__introduction to clinical services

8/7/2019 __INTRODUCTION TO CLINICAL SERVICES

1/32

PASS YOUR

PREVIOUS/NEW

RECITATIONCARDS


2/32


3/32

INTRODUCTION TOINTRODUCTION TO

CLINICAL SERVICECLINICAL SERVICE

Ruby Ann S. David,Ruby Ann S. David,RNDRND


4/32

INTERDISCIPLINARYINTERDISCIPLINARYTEAMWORKTEAMWORK

Different professional team thatprovides direct care:

Doctors

NursesPharmacists

Dietitians

Medical technologistAdministrative

Ward clerk/secretary encoder


5/32

Hierarchy of physiciansHierarchy of physicians

RANK THE PHYSICIANS INASCENDING ORDER OF

SUPERIORITY(1 as lowest) ____ THE ATTENDINGPHYSICIAN

____ THE RESIDENT ____ THE INTERN ____ THE FELLOW


6/32

HierarchyHierarchy

ofofphysiciansphysicians

1ST year resident

works in a temporary

position as an OJTtrainee; similar to an

apprenticeship.

Are not yet doctors

THE INTERN


7/32

HierarchyHierarchy


aka house officer / senior house

officerin UK)

person who has received amedical degree (MD) and

who practices medicine underthe supervision of fully licensedphysicians, usually in a hospital

or clinic. a member of the house staff

who has completed at least 1

year ofpostgraduate medical

education. Doctor whos beginning their

post graduate training aftermedical school may follow the internship year or

include the internship year as thefirst ear of residenc .

THE RESIDENT


8/32

HierarchyHierarchy


Fellowship is the period ofmedical training in a relevant

sub-specialty, and during thistime the physician is known

as a fellow.

a doctor who goes beyond

their typical expectedresidency training into asubspecialty that allowsthem to obtain a specialized

certificate in the area thatthey're focusing on. may or may not be active

members of a team (house staff)

and may not be obligated toteach medical students

THE FELLOW


9/32


10/32

ROUNDSROUNDS

Rounds are meetings of all members ofthe service for discussing the care of

the patient. These occur daily and areof three kinds:

MORNING ROUNDS (work rounds)

ATTENDING ROUNDS

EVENING ROUNDS (check-out rounds)


11/32


12/32

ROUNDSROUNDS

MORNING ROUNDS or WORK ROUNDS

take place anywhere from 6:30 to 9:00 AM onmost services

and are attended by residents, interns, andstudents.

time for discussing:

what happened to the patient during the night

the progress of the patients evaluation and/or

therapy

the laboratory and radiologic tests to be ordered for

the patient

talking with and evaluating the patient


13/32

ROUNDSROUNDS

ATTENDING ROUNDS

These vary greatly depending on the service and onthe nature of the attending physician. The same

people who gathered for morning rounds will be here,with the addition of the attending.

significant new laboratory, radiographic, and physicalfindings are described (often by the student caring forthe patient); and new patients are formally presented

to the attending (again, often by the medicalstudent).

most important priority for the student on attending rounds is

to know the patient.


14/32

ROUNDSROUNDS

EVENING ROUNDS or Check-out rounds

between 3:00 and 7:00 PM on most days

the patients are seen by the entire team a second

time are typically done only on surgical servicesand pediatrics.

Other services, such as, medicine, often will havecheck-out with the resident on call for the service

that evening (sometimes called card rounds). Orders are again written

laboratory work desired for early the next day is

requested

list of work to be done that night and a list of patients

who need close supervision.


15/32

ROUNDSROUNDS

BEDSIDE ROUNDS

the same as any other rounds except that tactis ata premium

patients whose case presentations were made atthe bedside which were usually made in aconference room.


16/32

CLINICAL WRITECLINICAL WRITE--UPSUPS Identification

Name, age, sex, referringphysician, and the informant

(eg, patient, relative, old chart)and the informants reliability

chief complaint State, in patients own words,

the current problem

history of the present illness(HPI)

past medical history Current medications (Rx or

OTC); vitamins, and herbals;

allergies; surgeries;hospitalizations; blood

transfusions; other illnesses

family history

psychosocial historyStressors (financial, significant

relationships, work or school,

health) and support (family,friends, significant other,

clergy); life-style risk factors(alcohol, drugs, tobacco,

caffeine; diet; and exposure to

environmental agents; andsexual practices)

Review of system (ROS)

physical examination

Database: laboratory and x-ray data

Problem-list

Assessment: clinical impression

Plan: Additional laboratory

tests, medical treatment,consults, etc.


17/32

Review of systems (ROS)Review of systems (ROS) General: Weight loss, weight

gain, fatigue, weakness,appetite, fever, chills, night

sweats

Skin: Rashes, pruritus, bruising,

dryness, skin cancer or other

lesions Head:Trauma, headache,

tenderness, dizziness, syncope

Eyes: Vision, glasses, lastprescription change,

photophobia, blurring,diplopia, spots or floaters,

inflammation, discharge, dryeyes, excessive tearing,

history of cataracts or

glaucoma

Ears: Hearing changes,

tinnitus, pain, discharge,vertigo, history of ear

infections

Nose: Sinus problems,

epistaxis, obstruction, polyps,

changes in or loss of sense ofsmell

Throat: Bleeding gums; dentalhistory (last checkup, etc);

ulcerations or otherlesions on

tongue, gums, buccal mucosa Respiratory: Chest pain;

dyspnea; cough; amountand color of sputum;

hemoptysis; history of

pneumonia, influenza, etc.


18/32

Review of systems (ROS)Review of systems (ROS) Cardiovascular.Chest pain,

orthopnea, dyspnea on exertion,paroxysmal nocturnaldyspnea,murmurs, palpitations

Gastrointestinal. Dysphagia,heartburn, nausea, emesis,hematemesis, indigestion,

abdominal pain, diarrhea,constipation, melena,hemorrhoids, change in stoolshape and color, jaundice, fattyfood intolerance, flatulence

Gynecologic: abortions; age atmenarche; last menstrual period(frequency, duration, flow);dysmenorrhea; spotting;menopause

Gynecologic:contraception;sexual history, frequency ofintercourse, number of partners,sexual orientation andsatisfaction, and dyspareunia.

Genitourinary. dysuria;hematuria; polyuria; nocturia;

discharge; sterility; impotence;polydipsia; and sexual history

Endocrine. Polyuria, polydipsia,polyphagia, temperatureintolerance,

glycosuria/glucosuria, hormonetherapy, changes in hair or skintexture

Musculoskeletal.Arthralgia,arthritis, joint swelling, redness,tenderness, back pain,musculoskeletal trauma, gout


19/32

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION Physical assessment techniques:

INSPECTION

examination to detect significant signs thatinvolves senses of sight, smell and hearing. (begins at the1st encounter) **vital signs/HEENT etc

PALPATION examining the body by using sense of touch

to assess the characteristics of body structures. (requires

positioning: erect, sitting, prone, supine/dorsal, dorsalrecumbent, lithotomy, sims, knee-chest/genupectoral)**vital signs, lymph nodes/HEENT/breast etc

PERCUSSION tapping of a particular area of the bodywith the fingertips or a percussion hammerin order to

elicit the character and density of the sound in theunderlying tissue. **chest/back (signs of stenosis) etc

AUSCULTATION listening to the sounds created in various

body organs to detect variations/abnormalities.

**ROS interviewing and observation (signs and symptoms)


20/32

Physical examinationPhysical examinationequipmentsequipments

Thermometer

Stethoscope

Sphygmomanometer

Otoscope

Ophthalmoscope

Penlight

Tongue depressor

Tape measure

Watch

Gloves andlubricant

Reflex hammer

Drapes andpatients gown

Weighing scale Height scale

Eye charts


21/32

CHARTWORKCHARTWORK

Admit: Admitting team,room number

Attending: The name ofthe attending physician,the person legallyresponsible for thepatients care. Alsoinclude the residents

and interns names. Diagnosis: List admitting

diagnosis or procedure ifpost-op orders.

Condition: Stable,

critical, etc

Vitals: Determinefrequency of vital signs(temperature, pulse,blood pressure, central

venous pressure,pulmonary capillarywedge pressure, weight,etc)

Activity: Specify bedrest,up ad lib, ambulate qid,bathroom privileges, etc

Allergies: Note any drugreactions or food or

environmental allergies.


22/32

CHARTWORKCHARTWORK Nursing Procedures

Bed Position. Elevatehead of bed 30 degrees,etc

Preps. Enemas, scrubs,

showersRespiratoryCare.

DressingChanges,WoundCare. Changedressing bid, etc

Notify House OfficerIf.Temperature >101F, BP


23/32

Clinical notesClinical notes Problem-oriented progress notes (list more than 1 problem

and its corresponding SOAP) SOAP

Subjective

How the patient feels, any complaints

Objective

How the patient looks

Vital signs

Physical examination

Laboratory data, etc

Assessment: (for each problem) Evaluation of the data and any conclusions that can be drawn

Plan: (for each problem)

Any new lab tests or medications

Changes or additions to orders

Discharge or transfer plans


24/32

APPLYING NUTRITION CAREAPPLYING NUTRITION CAREPROCESS in SOAPPROCESS in SOAP

NUTRITIONASSESSMENT (ABCD)

NUTRITION DIAGNOSIS

(analysis,interpretation)

NUTRITION CARE PLAN

NUTRITIONMONITORING ANDEVALUATION


25/32

APPLYING NUTRITION CAREAPPLYING NUTRITION CAREPROCESS in SOAPPROCESS in SOAP

Subjective

________________________

________________________

Objective

________________________

________________________

Assessment:

________________________

________________________

Plan:

________________________

________________________

________________________


26/32

PRECAUTIONS in writingPRECAUTIONS in writingnutrition care plannutrition care plan

qd = daily (this is a dangerous abbreviationand should not be used

q6h = every 6 h

qid = four times a day. (Note that qid andq6h are NOT the same orders: qid meansthat the medication is given four times a

day while awake (eg, 8 AM, 12 noon, 6PM, and 10 PM); q6h means that themedication is given four times a day but bythe clock (eg, 6 AM, 12 noon, 6 PM, 12

midnight).


27/32

Dangerous PracticesDangerous Practices 1. NEVER use a trailing zero.

Correct: 1 mg

Dangerous: 1.0 mg. If the decimal is not seen, a

10-fold overdose can occur.

2. NEVER leave a decimal point naked.

Correct: 0.5 mL

Dangerous: .5 mL. If the decimal point is notseen, a 10-fold overdose can occur.

3. NEVER abbreviate a drug name because theabbreviation may be misunderstood or have

multiple meanings.


28/32

Dangerous PracticesDangerous Practices 4. NEVER abbreviate U for units as it can

easily be read as a zero, thus 6 U regularinsulin can be misread as 60 units. The order

should be written as 6 units regular insulin. 5. NEVER use qd (abbreviation for once a

day). When poorly written, the tail of the qcan make it read qid or four times a day.


29/32


30/32

HOSPITAL EMERGENCY CODESHOSPITAL EMERGENCY CODES

Use to alert staff to various emergencysituations. (color or number)

Why need for code? It is intended to convey essential

information quickly and with a minimumof misunderstanding to staff, while

preventing stress or panic among visitorsto the hospital.


31/32

HOSPITAL EMERGENCY CODESHOSPITAL EMERGENCY CODES

Every institution have their own code

standards:

Code blue cardiac arrest; requires

immediate CPR (code white for pediatricpatient)

Code 99 and code 45 (similar to code blue

and white)

Code red fire/ total evacuation

Fire: Dr. Fire, Dr. Pyro, Dr. Firestone

Code triage patient influx


32/32

__introduction to clinical services

Documents