ACS

Immediate management ACS is an emergency situation and an initial ABCDE approach should be taken. See the Geeky Medics guide to the acute management of ACS for more information. Immediate management of ACS includes: Antiplatelet therapy: aspirin 300mg Analgesia: either GTN or intravenous opioids Initial anti-thrombin therapy: fondaparinux if low bleeding risk and the patient is not undergoing immediate angiography. Unfractionated heparin can be used for patients with renal impairment. Supplemental oxygen should be offered only to patients with SpO2 of less than 94%. Acute coronary syndrome (ACS) refers to a range of acute myocardial ischaemic states including: ST-elevation myocardial infarction (STEMI) Non-ST elevation myocardial infarction (NSTEMI) Unstable angina Myocardial infarction (MI) can be classified as either type 1 or type 2. Type 1 MIs are caused by plaque rupture whilst type 2 MIs occur secondary to decreased supply (e.g. anaemia, hypoxaemia, hypotension) or increased demand (e.g. arrhythmias such as atrial fibrillation with rapid ventricular response). ACS is life-threatening and must be recognised and treated in a timely manner. Remember: time is myocardium! This guide provides an overview of the recognition and immediate management of ACS using an ABCDE approach. The ABCDE approach can be used to perform a systematic assessment of a critically unwell patient. It involves working through the following steps: Airway Breathing Circulation Disability Exposure Each stage of the ABCDE approach involves clinical assessment, investigations and interventions. Problems are addressed as they are identified and the patient is re-assessed regularly to monitor their response to treatment. Clinical features of ACS Symptoms Typical symptoms associated with ACS include: Chest pain Referred pain­: chest pain can radiate to the epigastrium, arm, neck and jaw. Shortness of breath Palpitations Nausea and vomiting Sweating Syncope Clinical signs Typical clinical signs associated with ACS include: Tachycardia Tachypnoea Pallor Evidence of impaired myocardial function: hypotension, raised jugular venous pressure (JVP), coarse crackles on chest auscultation and additional heart sounds (e.g. pan-systolic murmur). Tips before you begin General tips for applying an ABCDE approach in an emergency setting include: Treat all problems as you discover them. Re-assess regularly and after every intervention to monitor a patient’s response to treatment. Make use of the team around you by delegating tasks where appropriate. All critically unwell patients should have continuous monitoring equipment attached for accurate observations. Clearly communicate how often would you like the patient’s observations relayed to you by other staff members. If you require senior input, call for help early using an appropriate SBARR handover structure. Review results as they become available (e.g. laboratory investigations). Make use of your local guidelines and algorithms in managing specific scenarios (e.g. acute asthma). Any medications or fluids will need to be prescribed at the time (in some cases you may be able to delegate this to another member of staff). Your assessment and management should be documented clearly in the notes, however, this should not delay initial clinical assessment, investigations and interventions. Initial steps Acute scenarios typically begin with a brief handover from a member of the nursing staff including the patient’s name, age, background and the reason the review has been requested. You may be asked to review a patient with ACS due to chest pain and/or shortness of breath. Introduction Introduce yourself to whoever has requested a review of the patient and listen carefully to their handover. Interaction Introduce yourself to the patient including your name and role. Ask how the patient is feeling as this may provide some useful information about their current symptoms. Preparation Make sure the patient’s notes, observation chart and prescription chart are easily accessible. Ask for another clinical member of staff to assist you if possible. If the patient is unconscious or unresponsive, start the basic life support (BLS) algorithm as per resuscitation guidelines. Airway Clinical assessment Can the patient talk? Yes: if the patient can talk, their airway is patent and you can move on to the assessment of breathing. No: Look for signs of airway compromise: these include cyanosis, see-saw breathing, use of accessory muscles, diminished breath sounds and added sounds. Open the mouth and inspect: look for anything obstructing the airway such as secretions or a foreign object. Interventions Regardless of the underlying cause of airway obstruction, seek immediate expert support from an anaesthetist and the emergency medical team (often referred to as the ‘crash team’). In the meantime, you can perform some basic airway manoeuvres to help maintain the airway whilst awaiting senior input. Head-tilt chin-lift manoeuvre Open the patient’s airway using a head-tilt chin-lift manoeuvre: 1. Place one hand on the patient’s forehead and the other under the chin. 2. Tilt the forehead back whilst lifting the chin forwards to extend the neck. 3. Inspect the airway for obvious obstruction. If an obstruction is visible within the airway, use a finger sweep or suction to remove it. Jaw thrust If the patient is suspected to have suffered significant trauma with potential spinal involvement, perform a jaw-thrust rather than a head-tilt chin-lift manoeuvre: 1. Identify the angle of the mandible. 2. With your index and other fingers placed behind the angle of the mandible, apply steady upwards and forward pressure to lift the mandible. 3. Using your thumbs, slightly open the mouth by downward displacement of the chin. Oropharyngeal airway (Guedel) Airway adjuncts are often helpful and in some cases essential to maintain a patient’s airway. They should be used in conjunction with the maneuvres mentioned above as the position of the head and neck need to be maintained to keep the airway aligned. An oropharyngeal airway is a curved plastic tube with a flange on one end that sits between the tongue and hard palate to relieve soft palate obstruction. It should only be inserted in unconscious patients as it is otherwise poorly tolerated and may induce gagging and aspiration. To insert an oropharyngeal airway: 1. Open the patient’s mouth to ensure there is no foreign material that may be pushed into the larynx. If foreign material is present, attempt removal using suction. 2. Insert the oropharyngeal airway in the upside-down position until you reach the junction of the hard and soft palate, at which point you should rotate it 180°. The reason for inserting the airway upside down initially is to reduce the risk of pushing the tongue backwards and worsening airway obstruction. 3. Advance the airway until it lies within the pharynx. 4. Maintain head-tilt chin-lift or jaw thrust and assess the patency of the patient’s airway by looking, listening and feeling for signs of breathing. Nasopharyngeal airway (NPA) A nasopharyngeal airway is a soft plastic tube with a bevel at one end and a flange at the other. NPAs are typically better tolerated in patients who are partly or fully conscious compared to oropharyngeal airways. NPAs should not be used in patients who may have sustained a skull base fracture, due to the small but life-threatening risk of entering the cranial vault with the NPA. To insert a nasopharyngeal airway: 1. Check the patency of the patient’s right nostril and if required (depending on the model of NPA) insert a safety pin through the flange of the NPA. 2. Lubricate the NPA. 3. Insert the airway bevel-end first, vertically along the floor of the nose with a slight twisting action. 4. If any obstruction is encountered, remove the tube and try the left nostril. Other interventions If the patient has clinical signs of anaphylaxis (e.g. angioedema, rash) commence appropriate treatment as discussed in our anaphylaxis guide. CPR If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR. Re-assessment Make sure to re-assess the patient after any intervention. Breathing Clinical assessment Observations Review the patient’s respiratory rate: A normal respiratory rate is between 12-20 breaths per minute. Patients with ACS may be tachypnoeic in an attempt to increase myocardial tissue oxygenation. Review the patient’s oxygen saturation (SpO2): A normal SpO2 range is 94-98% in healthy individuals and 88-92% in patients with COPD who are at high-risk of CO2 retention. Hypoxaemia may occur due to cardiac failure and secondary pulmonary oedema. Auscultation Auscultate both lungs: Reduced air entry bilaterally suggests significant airway compromise and the need for critical care input. Crackles or crepitations on auscultation may represent pulmonary oedema due to impaired cardiac function. Percussion Percuss the chest to assess for dullness associated with pleural effusion (e.g. secondary to cardiac failure). Investigations and procedures Arterial blood gas Take an ABG if indicated (e.g. low SpO2) to quantify the degree of hypoxia. An ABG should not delay the management of ACS. Chest X-ray A chest X-ray may be indicated if abnormalities are noted on auscultation (e.g. reduced air entry, coarse crackles) to screen for evidence of pulmonary oedema. A chest X-ray should not delay the emergency management of ACS. See our CXR interpretation guide for more details. Interventions Oxygen Administer oxygen if the patient has a low SpO2. This typically involves the use of a non-rebreathe mask with an oxygen flow rate of 15L. If the patient has COPD and a history of CO2 retention you should switch to a venturi mask as soon as possible and titrate oxygen appropriately. If the patient is conscious, sit them upright as this can also help with oxygenation. Continuous positive airway pressure Continuous positive airway pressure (CPAP) should be considered for patients who do not improve after supplemental oxygen and intravenous diuretics (see below). Commencing CPAP is a skill beyond the scope of most junior doctors and should always involve more senior doctors. CPR If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR. Re-assessment Make sure to re-assess the patient after any intervention. Circulation Clinical assessment Pulse Assess the patient’s pulse: Tachycardia is a common feature of ACS. Bradycardia is a late sign and often precedes cardiac arrest. Blood pressure Assess the patient’s blood pressure: Patients may be hypertensive due to increased sympathetic activity and pain. Hypotension is a late sign and represents cardiac failure. Inspection Inspect the patient from the end of the bed: they may appear in pain and clammy/pale. Fluid balance assessment Calculate the patient’s fluid balance: Calculate the patient’s current fluid balance using their fluid balance chart (e.g. oral fluids, intravenous fluids, urine output, drain output, stool output, vomiting) to inform resuscitation efforts. Reduced urine output (oliguria) is typically defined as less than 0.5ml/kg/hour in an adult. Investigations and procedures Intravenous cannulation Insert at least one wide-bore intravenous cannula (14G or 16G) and take blood tests as discussed below. See our intravenous cannulation guide for more details. Blood tests Collect blood tests after cannulating the patient including: Troponin: to help confirm the diagnosis of myocardial infarction. FBC: to screen for anaemia and signs of infection. U&Es: to assess renal function and electrolyte levels. CRP: to screen for evidence of infection. Serum glucose: to identify hyperglycaemia which should then be treated to improve outcomes. LFTs: to assess liver function (e.g. ischaemic hepatitis secondary to cardiac failure). Coagulation screen: to assess for coagulopathy. Record an ECG In the context of ACS, an ECG can provide valuable information as to the sub-type of ACS. Typical findings in each of the subtypes of ACS include: STEMI: ST elevation and/or new left bundle branch block (LBBB) NSTEMI: T wave inversion and/or ST depression Unstable angina: often there are no specific ECG abnormalities Interventions Morphine Morphine has a dual purpose in ACS treatment, both as a coronary artery vasodilator and as an analgaesic. Nitrates Nitrates, such as glyceryl trinitrate spray, cause coronary artery vasodilation and improve cardiac perfusion. If the patient is hypotensive, nitrates are contraindicated due to their vasodilatory effects. Aspirin and clopidogrel Aspirin (300mg) and clopidogrel (300mg) are administered to try and improve blood flow through the coronary vessels by inhibiting platelet aggregation. Diuretics If clinical signs of pulmonary oedema are present (e.g. shortness of breath, coarse bibasal crackles) consider administration of an intravenous diuretic (e.g. furosemide): Furosemide increases diuresis and aids the clearance of pulmonary oedema. If a patient is hypotensive, diuretics should not be administered in a ward setting and urgent critical care input should be sought. Fluid resuscitation Hypovolaemic patients require fluid resuscitation: Administer a 500ml bolus of Hartmann’s solution or 0.9% sodium chloride (warmed if available) over 15 mins. Administer 250ml boluses in patients at increased risk of fluid overload (e.g. heart failure). After each fluid bolus, reassess for clinical evidence of fluid overload (e.g. auscultation of the lungs, assessment of JVP). Repeat administration of fluid boluses up to four times (e.g. 2000ml or 1000ml in patients at increased risk of fluid overload), reassessing the patient each time. Seek senior input if the patient has a negative response (e.g. increased chest crackles) or if the patient isn’t responding adequately to repeated boluses (i.e. persistent hypotension). See our fluid prescribing guide for more details on resuscitation fluids. Percutaneous coronary intervention (PCI) Patients with clinical evidence of STEMI require urgent PCI and should be discussed with the on-call interventional cardiologist as soon as possible. CPR If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR. Re-assessment Make sure to re-assess the patient after any intervention. Disability Clinical assessment Consciousness In the context of ACS with hypotension, a patient’s consciousness level may be reduced. Assess the patient’s level of consciousness using the AVPU scale: Alert: the patient is fully alert, although not necessarily orientated. Verbal: the patient makes some kind of response when you talk to them (e.g. words, grunt). Pain: the patient responds to a painful stimulus (e.g. supraorbital pressure). Unresponsive: the patient does not show evidence of any eye, voice or motor responses to pain. If a more detailed assessment of the patient’s level of consciousness is required, use the Glasgow Coma Scale (GCS). Pupils Assess the patient’s pupils: Inspect the size and symmetry of the patient’s pupils Assess direct and consensual pupillary responses Drug chart review Review the patient’s drug chart for medications which may cause a reduced level of consciousness (e.g. opioids, sedatives, anxiolytics, insulin, oral hypoglycaemic medications). Investigations and procedures Blood glucose and ketones Measure the patient’s capillary blood glucose level to screen for causes of a reduced level of consciousness (e.g. hypoglycaemia or hyperglycaemia). A blood glucose level may already be available from earlier investigations (e.g. ABG, venepuncture). The normal reference range for fasting plasma glucose is 4.0 – 5.8 mmol/l. Hypoglycaemia is defined as a plasma glucose of less than 3.0 mmol/l. In hospitalised patients, a blood glucose ≤4.0 mmol/L should be treated if the patient is symptomatic. See our blood glucose measurement guide for more details. Imaging Request a CT head if intracranial pathology is suspected after discussion with a senior. See our guide on interpreting a CT head for more details. Interventions Maintain the airway Alert a senior immediately if you have any concerns about the consciousness level of a patient. A GCS of 8 or below warrants urgent expert help from an anaesthetist. In the meantime, you should re-assess and maintain the patient’s airway as explained in the airway section of this guide. CPR If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR. Re-assessment Make sure to re-assess the patient after any intervention. Exposure It may be necessary to expose the patient during your assessment: remember to prioritise patient dignity and conservation of body heat. Clinical assessment Inspection Inspect for relevant clues and clinical signs which may indicate increased cardiovascular risk (e.g. cigarettes, xanthelasma, corneal arcus). Look for any sources of bleeding which may have precipitated a myocardial infarction (e.g. rectal bleeding). Urine output Review the patient’s urine output as part of a fluid balance assessment to inform ongoing fluid management. Temperature Measure the patient’s temperature: If fever is present, make sure to consider co-existing infection. Patients with ACS may develop a fever as part of a catecholamine response. Interventions Catheterisation Catheterise the patient to closely monitor urine output to guide fluid resuscitation and need for escalation. CPR If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR. Re-assessment Make sure to re-assess the patient after any intervention. Reassess ABCDE Re-assess the patient using the ABCDE approach to identify any changes in their clinical condition and assess the effectiveness of your previous interventions. Deterioration should be recognised quickly and acted upon immediately. Seek senior help if the patient shows no signs of improvement or if you have any concerns. Support You should have another member of the clinical team aiding you in your ABCDE assessment, such a nurse, who can perform observations, take samples to the lab and catheterise if appropriate. You may need further help or advice from a senior staff member and you should not delay seeking help if you have concerns about your patient. Use an effective SBARR handover to communicate the key information effectively to other medical staff. Next steps Well done, you’ve now stabilised the patient and they’re doing much better. There are just a few more things to do… Take a history Revisit history taking to explore relevant medical history. If the patient is confused you might be able to get a collateral history from staff or family members as appropriate. See our history taking guides for more details. Review Review the patient’s notes, charts and recent investigation results. Review the patient’s current medications and check any regular medications are prescribed appropriately. Document Clearly document your ABCDE assessment, including history, examination, observations, investigations, interventions, and the patient’s response. See our documentation guides for more details. Discuss Discuss the patient’s current clinical condition with a senior clinician using an SBARR style handover. Questions which may need to be considered include: Are any further assessments or interventions required? Does the patient need a referral to HDU/ICU? Does the patient need reviewing by a specialist? Should any changes be made to the current management of their underlying condition(s)? Handover The next team of doctors on shift should be made aware of any patient in their department who has recently deteriorated. source : https://geekymedics.com/acute-coronary-syndrome-acs-emergency-management-abcde/

 

OLD CARTS

History-taking Mnemonic

Author: Lily Guo

Editors: Alyssa Haag, Ian Mannarino, MBA, MD, Kelsey LaFayette, DNP, RN

Illustrator: Jessica Reynolds, MS

Copyeditor: Sadia Zaman, MBBS, BSc

What does “OLD CARTS” mean?

"OLD CARTS" is a mnemonic device that assists clinicians in remembering the pertinent questions to ask while assessing an individual’s present illness. When a person presents to their clinician with complaints of a new or reoccurring medical problem, the clinician may use "OLD CARTS" as a structured guideline and framework from which they will ask questions and collect information before they perform a physical exam. Most commonly, "OLD CARTS" can be utilized for a patient who is experiencing pain, however, this mnemonic can be used as a framework for any presenting symptom. 

What is a history of present illness?

A history of present illness, abbreviated HPI, refers to the description of an individual’s current health complaint, typically described in chronological order from the onset of their first sign and symptom to the present, defined as the moment they are sitting in front of the clinician. It is a narrative written in full-sentence format by the clinician that provides the necessary information for the clinician to generate differential diagnoses, guide medical-decision making, investigate the problem, and ultimately, provide the proper treatment. 

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What does the “O” in “OLD CARTS” mean?

The O in OLD CARTS means onset, indicating when and how the complaint began. For example, the clinician may ask if the pain has been present for hours, days, months, or years as well as if the pain occurs abruptly or gradually. 

What does the “L” in “OLD CARTS” mean?

The “L” in “OLD CARTS” means location. This refers to where the pain is, including which specific body part (e.g., head, arm, leg, abdomen) and if the pain is isolated to one specific area (e.g., headache isolated to one side of the head, or abdominal pain of the right lower quadrant). 

What does the “D” in “OLD CARTS” mean?

The “D” in “OLD CARTS” means duration. This refers to how long or how often the complaint occurs. For example, the pain may last for minutes, hours, or days at a time.

What does the “C” in “OLD CARTS” mean?

The “C” in “OLD CARTS” means characteristic. The clinician may ask the individual to describe their pain using words such as achy, dull, stabbing, sharp, throbbing, squeezing, itching, or burning.

What does the “A” in “OLD CARTS” mean?

The “A” in “OLD CARTS” means alleviating and aggravating factors. The individual may be asked if they did anything to help alleviate the pain, such as taking medications or resting. If they did try home remedies, it would be helpful to know if they improved the symptom. The clinician may also ask if anything worsens the pain, such as changing body position, walking up stairs, or eating.

What does the “R” in “OLD CARTS” mean?

The “R” in “OLD CARTS” means radiation, which refers to whether the pain travels to other parts of the body or whether it is isolated to one region only. “R” in “OLD CARTS” may also refer to relieving factors, or activities or treatments that reduce the pain. The mnemonic may vary slightly depending on the source.

What does the “T” in “OLD CARTS” mean?

The “T” in “OLD CARTS” means timing. This refers to if the pain is constant and experienced at all times, or if it is intermittent, meaning it comes and goes. If the pain is constant, the clinician might ask if the severity fluctuates throughout the day, which is referred to as waxing and waning pain. Meanwhile, if the symptom is intermittent in frequency, clinicians might ask how many times a week, month, or year it occurs. 

What does the “S” in “OLD CARTS” mean?

The “S” in “OLD CARTS” means severity. For pain specifically, people are typically asked to rank their level of pain from one to ten, with ten being described as the worst pain they have ever experienced. Other questions to help gauge severity can include asking how the complaint interferes with day-to-day life or how bothersome the complaint is to the individual. 

What are the most important facts to know about the “OLD CARTS” mnemonic?

“OLD CARTS” is a mnemonic device used by providers to guide their interview of a patient while documenting a history of present illness. The letters stand for onset; location; duration; characteristic; alleviating and aggravating factors; radiation or relieving factors; timing; and severity. What each letter stands for may vary slightly depending on the source of the mnemonic. Onset refers to when the symptom, for example pain, first began and whether it was abrupt or gradual; location refers to the body part(s) affected; duration refers to the length of time the symptoms have persisted; and characteristic refers to the individual’s description of the symptoms (i.e., burning, aching, sharp). Alleviating and aggravating factors are factors that improve or worsen symptoms, respectively; radiation refers to whether there is any spread of pain; timing refers to whether the pain is constant or intermittent; and lastly, severity is typically ranked on a scale of one to ten, with ten being the most severe. When used to guide documentation of an HPI, the mnemonic “OLD CARTS” can make patient evaluation and management more concise and efficient. 

Physical health assessment

 Physical Health Assessment: Methods and Steps (theworldbook.org)

 

The Four Methods of Health Assessment

The four basic methods or techniques for physical health assessment are:

1. Inspection,
2. Palpation,
3. Percussion and
4. Auscultation. 

   3 Steps of Health Assessment

1. A complete medical history,
2. A general survey and
3. A complete physical assessment.

1. A Complete Medical History

History taking is the first step of Physical Health Assessment. The general framework for history taking is as follows:

• Presenting complaint.
• History of presenting complaint, including investigations, treatment, and referrals already arranged and provided.
• Past medical history: significant past diseases or illnesses, surgery, including complications, trauma.
• Drug history: now and past, prescribed and over-the-counter, allergies.
• Family history: especially parents, siblings, and children.
• Social history: smoking, alcohol, drugs, accommodation and living arrangements, marital status, baseline functioning, occupation, pets, and hobbies.
• Systems review: cardiovascular system, respiratory system, gastrointestinal system, nervous system, musculoskeletal system, genitourinary system

2. A General Survey

After collecting the health history and before going through the complete head to toe examination, some information or baseline data is collected which is called a general survey.

The general survey includes the person’s weight, height, body build, posture, gait, obvious signs of distress, level of hygiene and grooming, skin integrity, vital signs, oxygen saturation, and the person’s actual age compared and contrasted to the age that the person actually appears like.

For example, does the person appear to be older than his actual age? Does the person appear to be younger than his actual age?

3. A Complete Physical Assessment

A thorough physical assessment consists of the following:

• Vital Signs: The pulse, blood pressure, body temperature, and respiratory rate are measured.
• The Assessment of The Thorax and Lungs Including Lung Sounds: The size, symmetry, shape, and for the presence of any skin lesions and chest movements are observed. As well the breath sounds are observed and documented.
• The Assessment of The Cardiovascular System Including Heart Sounds: By listening to the heart sound it is observed that the heart is normal or not.
• The Assessment of The Head: The head movement is visualized over here.
• The Assessment of The Neck: The neck is visualized and the thyroid gland is inspected for any swelling and also for normal movement during swallowing.
• The Integumentary System Assessment: The color of the skin, the quality, distribution and condition of the bodily hair, the size, the location, color and type of any skin lesions are assessed and documented, the color of the nail beds, and the angle of curvature where the nails meet the skin of the fingers are also inspected.
• The Assessment of The Peripheral Vascular System: The peripheral veins are gently touched to determine the temperature of the skin, the presence of any tenderness, and swelling.
• The Assessment of The Breast and Axillae: The breasts are visualized to assess the size, shape, symmetry, color, and the presence of any dimpling, lesions, swelling, edema, visible lumps, and nipple retractions. The nipples are also assessed for the presence of any discharge, which is not normal for either gender except when the female is pregnant or lactating.
• The Assessment of The Abdomen: The abdomen is visualized to determine its size, contour, symmetry, and the presence of any lesions.
• The Assessment of The Musculoskeletal System: The major muscles of the body are inspected by the nurse to determine their size, and strength, and the presence of any tremors, contractures, muscular weakness and/or paralysis. All joints are measured for their full range of motion.
• The Assessment of The Neurological System: The Balance, gait, gross motor function, fine motor function and coordination, sensory functioning, temperature sensory functioning, kinesthetic sensations, and tactile sensory-motor functioning, as well as all of the cranial nerves, are measured.
• The Assessment of The Male and Female Genitalia and Inguinal Lymph Nodes: The skin and the pubic hair are inspected. The labia, clitoris, vagina and urethral opening are inspected among female clients. The penis, urethral meatus, and the scrotum are inspected among male clients.
• The Assessment of The Rectum and Anus: The rectum, anus and the surrounding area is examined for any abnormalities.

auscultation

 (6) SAM Online® Auscultation Training System by Cardionics - YouTube

 

What Is a Comprehensive Health Assessment?

• Published On: January 3, 2020

A comprehensive health assessment gives nurses insight into a patient’s physical status through observation, the measurement of vital signs and self-reported symptoms. It includes a medical history, a general survey and a complete physical examination.

The general survey consists of a patient’s age, weight, height, build, posture, gait and hygiene. Nurses use health assessments to obtain baseline data about patients and to build a rapport with them that can ease anxiety and lead to a trusting relationship.

A comprehensive health assessment is generally conducted at the time of admission into an acute care facility or during the first visit to an outpatient clinic. When nurses perform an assessment, they may use techniques such as:

Inspection

This is the most frequently used method for assessment. Nurses look for indications of a health problem by using their eyes, ears and nose. They may inspect skin color, lesions, bruises or rashes as well as pay attention to abnormal sounds and odors.

Auscultation

Nurses listen to the sounds of the abdomen by placing the diaphragm or bell of a stethoscope on the bare skin of a patient.

Palpation

Nurses apply varying degrees of pressure on the patient with different parts of their hands. Palpation allows nurses to assess for texture, tenderness, temperature, moisture, pulsations and the presence of masses.

Percussion

Nurses firmly press on sections of a patient’s body with the distal part the middle finger on their non-dominant hand. The technique is used directly over suspected areas of tenderness to check a patient’s level of discomfort.

What Steps Are Involved in a Comprehensive Health Assessment?

Typically, a comprehensive assessment begins with documenting a patient’s health history before starting a physical exam. According to AMN Healthcare Education Services, the health history includes: the patient’s medical complaint, present state of health, past health record, current lifestyle, psychosocial status and family history.

The health history provides nurses with in-depth information about symptoms, childhood illnesses, related medical experiences and risks for developing certain diseases.

After the health history data is recorded, a physical is conducted which covers a review of the patient’s body systems. A head to toe examination includes assessments of the following:

• Skin
• Neurological function
• Ears, eyes, nose and throat
• Respiratory function
• Cardiac-pulmonary system
• Abdomen
• Muscles and joints
• Limbs, shoulders, hips, ankles and feet
• Reproductive system
• Nutrition

A thorough and accurate assessment is important because it helps differentiate the normal condition of the patient from the abnormal. And, a comprehensive health assessment establishes if a patient needs diagnostic testing or additional medical care.

(5) Complete Physical Assessment - YouTube

 https://www.blogger.com/blog/post/edit/6486482301949636226/6937353938257075980

Prescribing

Prescribing is an important component of patient care, which unfortunately can very easily go awry. The dangerous nature of prescription medications means that the process of prescribing is heavy regulated through legislation, clinical guidelines, local, regional and national protocols. What may seem like a relatively simple and straightforward process can sometimes be much more complex than it first appears.

Prescriptions represent a request from one healthcare professional to another to administer or supply medication to or for a patient. Some medications do not require a prescription as they are considered safe enough for patients to use without professional supervision and these are legally classified as general sale list medications (GSL). Medications that are considered less safe and require supervision by healthcare professionals are classified as prescription only medications, referred to as POMs and can only be used under the supervision of a prescribing healthcare professional. Anything that is not a GSL or POM is classified as a pharmacy medication or P medicine, which is only available under the supervision of a pharmacist.

Something you should consider first is the practical elements of prescribing. Prescribing can be completed in a range of formats, from the technical methods that use ePrescribing systems or ‘regimen prescribing’ (where users click a button and automatically prescribe a combination of medications) to handwritten prescription using pen and paper, or a combination of both.

The technical aspects of the prescription will vary from place to place but there a few key elements of the prescription that will remain the same, as these are required by law in the United Kingdom (namely the Medicines Act 1968, Misuse of Drugs Act 1971 and Pharmacy Order 2010). This is particularly true for products that are likely to be misused and require extra controls to manage their supply. These products are known as controlled drugs and are grouped into schedules, from 1-5, where 1 indicates a high likelihood for abuse with little clinical application and 5 indicates a clear clinical application with a low likelihood for abuse. This differs from the class system used by Her Majesty’s Courts and Tribunals Service to categorise criminal possession of substances.

Download the prescribing basics PDF OSCE checklist, or use our interactive OSCE checklist. You may also be interested in our controlled drug prescribing OSCE guide.

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The patient

Any prescription must include the patient’s name. This information is used to identify the patient and ensure that the right medication is given to the right patient. The address of the patient could be their residential address, care home or the ward the patient is on. The age or date of birth of the patient is a useful way to identify the patient, however for patients under the age of 12 years it is a legal requirement to include the age or date of birth. Age is a useful indicator of liver and kidney function as well as fat/water ratio which can alter the distribution, metabolism and elimination of medication from the body. This makes the age of the patient an essential piece of information when deciding if medication is clinically suitable. This is particularly important for children, hence the legal requirement, but also for elderly frail patients so including the age or date of birth of the patient represents good clinical practice.

Summary

• Full name
• Address
• Age or date of birth (must be included if the patient is under 12 years old)

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The medication

Just like the technical aspects of prescribing, what can be prescribed will depend on where you are working and your level of training. Some medications can only be prescribed by healthcare professionals that are authorised to do so. This is typically the case for very expensive medications or very dangerous medications, such as chemotherapy or intravenous immunoglobulin.

You should check that you are authorised to prescribe the medication(s) you are trying to prescribe. This can be done easily on electronic systems, as the system may only let you select items you are authorised to prescribe, however, if using a manual prescribing process you should check the following resources:

• Clinical supervisor
• Practice or trust formulary
• Local formulary – developed by local and regional drug and therapeutics committees and usually available online
• Nurse Prescribers’ Formulary – for community nurse prescribers, available online
• Dental Practitioners’ Formulary – for dentists, available online

Decisions about which medication should be prescribed should be shared with patients and carers. About 1 out of every 10 prescribed medications are never started and about 50% of medications are not taken as they’re prescribed. Including patients in decisions about their care increases the likelihood that they will start and continue to take their medication.

Information that should be included on a prescription

Name of the drug

It is best practice to use the ‘generic’ or the actual name of the drug, rather than a branded product name, for most medications. As this will be cheaper for pharmacies to supply.

However, some medications should be prescribed using their branded name, particularly if they have a narrow therapeutic range. This means that the metabolism, distribution and elimination may be different between formulations of the same drug. For example, Lithium should be prescribed using the branded names of Priadel, Camcolit and Liskonum to ensure consistent drug serum levels.

The name of the drug must be included for schedule 2 and 3 controlled drug prescriptions.

Formulation

This is the ‘form’ you would like the medication to be in and describes how the drug will get into the patient. For example, as tablets, capsules, solution, elixir, suppository, pessary, cream, powder, pressurised inhaler, dry powder inhaler, subcutaneous injection, intramuscular injection or infusion.

There are many formulations available for most medications and if you’re unsure about which formulation to prescribe you should make a shared decision with the patient, if possible. If you’re not sure what form the medication takes, try and contact a pharmacist or pharmacy technician, who should be able to find out for you.

The formulation must be included for schedule 2 and 3 controlled drug prescriptions.

Strength

This is not the dose! The strength relates to how much drug is in the formulation you have requested. For example, 10mg tablets or 5mg tablets.

The strength must be included for schedule 2 and 3 controlled drug prescriptions.

Dose or instructions

Historically, doses were written using Latin and over time these were abbreviated. For example, omni die or once a day is abbreviated to OD. Many errors relating to prescriptions are caused by folks not just failing to read Latin, but failing to read abbreviated Latin! For example, quatro die or four times a day is abbreviated to QD, which can be misread as OD, if handwritten, leading to sub-therapeutic doses. To avoid errors then, try to write doses using plain English such as once, twice, three times (avoid thrice) or four times per day.

Doses can be ‘licensed’ or ‘unlicensed’. Licensed doses have been approved by regulators who have assessed the evidence for the product at a particular dose for a particular reason (or indication). Unlicensed doses or ‘off licence’ doses have not been approved and the evidence for use of the medication at that dose for that indication has not been assessed. When prescribing ‘off licence’ responsibility for the safety of the products use rests solely with the prescriber.

The dose of the medication should be checked in reliable resources, such as an up to date copy of the British National Formulary.

Some medications require a loading dose to enable a therapeutic serum level to be established quickly. For example, Warfarin requires the patient to be ‘loaded’ with a short term high dose followed by a longer-term lower dose. If you’re unsure if a medication requires a loading dose, contact a pharmacist.

Additionally, some medications have narrow therapeutic ranges, this means that patients can quite quickly build up toxic levels of the drug in their body and professionals need to monitor this. A very common example of this would be the Vitamin K antagonist Warfarin, which we monitor using the International Normalised Ratio or INR for short. The therapeutic range of a medication often depends on the indication and the patient, so make sure to check or set these for each prescription individually. Other approaches to monitoring may focus on the patient’s response to medication, for example monitoring white cell counts with clozapine, liver enzymes with statins or renal function with angiotensin-converting enzyme inhibitors.

Antagonists that block receptors should be introduced at low doses and gradually increased and, when stopping treatment, should typically be withdrawn slowly.

Dose or instructions must be included for schedule 2 and 3 controlled drug prescriptions.

Quantity

Quantity should be used to describe how long you would like the patient to use this medication. Many different units of measure can be used (e.g. days, weeks, months) or the actual quantity of medication you would like to be supplied (e.g. 7 tablets).

For schedule 2 or 3 controlled drugs you must include the actual quantity of medication you would like supplied in words and figures (e.g. SEVEN (7) tablets).

Summary

To summarise, good prescribers include the following information:

• Name
• Form
• Strength
• Dose
• Quantity

Table 1: Common controlled drugs used in practice	Schedule
Morphine	Schedule 2
Codeine	Schedule 5
Tramadol	Schedule 3
Pregabalin	Schedule 3
Temazepam	Schedule 3
Fentanyl	Schedule 2
Oxycodone	Schedule 2
Zopiclone	Schedule 4 Part 1
Somatropin	Schedule 4 Part 2
Cannabis	Schedule 1

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The professional

Many times as a junior prescriber you may be asked to sign a prescription, however, not every healthcare professional has the authority to prescribe every medication. For example, junior doctors can not prescribe chemotherapy. During the signing of the prescription, it is important that enough information is provided to create a record of which healthcare professional is authorising the supply or administration of a medication. This enables prescribing practices to be audited and ensure that poor practices are identified.

Information about the prescriber that is required by the person signing the prescription is discussed below.

Name

This should be legible and be your ‘professional name’.

Authority to prescribe

This should indicate what qualification the professional has to prescribe. For example, an MBBS degree, a BDS degree or an independent prescribing qualification, membership of an association or accreditation. This could also include a particular role within an organisation.

This could also be a registration number with statutory bodies that can be checked to verify a prescribers status, such as the GMC, GPhC, GDC and NMC.

Date

This should include the date that the prescription was issued by the professional. This may be different from the date that the prescription should be started and if the prescription is to begin on a specified date this information should be included under the dose or instruction section of the prescription.

Prescriptions can be pre-dated (for a time in the future) but should not usually be post-dated (to cover a period of use in the past) unless there are exceptional circumstances. For example, pharmacists can make supplies of medication legally if there is an agreement for a prescription to be written within the next 24 hours.

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What you need to decide: patient safety

The therapeutic decision-making process is influenced by lots of different things. Primarily, all therapeutic decisions should involve the patient and their carers, if possible.

All medication comes with side effects and avoidable adverse drug reactions cost the NHS approximately £98.5 million per year. Whenever you’re prescribing medication, you should always consider the risk and benefits of the medication. A good way to do this is to consider the necessity of the medication.

Dosing

Once necessity has been identified, you should consider how much of the medication is needed for a therapeutic effect. This decision should be evidence-based but person-centred. For example, some randomised controlled trials will identify a therapeutic dose, however, the participants in the trial may be very different to the patient in front of you.

Most medications are prescribed according to actual body weight (mg/Kg) but beware of hydrophilic medications that require dosing via ideal body weight, such as gentamicin.

Watch out for daily versus divided dosing (e.g. Paracetamol 15mg/Kg/dose or 60mg/kg/day).

Prescribing too much medication can lead to dose-dependent side effects, wastage and inappropriate polypharmacy so try to use the smallest dose for the shortest period where possible.

Duration

After dosing, consider the duration. Does the medication require acute or chronic use? Is this acceptable to the patient?

This is a particularly useful consideration for treatments that can cause dependence such as opioids, benzodiazepines, z-drugs, gabapentinoids as well medication where long-term use can lead to complications (e.g. corticosteroids) or resistance (e.g. antimicrobials).

Interactions

Before finalising a prescription, you should dedicate some time to reviewing what other medication the patient takes (if any) and how this newly prescription may interfere with absorption, distribution, metabolism and elimination of other medication. This can be tricky as interactions can be significant or non-significant. Useful resources include Stockley’s Drug Interactions, the BNF, MedicinesComplete Interaction Checker and a pharmacist or pharmacy technician.

Monitoring

The therapeutic effect of medication requires monitoring. This may include regular reviews with the patient regarding their symptoms as well as ordering and reviewing tests such as full blood count, liver and kidney function tests, eye tests, and lung function tests.

When making a plan to monitor medication, always consider and identify who will do this and by when. Pharmacists can help in monitoring long-term conditions and therapeutic outcomes, including making recommendations to deprescribe medications which are no longer beneficial for the patient.ABCDE Approach to Emergency Management