美国重症医学FCCM的基础教程患者评估英文.ppt
Assessment of the Seriously Ill Patient,Objectives,Early identification of patients at risk for life-threatening illnessRecognize early signs of critical illnessReview the initial assessment of critically ill patients,Why identify patients at risk?,Easier management with simpler interventionsPrevent further deteriorationProvide time for investigation and treatment,Challenging Patients,Young,fit patientsImmunosuppressed patientsDebilitated patientsPatients with abrupt deteriorationPatients with limited reserve,Risk Assessment,Background healthSeverity of acute physiologyVital signsOther clinical monitoringTrends and rate of deteriorationGoalsRecognition that problem existsMaintain stability,Risk Assessment,Making a diagnosisOften secondary to treatment of physiological abnormalitiesInvestigate while stabilizingRequires disciplined approach,Assessment,Primary surveyWhat is main physiological problem?First minutes of initial contactSecondary surveyWhat is underlying cause?Subsequent reviews,Assessment of the Seriously Ill Patient,History Physical examinationChart review and documentationInvestigationsTreatment,Patient,54 year old diabetic with shortness of breath3 days postoperative for laparoscopic cholecystectomy,What history would you obtain initially?,Initial Survey,HistoryMain symptomsPhysiological abnormalitiesCo-existing illness Major surgerySevere hemorrhage/transfusionLack of improvement,Patient,54 year old diabetic with shortness of breath3 days postoperative for laporoscopic cholecystectomy,What additional details would be helpful?,Secondary Survey,HistoryPast history,chronic diseasesPsychosocial issuesMedications/allergiesFamily historyEthical/legal issuesSystems review,Patient,54 year old diabetic with shortness of breath3 days postoperative for laporoscopic cholecystectomy,What parts of the physical examinationwould you concentrate on initially?,Initial Survey,ExaminationAirway Breathing CirculationLevel of consciousness,Secondary Survey,ExaminationRespiratoryCardiovascularAbdomen and genitourinary tractCentral nervous systemMusculoskeletal systemEndocrine,hematologic systems,Patient,BP 100/40 P 96 RR 26 T 37.8 CPulse oximetry 92%on 2 L cannulaAppears anxious,slightly confusedBibasilar ralesDecrease bowel sounds,distended abdomenWarm extremities,Which findings are most concerning?,Airway/Respiratory System,Observe mouth and chestRespiratory rate and patternTachypnea is the single most important indicator of critical illnessUse of accessory musclesLevel of consciousnessOxyhemoglobin saturation,Circulation,Peripheral pulses and blood pressureEvidence of decreased perfusionMost common cardiovascular disturbance in the seriously ill is hypotension caused by hypovolemia and/or sepsis,Patient,BP 100/40 P 96 RR 26 T 37.8 CPulse oximetry 92%on 2 L cannulaAppears anxious,slightly confusedBibasilar ralesDecrease bowel sounds,distended abdomenWarm extremities,What information from the chart wouldbe helpful?,Chart Review and Documentation,Initial surveyVital signsFluid balanceInspired oxygen concentrationMedicationsInvasive parameters,Chart Review and Documentation,Secondary surveyReview medical recordsDocument current eventsDocument diagnosis and treatment rationale,Patient,BP 100/40 P 96 RR 26 T 37.8 CPulse oximetry 92%on 2 L cannulaAppears anxious,slightly confusedBibasilar ralesDecrease bowel sounds,distended abdomenWarm extremities,What investigations should be ordered?,Investigations,Guided by history and physical examinationStandard biochemistry,hematology,microbiology,radiographsArterial or venous blood gas Lactate level,Metabolic acidosis is an important indicator of critical illness,Patient,BP 150/90,HR 70-80,RR 16,T 37.8 Pulse ox 97%(RA)Distended abdomenWarm extremitiesWBC 16,000/mm3BUN/creatinine norm,BP 100/40,HR 96,RR 26,T 37.8Pulse ox 92%on 2LDistended abdomenWarm extremitiesWBC 21,000/mm3BUN/creatinineABG 7.3/30/65,Previous exam Current exam,What now?,Information Action,Ensure physiological safetyOxygenIntravenous accessCirculatory supportDetermine patients reserveAssess likely diagnosis and treatments,Information Action,Refine treatmentAssess response to treatmentProvide organ system supportDetermine best site for careCall for advice and assistance,Key Points,Identify patients at risk earlyRecognize signs of critical illnessStabilize first,then determine diagnosisObtain detailed historyMonitor response to treatment,
