRIORITIES
  • 21. CARDIOVASCULAR SIGNS 1. HR 2. BP 3. PERFUSION 4. OLIGURIA 5. ARREST How To Recognize?
  • 22. 1. RATE 2. DISTRESS 3. THREATENED OBSTRUCTION/OBSTRUCTION 4. RISING PaCO2 5. DECREASING SPO2 6. ARREST RESPIRATOY SIGNS
  • 23. 1. THREATENED AIRWAY OBSTRUCTION/OBSTRUCTION 2. SUDDEN DETERIORATION IN CONSCIOUSNESS 3. GCS 4. ABSENT GAG/COUGH 5. FAILURE TO OBEY COMMANDS 6. REPEATED SEIZURES NEUROLOGICAL SIGNS
  • 24. 1. Initial assessment 2. Immediate management 3. Monitoring 4. Initial investigations What are the steps to be followed?
  • 26.  Basic hemodynamic monitoring ECG, BP, CVP, PAP, CO  ABGs, lactate, H ion,  Urine output  Fluid balance  Lung mechanics, capnography  Peripheral skin temp  O2 transport MONITORING
  • 30.  Failure to supply sufficient oxygen to meet the metabolic requirements of the tissues is the cardinal feature of circulatory failure or ‘shock’. SHOCK & LOW CO
  • 33. Level of consciousness Level of consciousness should also be assessed upon initial contact with your patient and continuously monitored for changes throughout your contact with the patient. THE COMMON VITAL SIGNS
  • 34.  a. AVPU. The AVPU scale is a rapid method of assessing LOC. The patient's LOC is reported as A, V, P, or U. Level of Consciousness
  • 35.  b. Glasgow Coma Scale. The Glasgow Coma Scale is an assessment based on numeric scoring of a patient’s responses based on the patient's best response to eye opening, verbal response, and motor response. The patient's score (3 to 15) is determined by adding his highest eye opening, verbal response, and motor response scores. Level of Consciousness (CONT)
  • 37.  c. PEARRL. Use the guide PEARRL when assessing the pupillary response of the patient's eyes. Level of Consciousness (CONT)
  • 38. BLOOD PRESSURE several factors that can affect a patient's blood pressure. a. Condition of Cardiovascular System. b. Age. c. Gender. d. Physical Fitness. e. Obesity. f. Pain. VITAL SIGNS
  • 39. g. Emotion. h. Gravity. i. Exercise. j. Disease. k. Drugs. l. Eating. m. Bleeding.
  • 40. FACTORS NOTED WHEN TAKING A PATIENT'S BREATHING RATE AND QUALITY a. Rate. b. Depth. c. Rhythm. d. Quality. e. Unusual Position. RESPIRATORY RATE
  • 42. FACTORS NOTED WHEN TAKING A PATIENT'S PULSE a. Pulse Rate. b. Strength. c. Rhythm. PULSE RATE
  • 43. A Regular. B Tachycardia. C Bradycardia, D Bounding. E Weak (thready). F Irregular. G Intermittent (irregular).
  • 44. WHAT CAUSES ABNORMAL TEMPERATURES? a. Infection. b. Environmental Conditions. BODY TEMPERATURE

Notas del editor

  1. A: Alert and oriented. (2) V: Responds to verbal stimulus. (3) P: Responds to pain. (4) U: Unresponsive.