美國(guó)重癥醫(yī)學(xué)FCCM的基礎(chǔ)教程患者評(píng)估英文課件

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,#,Assessment of the Seriously Ill Patient,Assessment of the Seriously Il,1,Objectives,Early identification of patients at risk for life-threatening illness,Recognize early signs of critical illness,Review the initial assessment of critically ill patients,ObjectivesEarly identification,2,Why identify patients at risk?,Easier management with simpler interventions,Prevent further deterioration,Provide time for investigation and treatment,Why identify patients at,3,Challenging Patients,Young,fit patients,Immunosuppressed patients,Debilitated patients,Patients with abrupt deterioration,Patients with limited reserve,Challenging PatientsYoung,fit,4,Risk Assessment,Background health,Severity of acute physiology,Vital signs,Other clinical monitoring,Trends and rate of deterioration,Goals,Recognition that problem exists,Maintain stability,Risk AssessmentBackground heal,5,Risk Assessment,Making a diagnosis,Often secondary to treatment of physiological abnormalities,Investigate while stabilizing,Requires disciplined approach,Risk AssessmentMaking a diagno,6,Assessment,Primary survey,What is main physiological problem?,First minutes of initial contact,Secondary survey,What is underlying cause?,Subsequent reviews,AssessmentPrimary survey,7,Assessment of the Seriously Ill Patient,History,Physical examination,Chart review and documentation,Investigations,Treatment,Assessment of the Seriously Il,8,Patient,54 year old diabetic with shortness of breath,3 days postoperative for laparoscopic cholecystectomy,What history would you obtain initially?,Patient54 year old diabetic wi,9,Initial Survey,History,Main symptoms,Physiological abnormalities,Co-existing illness,Major surgery,Severe hemorrhage/transfusion,Lack of improvement,Initial SurveyHistory,10,Patient,54 year old diabetic with shortness of breath,3 days postoperative for laporoscopic cholecystectomy,What additional details would be helpful?,Patient54 year old diabetic wi,11,Secondary Survey,History,Past history,chronic diseases,Psychosocial issues,Medications/allergies,Family history,Ethical/legal issues,Systems review,Secondary SurveyHistory,12,Patient,54 year old diabetic with shortness of breath,3 days postoperative for laporoscopic cholecystectomy,What parts of the physical examination,would you concentrate on initially?,Patient54 year old diabetic wi,13,Initial Survey,Examination,Airway,Breathing,Circulation,Level of consciousness,Initial SurveyExamination,14,Secondary Survey,Examination,Respiratory,Cardiovascular,Abdomen and genitourinary tract,Central nervous system,Musculoskeletal system,Endocrine,hematologic systems,Secondary SurveyExamination,15,Patient,BP 100/40 P 96 RR 26 T 37.8 C,Pulse oximetry 92%on 2 L cannula,Appears anxious,slightly confused,Bibasilar rales,Decrease bowel sounds,distended abdomen,Warm extremities,Which findings are most concerning?,PatientBP 100/40 P 96 RR,16,Airway/Respiratory System,Observe mouth and chest,Respiratory rate and pattern,Tachypnea is the single most important indicator of critical illness,Use of accessory muscles,Level of consciousness,Oxyhemoglobin saturation,Airway/Respiratory SystemObser,17,Circulation,Peripheral pulses and blood pressure,Evidence of decreased perfusion,Most common cardiovascular disturbance in the seriously ill is hypotension caused by hypovolemia and/or sepsis,CirculationPeripheral pulses a,18,Patient,BP 100/40 P 96 RR 26 T 37.8 C,Pulse oximetry 92%on 2 L cannula,Appears anxious,slightly confused,Bibasilar rales,Decrease bowel sounds,distended abdomen,Warm extremities,What information from the chart would,be helpful?,PatientBP 100/40 P 96 RR,19,Chart Review and Documentation,Initial survey,Vital signs,Fluid balance,Inspired oxygen concentration,Medications,Invasive parameters,Chart Review and Documentation,20,Chart Review and Documentation,Secondary survey,Review medical records,Document current events,Document diagnosis and treatment rationale,Chart Review and Documentation,21,Patient,BP 100/40 P 96 RR 26 T 37.8 C,Pulse oximetry 92%on 2 L cannula,Appears anxious,slightly confused,Bibasilar rales,Decrease bowel sounds,distended abdomen,Warm extremities,What investigations should be ordered?,PatientBP 100/40 P 96 RR,22,Investigations,Guided by history and physical examination,Standard biochemistry,hematology,microbiology,radiographs,Arterial or venous blood gas,Lactate level,Metabolic acidosis is an important,indicator of critical illness,InvestigationsGuided by histor,23,Patient,BP 150/90,HR 70-80,RR 16,T 37.8,Pulse ox 97%(RA),Distended abdomen,Warm extremities,WBC 16,000/,mm,3,BUN/creatinine norm,BP 100/40,HR 96,RR 26,T 37.8,Pulse ox 92%on 2L,Distended abdomen,Warm extremities,WBC 21,000/,mm,3,BUN/creatinine,ABG 7.3/30/65,Previous exam Current exam,What now?,PatientBP 150/90,HR 70-80,RR,24,Information Action,Ensure physiological safety,Oxygen,Intravenous access,Circulatory support,Dete。