醫(yī)、技學(xué)院(華盛頓醫(yī)療手冊(cè)培訓(xùn)-課程總論)PPT課件.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 外科病人靜脈血栓危險(xiǎn)分層 ACCP共識(shí)會(huì)議對(duì)外科手術(shù)病人靜脈血栓的危險(xiǎn)分層低危 年齡 40歲小手術(shù)無(wú)其他危險(xiǎn)因素中危 年齡 40歲大手術(shù)無(wú)其他危險(xiǎn)因素高危 年齡 40歲大手術(shù)合并一個(gè)其他危險(xiǎn)因素 MIs或VTE過(guò)去史腫瘤高凝狀態(tài) 極高危 年齡 40歲大或小手術(shù)合并多個(gè)其他危險(xiǎn)因素 VTE或IS過(guò)去史腫瘤高凝狀態(tài) 全髖或全膝關(guān)節(jié)置換術(shù)髖部骨折嚴(yán)重創(chuàng)傷脊柱損傷 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