医、技学院(华盛顿医疗手册培训-课程总论)PPT课件.ppt

TheWashingtongManualofMedicalTherapeuticsPatientCareinInternalMedicine JiananWangMDPhDFACCSecondAffiliatedHospitalZhejiangUniversitySchoolOfMedicine 1 GeneralCareoftheHospitalizedPatientGENERALPRINCIPLES IndividualizationbasedonEvidenceMedicineCarefulExplanation benefits risksandalternative BasicmeasuresminimizingrisksUseofstandardizedabbreviationsanddosedesignationsExcellentcommunicationbetweenphysiciansandothercaregiversInstitutionofappropriateprophylacticprecautionsPreventionofnosocomialinfections includingattentiontohygieneanddiscontinuationofunnecessarycathetersMedicinereconciliationatalltransfersofcare 2 HospitalOrders AdmissionOrderfollowingADCVANDALISMAdmittingservice location andphysicianresponsibleforthepatientDiagnosesConditionofthepatientVitalsignswithfrequencyActivitylimitationsNursinginstructions e g Foleycathetertogravitydrainage woundcare dailyweights Diet Rememberthat npo mayprecludeoralmedicationsunlessspecifiedAllergies sensitivities andpreviousdrugreactionsLaboratorytestsandradiographicstudiesIVfluids includingcompositionandrateSedatives analgesics andotherPRNmedicationsMedications includingdose frequency route andindication State Firstdosenow whenappropriate 3 ProphylacticMeasures VenousThromboembolismProphylaxisMostpreventablecauseofdeathinHosp DrugsforpreventionofDVTHeparineLMWH10aantagonist fondaparinux rivaroxaban 拜瑞妥 MechanicalprophylaxiswithintermittentpneumaticcompressionorgradedcompressionstockingsAspirinisnotindicatied 4 外科病人静脉血栓危险分层 ACCP共识会议对外科手术病人静脉血栓的危险分层低危 年龄 40岁小手术无其他危险因素中危 年龄 40岁大手术无其他危险因素高危 年龄 40岁大手术合并一个其他危险因素 MIs或VTE过去史肿瘤高凝状态 极高危 年龄 40岁大或小手术合并多个其他危险因素 VTE或IS过去史肿瘤高凝状态 全髋或全膝关节置换术髋部骨折严重创伤脊柱损伤 5 DVTRiskClassificationforSurgeryPatients Lowrisk 40yrs bigsurgery nootherriskfacorsHighrisk 40ys bigsurgery withoneoffollowingriskfactors VTE tumor hyper coagulationstate VeryhighRisk 40ys bigorminorsurgery withmultiplefollowingrisksVTE tumor hyper coagulationstate wholehipreplacement wholekneereplacement hipfracture severetrauma spinaltrauma 6 1 0 2 3 Lowrisk Increasedrisk 0 1 2 3 Classofpredisposingrisk DehydrationPolycythaemiaorthrombocytosisVaricosisVTEinfamilyHRTObesity ThrombophiliaHistoryofVTEActivemalignancyor 3risksfromcategory1 2risksfromcategory2 Nobasicrisk Age 65yearsPregnancyOralcontraceptionNephroticsyndromeMyeloproliferativesyndrome2risksfromcategory1 0 1 2 3 IschaemicstrokewithparalysisAcutedecompensationofCOPDwithventilationMyocardialinfarctionHeartfailure NYHAClassIIIandIV AcutedecompensationofCOPDwithoutventilationSepsisInfection acuteinflammatorydisease bed restInfection acuteinflammatorydisease non strictbed restCentralvenouslinesorportsystemNoacuterisk 0 1 2 3 IndividualizedRiskClassificationofDVTforInternalPatients LutzL etal MedWelt 2002 53 231 234COPD chronicobstructivepulmonarydiseaseHRT hormonereplacementtherapyNYHA NewYorkHeartAssociation Classofexposingrisk 7 PressureUlcerFallprecautionSeizureRestraint 8 Acutepatientcare ChestpainPulmonaryembolizationAorticdissectionAcuteCoronarySyndromeAcutecholecystitisAcutegastritis 9 DiagnosticTesting oxygenationstatuschestradiographyelectrocardiogram ECG Spiralcomputedtomography CT VQscans 10 Initialtherapy SuspiciousACSsupplementaloxygenAspirin Plavixnitroglycerin 0 4mgSLmorphinesulfate 1to2mgIV 11 Dysnea CHFcardiacischemiaBronchospasmpulmonaryembolusLunginfectionmucuspluggingaspiration 12 Fever DrugreactionMalignancyInfectionAutoimmunedisease Vasculitis SLEetc VTETissueinfarction 13 AntipyreticmedicationsAspirin avoidedforadolescent Acetaminophen 325to650mgPOorperrectumq4h Hypothermic cooling blanketsIcepacksTepidwaterbathsEmpiricantibiotics hemodynamicallyunstablepatientsinwhominfectionisaprimaryconcernNeutropenicAsplenic 14 Painmanagement AcetaminophenAspirinNSAIDsCyclooxygenase 2 COX 2 inhibitors celecoxib Meloxicam OpioidanalgesicsTramadol 15 PERIOPERATIVEMEDICINEPreoperativeCardiacEvaluation Figure1 Cardiacevaluationalgorithmfornoncardiacsurgery Adaptedfromthe2007ACC AHAguidelinesonperioperativeevaluationfornoncardiacsurgery Circulation2007 116 e418 16 PerioperativeAnticoagulationandAntithromboticManagement 17 18 19 PreoperativeSpecificSituation HypertensionPacemakersandImplantableCardioverterDefibrillators ICDs PulmonaryDiseaseandPreoperativePulmonaryEvaluation 20 AnemiaandTransfusionIssuesinSurgeryfiniteandcostlyresourcebloodborneinfectionstransfusion relatedacutelunginjury TRALI transfusionreactionsimmunosuppressiveeffects 21 DiabetesGlucosewell controlledbutpreventionofhypoglycemiaAdrenalInsufficiencyandCorticosteroidManagementChronicRenalInsufficiencyandEnd StageRenalDisease 22 PatientsRoundingandEvaluation 23 Preparationforpatientrounds 24 Knowledgeofthepatient scurrentcondition NursingrecordbesideevaluationcurrentlabreportsX rayreportspathologyreports 25 Necessary tools StethoscopePenlightTonguebladeAsmallrulerAreflexhammerAsmallpocketsizereferencebookNursingrecordetc 26 Aprofessionalappearance Cleanaidentificationbadge 27 Organizationoftheteam 28 Generalobjectivesforbothmedicalstudentsandresidents Bealtruistic compassionate andempatheticincaringforpatientsUnderstandthescientificbasisofmedicineandbeabletoapplyittothepracticeofmedicineBehighlyskilledinprovidingappropriatecaretopatientsbasedonthebestavailableevidenceBeabletocollaboratewithotherhealthcareprofessionals 29 InteractionwithPatientandFamily ShowingyourrespectandempathyaprofessionalappearancenonverbalskillsandbehaviorExplainingtheirillnessandtreatmentplanusesimplelanguagethatthefamilycanunderstandPatienteducation 30 Collectpatienthistory Patienthistory IdentificationChiefcomplaintHPI historyofpresentillness PMHx pastmedicalhistory MedicationsROS reviewofsystemsSocialHxPhysicalExamImpression diagnosisTreatmentplan 31 Takingmedicalhistory Self introductionstatethereasonforthevisitaskthepatient spermissionEnsurepatientcomfortduringtheinterviewBecome agoodlistener 32 PatientPhysicalExam Fourmajormodalities InspectionPalpationPercussionAuscultation Teachtheeyetosee thefingertofeel andtheeartohear SirWilliamOsler 33 PatientPhysicalExam MedicaltechnologycanneverrenderthephysicalexamWashingyourhandsinfrontofthepatientEnsuringpatientcomfortandprivacyHonest opencommunicationwiththepatientregardingabnormalphysicalfindings 34 Medicalrecordreview Therulesthatthephysicianshouldfollowwhenrecordingthehistoryandphysical recordallpertinentdataavoidextraneousdatausecommontermsavoidnonstandardabbreviationsbeobjectiveusediagramsorpictureswhenindicated 35 Detaileddailymedicalrecord FollowtheSOAPformat S subjectiveO objectiveA assessmentP Plan 36 Operativeorprocedurenotes DateandtimeProceduredoneIndicationsPatientconsentLabtestAnesthesiaDescriptionofprocedure 37 Dischargesummary Patient snameandmedicalrecordnumberDateofadmissionDateofdischargeAdmittingdiagnosisDischargediagnosisNameofattendingphysicianorteamresponsibleforpatientSurgicalorotherproceduresperformedDiagnostictestsperformedBriefhistory pertinentphysicalexamandlabdataHospitalcoursePatient sconditionatdischargeDischargeplanincludingfollow upappointmentDischargemedicationsProblemlistincludingallactiveandpastproblem 38 Patienteducation Function communicateaboutthediagnosticsignificanceoftheproblemsrecommendappropriatediagnosticproceduresandtreatmentenhancecopingabilitybyunderstandingthesocialandpsychosocialconsequencesofthediseaseandtreatment 39 Patientcasepresentation Themostimportantpart theimpressionorsuspecteddiagnosisincludingthedifferentialdiagnosisNotusea symptom asthediagnosisNotneglectthepatient Noteachingwithoutapatientforatext andthebestteachingisthattaughtbythepatienthimself WilliamOsler 40 PatientRapport Mustalwaysconsiderthepatient sem