early clinical experience gathering information for patient care
TRANSCRIPT
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Early Clinical Experience
Gathering Information for Patient Care
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OBJECTIVES
1. Discuss the importance of treatment planning
2. Discuss the role of data gathering in this process
3. Differentiate between signs and symptoms
- Discuss blood pressure including how to
take blood pressure
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1. TREATMENT PLANNING
• Treatment Plan: Blueprint for care
following careful assessment of patient’s needs and priorities
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Treatment Planning
• PRE-REQUISITES►DIDACTIC & CLINICAL KNOWLEDGE- What is normal, what is pathologic, what to
address, what is an issue, what is not
►DECISION MAKING – what IS best treatment?
►INFORMED CONSENT
►SEQUENCING (actual treatment)
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2. Data Gathering
ESSENTIAL FOR
►DIAGNOSIS
►PROGNOSIS
►TREATMENT PLAN
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INFORMATION TO GATHER
• PERSONAL HISTORY
• MEDICAL HISTORY
• DENTAL HISTORY
• CLINICAL OBSERVATIONS
• CLINICAL EXAMINATION
• DIAGNOSTIC AIDS - RADIOGRAPHS, DIAGNOSTIC CASTS
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#3. CLINICAL OBSERVATIONS
• SYMPTOMS and SIGNS
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SYMPTOMS
THAT WHICH ONLY THE PATIENT CAN RELATE TO YOU
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How do you find out the symptoms?
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SIGNS
• WHAT CAN BE OBSERVED OR MEASURED
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OBSERVATIONS
VITAL SIGNS• 1. PULSE• 2. BLOOD PRESSURE• 3. RESPIRATORY RATE• 4. TEMPERATURE
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PULSE
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• Result of alternate expansion and contraction of an artery as a wave of blood is forced through the heart
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LOCATION OF ARTERY?
• Several “good” sites:
• radial artery
• carotid
• brachial, temporal, facial
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HOW?• Tell the patient what you are
doing
• Place two or three fingers on area (not thumb)
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• COUNT/ TIME• OBSERVE - RHYTHM:
regular or irregular• VOLUME and STRENGTH -
full, strong, poor, weak, thready• RECORD AS BEATS/MIN
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• RANGES
• ADULT: 60-100 bpm
• CHILDREN: up to 130 for newborn
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BLOOD PRESSURE
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BLOOD PRESSURE
• Screening for hypertension in dental offices is an effective health care service
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WHAT IS BLOOD PRESSURE?
• THE FORCE EXERTED ON THE BLOOD VESSEL WALLS
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SYSTOLIC PRESSURE
• THE PEAK OR THE
HIGHEST PRESSURE - CAUSED BY VENTRICULAR CONTRACTION
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• “NORMAL”
• <130 mm
• “Range”
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DIASTOLIC
• LOWEST PRESSURE - EFFECT OF VENTRICULAR RELAXATION
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“NORMAL”
• < 85 mm Hg
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Factors that influence BP
• Force of the heart beat
• Peripheral resistance – elastic condition of the arteries – decreases with age
• Volume of blood in the circulatory system
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Factors that acutely increase BP in a healthy individual
• Exercise
• Eating
• Stimulants
• Emotional experiences
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Factors that decrease BP in a healthy individual
• Fasting
• Rest
• Depressants
• Calming environment
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How is blood pressure taken?
Use a sphygmomanometer which consists of an inflatable cuff and two tubes – one connected to the pressure hand control bulb, the other to the pressure gauge measured in mm Hg
The cuff is wrapped around the arm and the pressure increased so that the artery deflates
When the pressure is released, the blood rushes back into the artery this is maximum pressure or systolic which can be heard with a stethoscope
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• When the cuff pressure is below the lowest pressure against the arteries (diastolic pressure) – we no longer hear anything
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How to measure?• AUSCULTATORY METHOD most widely used • Locate the pulse of the brachial artery – circle it
with pen for your classmates only• Located on medial side of the arm at the elbow• Bisect just to the medial of middle of the elbow
with the middle, ring, and pointer fingers , ‘fall’ medially and the pulse should be palpable
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Brachial and radial arteries
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Next Place the cuff of the
sphygmomanometer following instructions on the cuff about 2 finger’s width above the pulse
• Tight enough it doesn’t come off if you gave a gentle tug, loose enough that you can fit 2 fingers underneath
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Placement of the cuff
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Cuffs come in various sizes
• “Normal” adult size
• “Large” adult size
• “Pedo” size
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Stethoscope
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Infection Control
• No gloving necessary when performing BP
• Disinfect the ear pieces both before and after using – remember that disinfection requires that the disinfectant be in contact with the surface being disinfected for manufacturer recommended time
• Optim = 1 minute
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Preparing your stethoscope
Place it into your ears- Note the correct direction
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Make sure that it is ‘turned’ on
Some canbe twisted here-Tap the diaphragmto check thatyou can hear it
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• Biggest mistake that students make is thinking that they should hear the brachial pulse as soon as the cuff is put on
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Taking blood pressure• Tell your patient what you are doing• Seat the patient with the arm slightly flexed,
palm up, with the forearm supported on a level surface at the level of the heart
• Do not take pressure through sleeve of clothing- roll or remove
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Procedure
• Place fingers of one hand on the radial pulse.
• Pump the cuff pressure just until the radial pulse is lost, then pump it 30mm higher than this
• Place stethoscope
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‘How To’ continued….
• Let pressure fall 2-3mm/second until you hear first sound, note it, and keep listening until there are no more sounds, note it, and release totally
• Record first reading and last reading
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SYSTOLIC PRESSURE
• FIRST SOUND - CALLED SYSTOLE or systolic
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• INDICATES THE BEGINNING OF THE FLOW OF BLOOD PAST THE CUFF
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• CONTINUE TO RELEASE THE PRESSURE SLOWLY UNTIL THERE IS NO LONGER A SOUND - NOTE ON THE GAUGE WHERE THE LAST TAP WAS - ANOTHER 10 mm - LAST SOUND
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•DIASTOLIC
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• LET THE LAST OF THE AIR OUT RAPIDLY
• REMOVE THE CUFF• RECORD AS mm Hg
SYSTOLIC/DIASTOLIC• DISINFECT/RETURN
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Phases of Korotkoff Sounds
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Auscultatory Gap
• Doesn’t occur often but if it does, it could have far reaching consequences
• This gap represents a loss of sound between systolic and diastolic pressures, with the sound reappearing at a lower level
• (Malamed, Stanley F. Malamed. Medical Emergencies in the Dental Office, 5th Edition. Elsevier, 1999. 2.2.4.1).
• (
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To prevent this from happening
• Always perform a radial pulse check
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Silent Auscultatory Gap
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Patient management is performed depending on blood pressure range
• A patient with a systolic pressure in excess of ~200 mmHg or a diastolic in excess of ~115 (ASA IV) is at significant risk and ought not to undergo invasive elective dental care until the blood pressure elevation has been brought under control.
• (Malamed, Stanley F. Malamed. Handbook of Local Anesthesia, 5th Edition.
Elsevier, 2004. 10.3.2).
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BP CLASSIFICATIONS• CATEGORY SYSTOLIC DIASTOLIC
• NORMAL <130 <85
• HIGH NORM 130-139 85-90
• STAGE 1 140-159 90-99
• STAGE 2 160-179 100-109
• STAGE 3 180-209 110-119
• STAGE 4 210+ 120+
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BP Less than 140/90
• Routine dental treatment
• Recommend lifestyle modifications
• Retake BP at continuing care appointments as a screening strategy for detection of hypertension
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BP 140-159/90-99
• Allow patient to relax; retake BP after 5 minutes
• Routine dental treatment
• Employ stress-reduction strategies
• If BP is above normal on three separate appointments and if patient is not under physician’s care for hypertension, refer to physician
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BP 160-179/100-109
• Retake BP after patient has rested for 5 minutes
• If still elevated, inform patient of readings
• Refer to physician within 1 month; delay treatment if patient cannot handle stress or if dental procedure to be performed is stressful
• Routine dental treatment can be provided
• Employ stress-reduction strategies
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BP 180/110
• Retake BP after 5 minutes
• If still elevated, delay treatment until BP is controlled
• Refer to physician for immediate evaluation
• Require written medical release form from physician prior to dental treatment
• Emergency dental treatment can be done in a hospital dental setting
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Summary Blood Pressure
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Summary
• BP is the pressure created against the vessel walls when the heart beats.
• Systolic pressure is the most important in management of blood pressure.
• High blood pressure has no symptoms.
• High blood pressure is easy and painless to detect in a few minutes with a blood pressure cuff and stethoscope.
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Blood pressure assessment should be a routine part of the initial appointment for all new dental patients.
• The Korotkoff soundsKorotkoff sounds are the series of sounds heard as the pressure in the BP cuff is released.
• Failure to recognize the auscultatory gap results in an inaccurateinaccurate blood pressure reading.
• Management for patients with hypertension is recommended.
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Pulse and Respiratory Rate
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Respiratory rate and Temperature
• Respiratory rate – done without the patient knowing or during pulse taking – changes as soon as someone knows it is being done – done more during emergency than in normal practice
• Temperature – can be done, but is rarely done in GP dental office
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Chart Entries
• Record blood pressure on the screening page only – not on DRT and date it
• In Daily Treatment Record (DTR) write:
DATE: NCMH (or change if it has occurred)
Recorded blood pressurethen Print your name & Sign your
name- GET AN INSTRUCTOR’S SIGNATURE
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Please ensure that….
• #1. You always fill out the chart after performing any clinical activity and have an instructor sign it.
• #2. Hand in your chart before leaving.
• #3. ‘Check out’ units with the assistants before leaving clinic.
• #4. Complete Evaluation forms