Early Clinical Experience

Gathering Information for Patient Care

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

1. TREATMENT PLANNING

• Treatment Plan: Blueprint for care

following careful assessment of patient’s needs and priorities

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)

2. Data Gathering

ESSENTIAL FOR

►DIAGNOSIS

►PROGNOSIS

►TREATMENT PLAN

INFORMATION TO GATHER

• PERSONAL HISTORY

• MEDICAL HISTORY

• DENTAL HISTORY

• CLINICAL OBSERVATIONS

• CLINICAL EXAMINATION

• DIAGNOSTIC AIDS - RADIOGRAPHS, DIAGNOSTIC CASTS

#3. CLINICAL OBSERVATIONS

• SYMPTOMS and SIGNS

SYMPTOMS

THAT WHICH ONLY THE PATIENT CAN RELATE TO YOU

How do you find out the symptoms?

SIGNS

• WHAT CAN BE OBSERVED OR MEASURED

OBSERVATIONS

VITAL SIGNS• 1. PULSE• 2. BLOOD PRESSURE• 3. RESPIRATORY RATE• 4. TEMPERATURE

PULSE

• Result of alternate expansion and contraction of an artery as a wave of blood is forced through the heart

LOCATION OF ARTERY?

• Several “good” sites:

• radial artery

• carotid

• brachial, temporal, facial

HOW?• Tell the patient what you are

doing

• Place two or three fingers on area (not thumb)

• COUNT/ TIME• OBSERVE - RHYTHM:

regular or irregular• VOLUME and STRENGTH -

full, strong, poor, weak, thready• RECORD AS BEATS/MIN

• RANGES

• ADULT: 60-100 bpm

• CHILDREN: up to 130 for newborn

BLOOD PRESSURE

BLOOD PRESSURE

• Screening for hypertension in dental offices is an effective health care service

WHAT IS BLOOD PRESSURE?

• THE FORCE EXERTED ON THE BLOOD VESSEL WALLS

SYSTOLIC PRESSURE

• THE PEAK OR THE

HIGHEST PRESSURE - CAUSED BY VENTRICULAR CONTRACTION

• “NORMAL”

• <130 mm

• “Range”

DIASTOLIC

• LOWEST PRESSURE - EFFECT OF VENTRICULAR RELAXATION

“NORMAL”

• < 85 mm Hg

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

Factors that acutely increase BP in a healthy individual

• Exercise

• Eating

• Stimulants

• Emotional experiences

Factors that decrease BP in a healthy individual

• Fasting

• Rest

• Depressants

• Calming environment

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

• When the cuff pressure is below the lowest pressure against the arteries (diastolic pressure) – we no longer hear anything

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

Brachial and radial arteries

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

Placement of the cuff

Cuffs come in various sizes

• “Normal” adult size

• “Large” adult size

• “Pedo” size

Stethoscope

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

Preparing your stethoscope

Place it into your ears- Note the correct direction

Make sure that it is ‘turned’ on

Some canbe twisted here-Tap the diaphragmto check thatyou can hear it

• Biggest mistake that students make is thinking that they should hear the brachial pulse as soon as the cuff is put on

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

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

‘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

SYSTOLIC PRESSURE

• FIRST SOUND - CALLED SYSTOLE or systolic

• INDICATES THE BEGINNING OF THE FLOW OF BLOOD PAST THE CUFF

• 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

•DIASTOLIC

• LET THE LAST OF THE AIR OUT RAPIDLY

• REMOVE THE CUFF• RECORD AS mm Hg

SYSTOLIC/DIASTOLIC• DISINFECT/RETURN

Phases of Korotkoff Sounds

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).

• (

To prevent this from happening

• Always perform a radial pulse check

Silent Auscultatory Gap

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).

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+

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

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

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

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

Summary Blood Pressure

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.

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.

Pulse and Respiratory Rate

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

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

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