美國重癥醫(yī)學(xué)（FCCM）的基礎(chǔ)教程-患者評估（英文）課件

1、Assessment of the Seriously Ill PatientObjectivesEarly identification of patients at risk for life-threatening illnessRecognize early signs of critical illnessReview the initial assessment of critically ill patientsWhy identify patients at risk?Easier management with simpler interventionsPrevent fur

2、ther deteriorationProvide time for investigation and treatmentChallenging PatientsYoung, fit patientsImmunosuppressed patientsDebilitated patientsPatients with abrupt deteriorationPatients with limited reserveRisk AssessmentBackground healthSeverity of acute physiologyVital signsOther clinical monit

3、oringTrends and rate of deteriorationGoalsRecognition that problem existsMaintain stabilityRisk AssessmentMaking a diagnosisOften secondary to treatment of physiological abnormalitiesInvestigate while stabilizingRequires disciplined approachAssessmentPrimary surveyWhat is main physiological problem?

4、First minutes of initial contactSecondary surveyWhat is underlying cause?Subsequent reviewsInitial SurveyHistoryMain symptomsPhysiological abnormalitiesCo-existing illness Major surgerySevere hemorrhage/transfusionLack of improvementPatient54 year old diabetic with shortness of breath3 days postoper

5、ative for laporoscopic cholecystectomyWhat additional details would be helpful?Secondary SurveyHistoryPast history, chronic diseasesPsychosocial issuesMedications/allergiesFamily historyEthical/legal issuesSystems reviewPatientBP 100/40 P 96 RR 26 T 37.8 CPulse oximetry 92% on 2 L cannulaAppears anx

6、ious, slightly confusedBibasilar ralesDecrease bowel sounds, distended abdomenWarm extremitiesWhich findings are most concerning?Airway/Respiratory SystemObserve mouth and chestRespiratory rate and patternTachypnea is the single most important indicator of critical illnessUse of accessory musclesLev

7、el of consciousnessOxyhemoglobin saturationCirculationPeripheral pulses and blood pressureEvidence of decreased perfusionMost common cardiovascular disturbance in the seriously ill is hypotension caused by hypovolemia and/or sepsisPatientBP 100/40 P 96 RR 26 T 37.8 CPulse oximetry 92% on 2 L cannula

8、Appears anxious, slightly confusedBibasilar ralesDecrease bowel sounds, distended abdomenWarm extremitiesWhat information from the chart wouldbe helpful?Chart Review and DocumentationSecondary surveyReview medical recordsDocument current eventsDocument diagnosis and treatment rationalePatientBP 100/

9、40 P 96 RR 26 T 37.8 CPulse oximetry 92% on 2 L cannulaAppears anxious, slightly confusedBibasilar ralesDecrease bowel sounds, distended abdomenWarm extremitiesWhat investigations should be ordered?InvestigationsGuided by history and physical examinationStandard biochemistry, hematology, microbiolog

10、y, radiographsArterial or venous blood gas Lactate levelMetabolic acidosis is an important indicator of critical illnessPatientBP 150/90, HR 70-80, RR 16, T 37.8 Pulse ox 97%(RA)Distended abdomenWarm extremitiesWBC 16,000/mm3BUN/creatinine normBP 100/40, HR 96, RR 26, T 37.8Pulse ox 92% on 2LDistend

11、ed abdomenWarm extremitiesWBC 21,000/mm3BUN/creatinineABG 7.3/30/65Previous exam Current examWhat now?Information ActionEnsure physiological safetyOxygenIntravenous accessCirculatory supportDetermine patients reserveAssess likely diagnosis and treatmentsInformation ActionRefine treatmentAssess response to treatmentProvide organ system supportDetermine best site for careCall for advice and as