高血压英文ppt精品课件the medical patient the renal system hypertensive

The Medical Patient The Renal System; Hypertensive Emergencies Condell Medical Center EMS System October 2008 CE Site Code # 10-7200E1208 Prepared by: Sharon Hopkins, RN, BSN, EMT-P Objectives Upon successful completion of this module, the EMS provider should be able to: List the components and function of the urinary system State signs and symptoms of chronic kidney disease Define hemodialysis Identify the differences between AV fistulas and AV shunts retroperitoneal area 1 behind the spleen; 1 behind the liver Ureters Urinary bladder Urethra Function of the Urinary System Major functions Maintains blood volume via proper balance of water, electrolytes, and pH Retains key compounds (ie: glucose) and eliminates wastes (ie: urea) Monitors and maintains arterial blood pressure (in addition to other mechanisms) Regulates erythrocyte (RBC) development Urinary Bladder Storage receptacle for the production of urine until it is convenient or necessary to void Fully distended can hold 500 ml of urine The more distended the bladder, the more vulnerable to blunt trauma After urination, the bladder contains about 10 ml of fluid Chronic Kidney Disease Can be from a specific kidney disease or as a complication from other conditions Diabetes #1 reason in USA for need for kidney transplant Hypertension Kidney inflammation (glomerulonephritis) Inflammation of blood vessels (vasculitis) Polycystic kidney disease Chronic Kidney Disease Diseased or injured kidneys Blood flow through the renal system decreases Inflammatory changes occur in the glomeruli A group of capillaries where blood is filtered into a nephron (structure that produces urine) Capillary walls thicken decreasing permeability Glomerular filtration rate (GFR) is reduced Volume of blood filtered per day thru glomeruli Symptoms of Chronic Kidney Disease Most common symptoms Swelling, usually of lower extremities Fatigue Weight loss, loss of appetite Nausea and/or vomiting Change in urination Reduction in volume or frequency Change in sleep patterns Headache Itching high levels of phosphorus in system; dry skin Difficulties with memory or concentration Complications of Chronic Kidney Disease Hypertension May be a leading cause but can also develop in the early stages as a complication Anemia Decreased production of red blood cells Bone disease Disorders of calcium and phosphorus Malnutrition Altered functional status and well-being Dialysis Dialysis is required when the kidneys fail and a transplant is not performed Peritoneal dialysis uses a catheter thru the abdominal wall to filter the blood Hemodialysis Hemodialysis is a procedure in which a machine filters harmful waste and excess salt and fluid from your body Access points are created to be functional within weeks and to last several to many years Usual access point is the forearm Fistulas and Shunts Arteriovenous (AV) fistula Most common type of access Fistula created internally by sewing an artery to a vein forming a small opening between the two Pressure from the arterial flow eventually enlarges and strengthens the vein May take 6 weeks to heal but can last for years Arteriovenous (AV) graft Access is similar to a fistula A synthetic tube is used to surgically connect the artery to the vein AV graft often heals within 2-3 weeks With proper care, can last several years Higher likelihood of forming clots or becoming infected than an AV fistula Renal Dialysis Hemodialysis Most people treated with hemodialysis 3 times a week Each session lasts approximately 3-5 hours Some patients, at some dialysis centers, may choose daily dialysis Usually performed 6 days per week for 2 21/2 hours each session Patients often report improved B/P and quality of life Continuous Ambulatory Peritoneal Dialysis CAPD is a self-care treatment where the patient instills dialysate fluid into the peritoneal (abdominal) cavity through a surgically implanted catheter through the abdominal wall The dialysate stays in the abdominal cavity a prescribed period of time and then is drained out CAPD Instructions Do not disconnect the CAPD bags from the catheter If the patient is transported, transport with the drainage bag remaining below the level of the patients waist Do not infuse any fluids or medications directly into the catheter This IS NOT an alternate IV site Transport the patient with the CAPD intact Renal Protocol Care of Patients with Grafts or Shunts Do NOT take B/P on arm with active fistula or graft Do NOT start IV on arm with active fistula or graft If site is bleeding, apply direct pressure In case of arrest and no IV access consider IO site vAccess of fistula or graft is only with contact to Medical Control Care of The Renal Patient Best to err on the side of conservative treatment Monitor and support the ABCs High flow O2 is appropriate to maximize respiratory efficiency Carefully monitor fluid administration Monitor cardiac rhythm for disturbances Caregivers can help manage the additional equipment on the patient Abdominal Pain Assessment Chief complaint The sign or symptoms that prompted the patient to call for help Use an open ended question to determine the reason for the call “Why did you call us today?” or “What seems to be the problem?” During the interview the chief complaint generally becomes more specific Assessment O onset of the problem Did problem start suddenly or gradually? What was patient doing at the time? P provocation/palliation What makes the symptoms worse? Better? Q quality In the patients own words how do they describe their pain (ie: crushing, tearing, sharp, dull?) R region/radiation Where is the symptom? Does it move? If the patient uses one finger or isolates to one spot, the pain is considered localized If the pain is described using both hands or indicating a larger area, the pain is diffuse Is there referred pain (pain felt in a body area away from the source)? S severity Intensity of pain or discomfort 0 10 scale “0” is no pain; “10” is the worse pain in your life Can the patient be distracted? Do they lie still or are they writhing about? T time When did the symptoms begin? Associated symptoms Are other symptoms present that are commonly linked to certain diseases that can help rule in or out your diagnosis? Pertinent negatives Are any likely associated symptoms absent? Absence of symptoms can be information as helpful as presence of other symptoms Assessment Pitfalls in the Chronic Renal Patient The challenge to the medical professional is to separate the acute complaint from the chronic condition What is new today that changes your status? Many of these patients have unstable baselines to start with Fluid and electrolyte imbalance EKG disturbances Physical Assessment - Abdomen Boundaries run from xiphoid process to symphysis pubis A full bladder will distort assessment and increase discomfort for the patient To relax the abdominal wall or to ease pain, a pillow placed under the knees would be helpful Start by asking the patient where it hurts Examine painful areas last Warm your hands and stethoscope If hands are cold, palpate over clothing until hands warm up Monitor facial expressions for pain or discomfort Validate the facial expression Often the patient scrunches their face in anticipation of pain Assessment techniques to use Inspection, auscultation, percussion, lastly palpation Abdominal Assessment Techniques Inspection A visual review looking for abnormalities Auscultation Move the stethoscope in a circle approximately 2 inches from the umbilicus listening for bowel sounds Normal bowel sounds gurgle approximately every 5-15 seconds Percussion Not often performed in the field Helps determine size and location of organs Determines gas, solid, and fluid filled areas Tympany heard over most of abdomen Dullness percussed over spleen and liver Palpation Palpate painful areas last To increase comfort to patient, have them take slow, deep breaths thru open mouth Flexing knees relaxes abdominal wall Abdominal pain on light palpation indicates peritoneal irritation or inflammation Voluntary guarding patient anticipates pain or is not relaxed Involuntary guarding peritoneal inflammation (lining of abdominal cavity) SOP Abdominal Pain Stable Patient Routine medical care Watch the patient for vomiting Stable patient Patient alert Skin warm and dry Systolic B/P 100 mmHg Contact Medical Control for pain management SOP Abdominal Pain Unstable Patient Routine medical care Watch the patient for vomiting Unstable patient Altered mental status Systolic B/P 230 mmHg Diastolic B/P 120 mmHg Usually seen in patients with untreated or poorly controlled hypertension Hypertensive Emergency Signs and symptoms Epistaxis nosebleed The nasal tissue is very thin and prone to bleed Headache “The worst headache in my life” often indicates a subarachnoid bleed Visual disturbances (ie: blurred, blindness) Restlessness Confusion Nausea and vomiting Neurologicial changes Altered mental status to seizures to coma Complications Hypertensive encephalopathy Severe headache, vomiting, visual changes, paralysis, seizures, stupor, coma Ischemic (clot) or hemorrhagic (bleed) stroke Field Assessment Chief complaint received is often headache Additional accompanying complaints Nausea and/or vomiting Blurred vision Shortness of breath Epistaxis (nosebleed) Vertigo (dizziness) Level of consciousness may be normal, altered, or patient may be unconscious Field Assessment Findings Skin may be pale, flushed, or normal Skin may be warm or cool; moist or dry If hypertensive encephalopathy is present, it may cause left ventricular failure Patient will be in pulmonary edema Lung sounds clear unless in pulmonary edema Pulse often strong and bounding SOP - Hypertensive Emergency Routine Medical Care Obtain and record the B/P in both arms Monitor accuracy is debatable If the radial pulse is palpated, the B/P is said to be roughly 80 mmHg If the femoral pulse is palpated, the B/P is said to be roughly 70 mmHg If only the carotid (central) pulse is felt, the B/P is said to be roughly 60 mmHg A “Neuro” Assessment Level of consciousness A alert (means awake but not necessarily oriented; spontaneous eye opening; responds to voice but can be confused; and has motor function ) V responds to verbal command no matter how slight and type of response P responds to pain or tactile stimuli only U unresponsive with no eye, voice, or motor response at all to voice or pain Ask 2 questions to determine level of consciousness “What month is this?” “How old are you?” Obtain the Glasgow Coma Scale (GCS) on all EMS patients Best eye opening (4 points) Best verbal response (5 points) Best motor response (6 points) Evaluate pupillary response Performing a Pupillary Check Ask patient to focus on an object (ie: tip of your nose) Bring the light in from the side and out the same way Without shining in the eyes move the penlight into position for the opposite side and repeat Vital signs Signs of increasing intracranial pressure include increasing B/P and dropping heart rate Check muscle tone and strength Evaluate facial symmetry (smile) Evaluate clarity of speech The above 3 are the Cincinnati Stroke Scale Arm drift, facial symmetry, speech Additionally: Coordination or gait and sensory Movement and sensation Repeat Assessment If you want to see where the patient is going, youve got to know where theyre coming from GET A BASELINE EVALUATION You can anticipate something happening if you are watching the trends PERFORM REPEAT ASSESSMENTS AS OFTEN AS INDICATED Prevents surprises Need to constantly monitor the situation Watch for trends Anticipate surprises Pain Management SOP Routine trauma or medical care Continuous patient monitoring Respiratory status SaO2 Blood pressure Morphine 2 mg slow IVP over 2 minutes May repeat every 2 minutes Maximum total 10 mg Respiratory Depression Related to Morphine Use Supportive oxygenation If SaO2 is falling and ventilation rates are declining, consider supportive bagging Ventilation rates for supportive bagging (AHA) Adult 1 breath every 5 6 seconds Pediatric patients 8 and less 1 breath every 3 5 seconds Narcan (narcotic antagonist) 2 mg IVP if respiratory depression Glasgow Coma Scale Exercise Review the following 3 patients assessment findings Evaluate for their GCS Determine the best response and score the patients Best eye opening 1 - 4 points Best verbal response 1 5 points Best motor response 1 - 6 points Note: GCS to be obtained on all patients! GCS Exercise #1 You are assessing a 56 year-old patient The patient is unresponsive. Nothing happens when you call the patients name. when you pinch the patient, their eyes open, then close. When pinched, the patient says “dont, stop” and then is silent. When pinched, the patient pushes you away GCS Exercise #2 Your patient is a 16 year-old male. Upon approaching, the patients eyes are open and they are looking around with an anxious look. They do not answer questions; they groan if pinched. They do not follow commands. When touched, the patient grabs your arm and doesnt let go. GCS Exercise #3 Your patient is an 8 month-old. Their eyes are closed. There is no response to pinching. When pinched, the patient groans weakly. When pinched, the patient tries to pull away or turn away from the evaluator. GCS Exercise Answers GCS #1 total 11 Eye opening 2 Verbal response 4 Motor response 5 GCS #2 total 11 Eye opening 4 Verbal response 2 Motor response - 5 GCS #3 total 7 Eye opening 1 Verbal response 2 (groans to pain incomprehensible words) Motor response 4 (withdraws to pain) Skill In-line Albuterol For Albuterol to have its bronchodilating effects, it must be delivered down into the lungs If the patient cant inhale it in, we have to push it in Normal use with corrugated tubing connected to the T-piece Kit connected to oxygen and run at 6 l/minute (enough to c