EMER 109 Patient Assessment Flashcards
<p>Patient Assessment Order</p>
dispatch
windshield survey (POPP)
general appearance
initial assessment (loc, abc, skin)
chief complaint
focused assessment (sample, opqrst, vitals)
interventions (can be provided as focused assessment is being performed)
decision and transport
reassessment of patient (initial, c/c, injuries, tx)
complete head to toe exam ongoing (if not necessary, must state why and complete a focused exam)
adapt patient care plan to changes in the patients condition
radio patch ER
report given to receiving facility
<p>Dispatch will provide the following</p>
Number of pts (will you require additional EMS response)
Special considerations (identified hazards that require you to stand down)
Additional response (do you require assistance of Police or Fire)
<p>POPP: people</p>
Number of patients
Number and state of bystanders
Mechanism of injury
<p>POPP: odours</p>
Are there any odours that would indicate hazards ?
Are there any odours that would indicate poor living conditions or self care?
<p>POPP: pets</p>
Are there any pets present?
Are they secured?
Are they a threat?
<p>POPP: pathways</p>
Where is the pt located?
Do you have direct access to patient and/or scene?
Do you need additional resources to gain access to the patient?
How big is the area the patient is in located?
Will you have enough room to get yourself, partner and equipment in the room and still be able to care for the patient?
<p>what should you look for besides POPP during scene survey</p>
patient location patient environment hot or cold lifestyle number of pts MOI evaluate need for additional resources
<p>what do you do upon entry to someones home</p>
<p>announce prescenceindoor scene assessment</p>
<p>why is allergy history important</p>
<p>helps determine if problem is an allergic reaction helps you avoid any meds or items such as latex gloves in treatment plan help you determine if it is a true allergy versus a medication side effect</p>
<p>2 types of medication history</p>
<p>Primary medication history the best possible medication history</p>
<p>Primary medication history</p>
<p>Quickly captures a list of medications. Determines the relationship between dosage and frequency of administration with respect to the patient’s complaint. Is created without other reliable sources of information</p>
<p>Complete documentation of a primary medication history includes:</p>
<p>Drug name Dosage Route Frequency</p>
<p>Best Possible Medication History (BPMH)</p>
<p>Is a systematic process of interviewing the patient/family. Is a review of at least one other reliable source of information to obtain and verify all of a patient’s medication use</p>
<p>Medication Reconciliation</p>
<p>a complete list of each patient’s current medications is obtained every time the patient enters the health care organization and is then communicated to subsequent providers in or out of the same health care organization</p>
<p>goal of Medication Reconciliation</p>
<p>prevent adverse drug events that could occur by allergic reactions, omissions, substitutions, and/or duplications</p>
<p>primary goal of the incident history interview</p>
<p>identify the patient’s chief complaint</p>
<p>Questioning the patient during the interview should focus on</p>
<p>specific symptoms or important medical information that will facilitate reaching an accurate diagnosis</p>
<p>O - Onset</p>
<p>“What were you doing, when the symptom/pain began?”"did it start suddenly"</p>
<p>P - Provocation</p>
<p>"Does anything make it better or worse ?”</p>
<p>Q - Quality</p>
<p>“What does the pain feel like?""can you describe what it feels like?"</p>
<p>R - Radiation/Region</p>
<p>“Does the pain move anywhere?""Do you have any other pain with this?”</p>
<p>S - Severity FOR PAIN</p>
<p>“On a scale of 0-10; 0 being no pain or completely pain-free, and 10 being the worst pain ever, how would you rate the pain?”</p>
<p>S - Severity FOR SOB</p>
<p>"would you say your shortness of breath is mild moderate or severe?"</p>
<p>T - Time</p>
<p>“What time did the symptom/pain begin?”</p>
<p>S – Signs and Symptoms</p>
<p>sign: what you seesymptoms: what they feelex: "what's going on?""what are you feeling?""what is hurting?""where does it hurt?"</p>
<p>A – Allergies</p>
<p>" do you have any allergies?""what happens if you come in contact with the allergen?"</p>
<p>M – Medications</p>
<p>prescriptions over the counter herbal remedies vitamins/supplements"are you compliant with your meds"</p>
<p>P – Past Medical History</p>
<p>(“The Big 7”) Respiratory problems Diabetes Seizures Cardiac problems Strokes Syncope Hypertension/Hypotension</p>
<p>L – Last Oral Intake</p>
<p>What was it? Was it normal?</p>
<p>E – Events Leading up to Current Event</p>
<p>"what happened""what caused this""what were you doing""do you remember what you were doing""is that something you often do"</p>
<p>why is last oral intake important</p>
<p>provide great insight into what their life has been like in last the 24 hours Inquire if they’ve had any recent changes in their dietary patterns (diets) In the event that surgery is required, the last oral intake may influence surgical times provide some indication of the patients’ underlying complaintcan be particularly important in the presence of diseases such as diabetes</p>
<p>what is a Primary Assessment</p>
<p>first assessment that you will perform on every patient contact identify life threats It is to be performed quickly on every call upon patient contact</p>
<p>Components of a Medical initial/Primary Assessment</p>
<p>General Impression LOCABCSkin</p>
components of general impression
*Signs of distress (does patient track, accessory muscle use, too sob to speak)
*Pts colour
*Positioning
*deadly bleeds
Body type
Personal hygiene/Body odour Signs of abuse
Speech
Mood
Movement
<p>components of Level of Consciousness (LOC)</p>
AVPU
Alert and Oriented questions
GCS scale
<p>AVPU</p>
<p>alert- do they track you, are they alert and oriented x4Verbal- Do they respond to verbal stimuli? Pain- Do they only respond with painful stimuli? Unresponsive- Are they unresponsive to all stimuli?</p>
<p>Alert and Orientated x4 questions</p>
<p>personplacetimeevent"what is your name""where are you""what month is it""what happened"</p>
airway
Quickly identify airway status
Is airway open and patent?
If not, immediately intervene
Breathing
look, listen feel
Identify quality and effectiveness of breathing
speed: fast/slow
regularity: regular/irregular
volume: shallow/deep
relative rate
effort: laboured/non laboured
- number of words spoken in a sentence
Circulation
speed:fast/slow
strength:strong/weak
regularity:regular/irregular
relative rate
present or not
skin
Colour (normal, pale, grey, ashen, cyanotic or mottled)
Temperature (warm, cool, or hot)
texture (dry, diaphoretic, moist
other findings (rashes, burns)
unstable patient would be:
Altered level of consciousness
Airway compromise
Absent breathing or
inadequate breathing
Pulse that is absent or inadequate
Skin findings that indicate circulation compromise
Head to toe check: head and neck
Jugular vein distention (JVD)
Wounds
Tracheal deviation
Head to toe check: chest
Assess for: Asymmetry Contusions Penetrations Tenderness Instability Crepitus
Listen to:
- The chest in 2 places to assess if equal (if unequal perform percussion)
- Heart tones
Head to toe check: abdomen
look for: Contusions Penetrations Evisceration Distention Tenderness Rigidity
Head to toe check: pelvis
Tenderness
Instability
Crepitus
head to toe check: Upper/lower extremities
Obvious swelling or deformity
Motor and sensation
head to toe check: posterior
Obvious wounds
Tenderness
Deformity
head to toe check: If altered mental status
Brief neurological exam
Pupil size, reactivity, equality
Glasgow coma scale
DCAP BLS TIC
deformities
contusions
abrasions
penetrations
burns
lacerations
swelling
tenderness
instability
crepitus
what is a secondary assessment
After primary assessment and after treated life threats
guided by the patient’s primary complaint
allows you to focus your assessments on a specific illness or injury
patient history and vital signs
Cardiac/ Respiratory Focused Assessment: NECK
Jugular vein distention (JVD)
Accessory muscle use
Tracheal deviation
Cardiac/ Respiratory Focused Assessment: CHEST
Look for: Any visible trauma Pacemakers Medication patches Surgical scars Accessory muscle use Hyperinflation
Listen to:
- The chest in four places to assess if breathing is clear and equal
- Upper lobes (middle clavicular line below collar bones)
- Lower lobes (Fifth intercostal space)
- Have patient take two deep breaths when assessing each area
Palpate:
- Chest to assess if patient has any pain
- If there is pain, does the pain change (increase on palpation/inspiration or no change at all)
Cardiac/ Respiratory Focused Assessment: ANKLES
- Check for pedal edema (swollen)
- Push down and count how long it takes to rebound (ex: edema x 2 secs)
- If edema is present check if pitting edema is present in one or both ankles
Neurological Focuses Assessment: FACE/HEAD
check for facial droop (have patient smile)
trauma
pupillary changes
- constriction/dilation
- unequal\reaction to light
- pearl (pupils equal and reactive to light)
note clarity of speech (slurred speech, inability to speak)
ask if they have a:
- headache
- dizzy/lightheaded
- blurred vision
- double vision
- hard time remembering events
Neurological Focuses Assessment: UPPER EXTREMITIES
do a comparison of both hands assessing movement, sensation, and equality
-grip strength
test arm drift
numbness or tingling in the extremities
Neurological Focuses Assessment: LOWER EXTREMITIES
check movement
sensation
colour
temperature
are pulses present in the lower extremities?
Strength should be assessed by having patients push and pull with their feet
Numbness or tingling in the extremities
Neurological Focuses Assessment: if they have a:
- headache
- dizzy/lightheaded
- blurred vision
- double vision
- hard time remembering events
BGL
Stroke assessment
GCS Scale
Stroke assessment
FAST Facial droop Arm drift Slurred speech -Ask if slur is normal Time
Gastrointestinal/genitourinary focused assessment: ABDOMEN
look for:
- distention
- bruising
- surgical scars
- visible masses
- pulsating masses
palpate:
- start at the opposite side of where the patient has pain
- rigidity
- rebound tenderness
- guarding
- DO NOT palpate any pulsating masses
Gastrointestinal/genitourinary focused assessment: PELVIS
continent or incontinent
Gastrointestinal/genitourinary focused assessment: LOWER EXTREMITIES
check color and temperature
check pulses if suspecting abdominal aortic aneurysm (AAA)
Gastrointestinal/genitourinary focused assessment: QUESTIONS YOU NEED TO ASK
urinary frequency/complications/changes
bowel movements- any noticeable changes
Eyes, Ears, Nose, Mouth and Throat (EENT) Focused Assessment: EYES
inspect the external portions including sclera, cornea and iris
inspect structures around the eyes including eyelids, lashes and tear ducts
test visual acuity at varying distances in each eye separately
test peripheral vision (confrontation test)
test eye movement
-Have patient follow finger as you move it in a figure of z or h pattern
Test pupil size and reaction to light
Eyes, Ears, Nose, Mouth and Throat (EENT) Focused Assessment: EARS
Visual inspection for wounds, infection discharge and excessive cerumen
Test hearing with voice test or similar
Palpate external structures if applicable
Eyes, Ears, Nose, Mouth and Throat (EENT) Focused Assessment: NOSE
Inspect the nose
- Is there any discharge (color?)
- Look for symmetry, color and structural abnormalities
Palpate if applicable and test nasal patency (sniff test)
Eyes, Ears, Nose, Mouth and Throat (EENT) Focused Assessment: MOUTH/THROAT
Inspect the mouth including lips, teeth, gums and tongue
Inspect the throat including tonsils, uvula and pharyngeal wall for redness and swelling
Breath odour
Unconcious/unkown Focused Assessment: FACE/HEAD
facial droop
trauma
pupillary changes (constricted or dilated)
equality
reaction to light
Unconcious/unkown Focused Assessment: NECK
jugular vein distension
accessory muscle use
Unconcious/unkown Focused Assessment: CHEST
look for:
- any visible trauma
- pacemakers
- medication patches
- surgical scars
- use of accessory muscles
listen to:
- the chest in four places to assess if the breathing is clear and equal
- have the patient take two deep breaths when assessing each area
palpate:
- the chest to assess if the patient has any pain
- if there is pain, does the patients pain change (increase on palpation/inspiration or no change at all)
Unconcious/unkown Focused Assessment: ABDOMEN
look for:
- distention
- bruising
- surgical scars
- visible masses
- pulsating masses
palpate:
- start the opposite side of where pain is
- rigidity
- rebound tenderness
- guarding
- DO NOT palpate any pulsating masses
Unconcious/unkown Focused Assessment: PELVIS
Look for trauma and evidence of urinary and bowel incontinence
Palpate the pelvis to check stability or crepitus
Unconcious/unkown Focused Assessment: UPPER EXTREMITIES
Asses movement and sensation
Hand grips and do a comparison in both hands for equality of strength
Unconcious/unkown Focused Assessment: LOWER EXTREMITIES
Check movement
Sensation
Colour
Temperature
Prescence of pulse in the
lower extremities
Unconcious/unkown Focused Assessment: BACK
Check for any visible or palpable abnormalities
R’s of Medication
right patient
right medication
expiry date
right dose
right route
right time
right documentation
CTAS (Canadian triage and acuity scale)
method of categorizing patient severity and level of distress pre-hospital is with the use of the Pre-CTAS system
Pre-CTAS level 1 TRANSPORT
patients should be transported to the closest emergency department.
An exception to this would be a designated trauma center, a stroke center, or pediatric hospital.
Pre-CTAS level 2 TRANSPORT
patients should be transported to the nearest appropriate emergency department based on the patient’s chief complaint.
Pre-CTAS level 3, 4, and 5 TRANSPORT
patients are stable, and a destination can be determined based on several criteria including; chief complaint, emergency department busyness, or patient request.
CTAS Level 1
resuscitation
Conditions that are a threat to life, limb or imminent risk of deterioration and require immediate intervention
Obvious signs of distress and unstable or abnormal vital signs
Immediate risk of significant deterioration or death
Examples:
- Cardiac arrest
- Active seizure
- Respiratory arrest
- Majour trauma with sings of shock
- Severe respiratory distress
- Alters LOC with GCS 9 or less
CTAS Level 2
emergent
Conditions that are potential threat to life or limb and require rapid intervention
Vital signs are abnormal
Examples:
- Moderate respiratory distress altered LOC with GCS of 10-13\severe abdominal pain with a rating of 8-10/10
- Fever with temp greater than 38 or signs of sepsis
- Chest pain with cardiac features
- Chest pain with non-cardiac features
- Hypertension with systolic greater than 220 and diastolic greater than 130 with symptoms
- Hypothermia with a core temp of 32 degrees or les
- Headache that is sudden and severe
CTAS level 3
urgent
Conditions that could potentially progress to a serious problem that require rapid intervention
Vitals are typically in the normal range
Examples:
- Mild respiratory distress
- Moderate abdominal pain with a rating of 4-7/10
- Post seizure with normal level of alertness
- Diarrhea
- Hypertension with systolic greater than 220 and diastolic greater than 130 with no symptoms
- Headache with moderate pain rated as 4-7/10
- Upper extremity with obvious deformity
CTAS Level 4
less urgent
Conditions that relate to patient age, distress or potential for the deterioration that would benefit from intervention
Typically have normal vitals
Examples:
- UTI complaints and symptoms
- Constipation with mild pain rated as less than 4/10
- Chronic confusion
- Laceration or puncture that requires sutures
CTAS Level 5
non urgent
Conditions that are acute but non urgent
May be part of chronic problem with no signs of deterioration
Intervention or investigation can be delayed or referred
Examples:
- Mild diarrhea with. No dehydration
- Minor bites
- Dressing change with normal vitals
- Medication request
- Laceration or puncture with no sutures required
Pulse Locations
Carotid Femoral Brachial Radial Posterior tibial Dorsalis pedis pulse
Pulse Rate Assessment
rate, rhythm, and quality
factors that can affect Radial pulse
Medications
Medical history
Age
Exercise
Normal Pulse Rates
Infant
100-160 bpm
Toddler
90-150 bpm
Preschool-aged child
80-140 bpm
School-age child
70-120 bpm
Adolescent
60-100 bpm
Adult
60-100 bpm
Factors that influence pulse quality
low blood pressure, shock and underlying medical conditions
Normal findings for a skin assessment
pink, warm, and dry
or
good color, warm and dry
possible causes: RED SKIN
Fever
Hypertension
Allergic Reaction
Carbon monoxide poisoning
possible causes: PALLOR SKIN
Excessive blood loss
Fear
Shock
possible causes: CYANOSIS SKIN
Hypoxemia
possible causes: MOTTLED SKIN
Cardiovascular compromise
possible causes: HOT, DRY SKIN
Excessive body heat
possible causes: COOL, DRY SKIN
Reaction to increased internal or external temperature
possible causes: COOL, WET SKIN
Expose to cold
possible causes: TENTING SKIN
Dehydration
most reliable site for assessing for changes of skin colour
areas of least pigment, such as under the tongue, the buccal mucosa, the palpebral conjunctiva, and the sclera
what can assessment of skin give insight to
the function of the cardiovascular system, respiratory system and overall physiological well-being
what can assessment of pupils give insight to
the status of cerebral perfusion, oxygenation, and overall condition
parasympathetic nerve fibers
make pupils constrict (miosis)
sympathetic nerves
make pupils dilate (myotises)
look for the following when assessing pupils
Are the pupils constricted or dilated?
What size are they in millimetres?
Are the pupils equal or unequal to each other?
Do the pupils respond to light?
At what speed do they respond to light? Are they brisk or sluggish?
Pupil Responses: midbrain dysfunction
midposition and fixed
Pupil Responses: Pontine dysfunction
pinpoint
Pupil Responses: Dysfunction of the tectum (roof) of the midbrain
large “fixed” hippus
Pupil Responses: metabolic imbalance
small, reactive and regular
Pupil Responses: Diencephalic dysfunction
small and reactive
pupil responses: Dysfunction of third cranial nerve
sluggish, dilated and fixed
GSC Scale Tips:
ESPN
Our Country WIN
Can’t Live Without FANs
Eye response Mnemonic ESPN -eye opening spontaneously -to sound -to pain -no response
verbal response mnemonic Our Country WIN -our- oriented -country- confused -W- words (inappropriate) -I- incomprehensible sound -N- No response
Motor Response Mnemonic Can’t Live Without FANs -Can’t- obeys Commands -Live- localizes to pain -Without- withdraws to pain -F- flexion (decorticate) -A- abnormal extension (decerebrate) -N- no response
factors that can affect respirations
Meds
Anxiety
Exercise
Assessing respiration
Regular resp count for 30 seconds
Irregular count for full 60 secs
Note depth: Shallow, normal or deep
Rhythm: should be regular and uninterrupted
Patterns of Respiration: NORMAL
regular and comfortable
12 to 20 per minute
Patterns of Respiration: ATAXIC
significant disorganization with irregular and varying depths of respiration
Patterns of Respiration: BRADYPNEA
slower than 12 per min
Sleep
OD
Head trauma
Strokes
Patterns of Respiration:
HYPERPNEA
faster than 20 per min
** deep breathing
Patterns of Respiration: SIGHING
frequently interspersed deeper breaths
Patterns of Respiration: AIR TAPPING
increasing difficulty in getting breath out
Patterns of Respiration: BIOT RESPIRATIONS
irregularity interspersed periods of apnea in disorganized sequence of breaths
CNS insults (especially infections)
Patterns of Respiration: CHEYNE- STROKES BREATHING
varying periods of increasing depth interspersed with apnea
Brain stem insult
Increase ICP
Patterns of Respiration: KUSSMAUL
rapid
deep
laboured
Metabolic acidosis and DKA
Patterns of Respiration: TACHYPNEA
faster than 20 per min
Shock
Panick
Fear
Normal Respiratory rates
Infant
30-60 bpm
Toddler
24-40 bpm
Preschool-aged child
22-34 bpm
School-age child
18-30 bpm
Adolescent
12-16 bpm
Adult
10-20 bpm
factors that affect respiratory rate
high fever, anxiety, pain, excitement, and underlying medical and traumatic conditions
Signs of Inadequate Breathing
Slow or fast respirations for patient’s age
Shallow breathing
Adventitious: abnormal breath sounds like wheezing, crackling or stridor
Altered mental status
Cyanosis
methods for obtaining body temp
Oral tympanic axillary temporal rectal
hypothermia temps
Core temperature less than 35°C
Mild: 32-35°C
Moderate 28-32°C
Severe: Less than 28°C
fever temps
increase in temperature above 38°C
Can be a response to infection, inflammation, or drug therapy
Hypothalamus still functioning normally
hyperthermia
Core temperature is greater than 40°C
Body temperature is out of control
normal body temp
Range of 35.8-37.3°C considered normal range for oral temperature
Factors that can Affect Temperature: OVULATION
Increased body temperature
Factors that can Affect Temperature: TIME OF DAY
Increased temperature in evening; lower temperature in the early morning
Factors that can Affect Temperature: AGE
Young and old; poor thermoregulation
Factors that can Affect Temperature: EXERCISE
Increase body temperature
Factors that can Affect Temperature: THYROID
Increase metabolic rate so corresponding increase in body temperature
Core body temperature
found in blood supplying organs such as the brain, abdominal, and thoracic cavities
Core temperature is affected by
internal factors
True core temperature readings can only be measured by
invasive methods such as placing a probe in the esophagus, pulmonary artery, or bladder
Peripheral temperature
the temperature of tissues, such as the skin
greatly influenced by environmental factors
not as reliable a source
Blood pressure
is the force blood exerts on the vessel wall
Systolic pressure
the maximum pressure felt during left ventricle contraction
Diastolic pressure
the pressure exerted during the relaxation phase
Pulse pressure
the difference between the two values
BP Palpation
systolic blood pressure (BP)
rough BP estimate quickly without the use of a stethoscope
underestimated by 5–10 mmHg
Find radial pulse
Fill cuff till pulse disappears
Release some air slowly
When pulse returns number is systolic pressure
BP Auscultation
Inflate cuff to 30 over usual pressure
Slowly release pressure valve 2-3 mmhg per second
Note when you hear the first clear sound (systolic pressure)
When sound disappears (diastolic pressure)
Factors that affect blood pressure
Age: BP rises with age
Gender: Males have a higher BP than females but after menopause the reverse is true
Ethnic background: Those of African descent typically have a higher BP
Time of day: BP is typically higher later in the day and into the evening
Weight: BP is higher in obese individuals
Exercise: BP increases during exercise
Emotions: BP rises with anger, fear, and pain due to a sympathetic response
Stress: BP is higher in those that are under chronic stress
Factors that can cause inaccurate blood pressure results
The cuff is not of the proper size
The cuff is positioned too loosely
The patient’s arm is not positioned properly
The patient is not seated properly
The cuff is inflated slowly
If the cuff is re-inflated immediately after an initial reading
non-invasive blood pressures (NIBP) monitors
uses the oscillometer measurement technique
the oscillometer measurement technique
measures the changes in pressure pulses that are caused by the flow of blood through the artery
trouble shooting when using a non-invasive blood pressure monitor:
The monitor measures a pulse, but there is no oxygen saturation or pulse rate
Excessive patient motion
Patient perfusion may be too low
trouble shooting when using a non-invasive blood pressure monitor:
SpO2: NO SENSOR DETECTED message appears
Sensor not connected to patient or cable disconnected from monitor/defibrillator
Damaged cable or sensor
trouble shooting when using a non-invasive blood pressure monitor:
No SpO2 or SpCO, or SpMet value (—) is displayed
Sensor may be too tight
Patient is in cardiac arrest or shock
Oximeter may be performing self-calibration or self-test
Defibrillator shock just delivered
High-intensity lights (such as pulsating strobe lights) may be interfering with performance
Damaged cable or sensor
trouble shooting when using a non-invasive blood pressure monitor:
Different SpCO or SpMet measurements on same patient
Every measurement, even on the same patient, can be different
trouble shooting when using a non-invasive blood pressure monitor:
XXX appears in place of SpO2 reading
SpO2 module failed
nternal cable failed
Explain Mean Arterial Pressure
the average pressure in a patient’s arteries during one cardiac cycle (averaged BP)
A MAP of ——-mmHg or greater is believed to be needed to maintain adequate tissue perfusion
60
usual MAP range
70-110 mmHg
MAP formula
[(Diastole × 2) + systole ] ÷ 3
Indications for blood glucose monitoring as defined by the Saskatchewan Paramedic Clinical Practice Protocols include:
- Seizure
- Sick pediatric patients
- Decreased level of consciousness
- Syncope
- Abnormal behaviour
- Any patient suspected of being hypoglycemic
Factors that Affect Accuracy of Glucometric Testing
Outdated strips
Incompatible strips
Dirty skin at the site of the sample
Temperature changes – always store strips and monitor at manufactures recommended temperature range
Wet finger
Poor test sample
Poor monitor maintenance
normal blood glucose range
4-7 mmol/L
When levels drop below —– mmol/L, or with extreme highs, we may start to see a change in LOC
4
Below —– mmol/L, we will see severe confusion and unconsciousness
2
When the level drops even further to below — mmol/L, the brain is unable to function and if not treated quickly it may be fatal
0.6
Factors that can influence an individuals blood glucose levels
Increased/decreased body temperatures. Increased metabolism. Trauma. Shock. Childbirth/pregnancy. Medications. Chronic disease. Alcohol.
two basic methods for monitoring glucose levels
urine
serum glucose
two ways to measure the level of serum glucose in the blood
the use of glucose reagent strips (visual method)
the use of an automated glucose monitor
steps to perform glucose
Prepare the equipment
Prepare the patient
Wear PPE
Prepare the monitor and strip
Prepare the patient’s skin
Obtain blood sample and glucose reading
Record the glucometer reading
Dispose of all contaminated materials
troposphere
First layer extending from the earth’s surface to 8–14.5 km high.
The temperature drops with ascent (dry adiabatic lapse rate is 10 °C/1,000 m and moist is 5–6 °C/1,000 m).
Water vapour reduces with the ascent.
Weather and turbulence are present.
Atmospheric pressure drops with the ascent.
Stratosphere
The layer above troposphere extending to 50 km.
No water vapours.
The ozone layer is here.
Temperature is constant at -56 °C.
Mesosphere
Just above the stratosphere and extends to approximately 85 km.
Temperature is -90 °C at the top of the layer.
Thermosphere
Just above the mesosphere.
Satellites orbit here.
Northern lights are formed in this layer.
Height and temperature vary based on energy from the sun so the height can be anywhere from 500 and 1,000 km.
Ionosphere
Not a distinct layer as it is overlapping into mesosphere and thermosphere.
Ultraviolet radiation strikes gas molecules causing the atoms of the gas to separate and become charged. This is ionization and provides the “reflector” layer for electromagnetic radio waves that strike this layer and are reflected back to earth.
UV rays combine with oxygen at 15 to 42 km yielding an irritating corrosive substance called ozone.
Exosphere
The layer above thermosphere up to 100,000 km or more and gradually extending into outer space.
Atmospheric pressure
is a product of the partial pressures of the total gases contained in the atmosphere
the standard atmosphere has been given the following characteristics:
Air is absolutely dry and acts as a perfect gas.
The atmospheric pressure at sea level is 29.921 inches of mercury, 14.696 pounds per square inch or 760 millimetres of mercury.
The temperature at sea level is 15 degrees Celsius (59 degrees °F ).
Up to an altitude of 35,332 feet, the temperature will fall at a rate of 1 degree per 100 m.
Between 35,332 feet and approximately 80,000 feet, the temperature remains constant at -55 degrees Celsius (-67 degrees °F ).
four variables that influence gases and their responses
Temperature, pressure, volume, and mass
Boyle’s Law
The volume of a gas is inversely proportional to its pressure, the temperature remaining constant. (P1V1 = P2V2 where P is pressure and V is volume)
This law applies to all gases and explains why a weather balloon increases in size as it ascends in altitude.
Boyle’s Law patient care
This phenomenon is the principle reason why intravenous (IV) containers made of glass cannot be used during air transport and why paramedics will use sterile water or saline to fill the balloon of the endotracheal tube rather than using air, which is the norm on the ground
gas in the gastrointestinal (GI) tract, sinuses, or the middle ear of the air medical personnel will expand with ascent
- gas must be vented, or it will put pressure on tissues during expansion
- reduce GI distention, air medical personnel should avoid chewing gum and the ingestion of gas forming/containing food or beverages
- Gas expansion in the middle ear and/or sinuses may not be vented adequately resulting in pain, inflammation, and/or the possibility of rupture of the eardrum
Charles’ Law
The volume of a gas is proportional to its absolute temperature when pressure and mass is constant.
Universal Gas Law
combination of Boyle’s and Charles’ laws
describes relationship between Volume (V), Pressure (P), and Temperature (T) of gas in a more realistic environment similar to that of air medical transport
Dalton’s Law
the total pressure of a gaseous mixture is equal to the sum of the partial pressures of the individual gases in the mixture.”
must understand the composition of the earth’s atmosphere and the effect of ascent in the atmosphere on barometric pressure
- -Increasing altitude results in a drop in atmospheric pressure
- -As total atmospheric pressure drops, the pressure of individual component gases also declines
- -As a result, the availability of oxygen decreases with an ascent in altitude
Dalton’s Law Patient Care Implication
To counteract this problem, oxygen delivery must increase with ascent to maintain the inspired oxygen concentration required by the patient.
Environmental Flight Stressors
mnemonic, GHOSTBAND:
G — Gravitational forces H — Humidity/hyperventilation O — Oxygen S — Shakes/vibration T — Temperature B — Barometric pressure A — Atmosphere N — Noise D — Disorientation
Effects of flight on patients: GRAVITATIONAL FORCES
Patient positioning can alleviate some of the effects depending on the nature of the patient’s condition
A head forward position will be beneficial for patients with head injury or fluid overload problems and a feet forward position might be best for obstetrics patients or those suffering from hypovolemia
Effects of flight on patients: HUMIDITY/HYPERVENTILATION
Humidity is a concern especially if the flight will be long and/or at higher altitudes
The concentration of water vapour decreases with ascent and the aircraft obtains fresh air from the external environment
can result in dehydration
On long transports, the patient may require oral fluids to keep the mouth moist, eye care for dry eyes, and humidified oxygen delivery
Hyperventilation may develop in the aircraft and is primarily caused by hypoxia, anxiety, or fear
Effects of flight on patients: : OXYGEN
The availability of oxygen is reduced as the aircraft ascends which can lead to the development of hypoxia
Effects of flight on patients: SHAKES/VIBRATIONS
can produce increased metabolic rates, (heart rate, respiratory rate, etc.) reduced concentration, fatigue, nausea, and chest or abdominal pain
Vibrations can also have a psychological effect on the patient and their perception of risk
Effects of flight on patients: TEMPERATURE
Extremes in temperature can have physiological effects on both patients and flight crew members
These are rarely an issue as most aircraft have reliable heat sources and air conditioning units
Effects of flight on patients: BAROMETRIC PRESSURE
has extensive implications to human physiology as discussed earlier
Effects of flight on patients: ATMOSPHERE
The Atmosphere has extensive implications to human physiology as discussed earlier.
Effects of flight on patients: NOISE
Noise or unwanted sound can have negative physiologic effects as well as make it difficult to assess and monitor the patient
can cause disorientation, increased fatigue, nausea, headache, and is capable of mild cardiovascular stimulation
Effects of flight on patients: DISORIENTATION
Orientation is the individual’s recognition of body position in relation to the earth’s surface maintained through sight, balance and sensors in joints and skin
the motion of the craft greatly confuses the picture and provides the brain with misleading information leading to disorientation
Advantages of Air Transport
They can reduce transport time.
Highly trained personnel are on board.
Can provide access to remote locations.
Some hospitals allow for the direct landing of a helicopter thus decreasing time to definitive care.
Disadvantages of Air Transport
Weather and environment may cause an inability to fly.
Based on the inability to establish a safe landing zone or lack of airstrip, the aircraft may not be able to land.
There is a high cost.
Cardiac arrest patients are not suitable candidates due to response times and lack of space to perform CPR.
Lack of space in the cabin can create problems if trying to perform interventions.
When to Activate Air Transport: GENERAL SITUATIONS
The patient requires critical care during transport.
The patient requires rapid transport.
If there are any potential delays associated with ground transport that may be detrimental to patient condition.
Use of ground transport would leave the local area without ambulance coverage.
When to Activate Air Transport: TRAUMA SITUATIONS
Fall from greater than 6 feet.
Penetrating central injuries.
Scalping injury.
Severe hemorrhage.
Major burns to face or chest.
Injuries to face or neck that result in airway concern.
Multi-trauma pediatric patient.
Lengthy extrication where critical care team will benefit the patient by arriving at the scene.
The following mechanism of injury:
- Ejected from a vehicle.
- Another occupant of the vehicle died.
- Thrown from a motorcycle.
Patient older than 55 with multiple injuries.
Adult patient with a respiratory rate under 10 or over 30, or heart rate of under 60 or greater than 120 bpm.
When to Activate Air Transport: MEDICAL SITUATION
The patient was previously in cardiac or respiratory arrest (Not currently in cardiac arrest).
Respiratory failure was not responsive to intervention.
Patient requires continuous medication infusion or ventilation to maintain cardiac output.
Patient requires mechanical ventilation.
Hypothermia that requires immediate invasive therapy.
Respiratory rate is less than 10 or greater than 30.
Heart rate less than 50 or greater than 150 bpm.
BP less than 90 mm/Hg or greater than 200 mm/Hg systolic.
Acute MI, evolving stroke or dissecting or leaking aneurysm.
Pregnant patient with high-risk obstetrical condition.
When to Activate Air Transport: PEDIATRIC PATIENTS
The patient is high risk for cardiac dysrhythmia or failure.
The patient is high risk for respiratory failure or arrest.
The patient requires invasive airway interventions or ventilation.
The patient is showing signs of shock.
The patient presents with any of the following:
- Near-drowning.
- Acute bacterial meningitis.
- Acute respiratory failure.
- Status epilepticus.
- Hypothermia.
- Multiple trauma.
Patient Care Principles of Aeromedical Transport
stabilization of the patient prior to transport
The priority of patient care is airway management whether on the ground or in the air
Breathing must be assessed and assisted if inadequate
Respiratory emergencies (pulmonary edema, hemothorax, flail chest, and pneumothorax) must be managed on the ground before the flight
ardiac arrest, transport should not be initiated until circulation has been restored
Neurological status must be assessed for a spinal injury and for evidence of increased intracranial pressure
Nasogastric or orogastric tubes should be inserted in all intubated patients and in patients with gastric distention or gastrointestinal disorders
Preparing for stars arrival
Select landing zone officer
Wear proper PPE
Select site
Set up landing zone
- -Safe from hazards
- -120 meters from accident
- -Talk to stars through radio
STARS arrival
Ensure landing zone is clear
Stand in middle of the upwind
side of the landing zone with your back to the wind
Give the all clear signal by raising arms straight up in air
Kneel as helicopter approaches
Do not move your spot
If not safe to land, wave your arms above head
STARS departure
ensure landing zone is clear
Give pilot all clear signal
Maintain your position
If unsafe wave arms above head
Highway landing STARS
2 way high way traffic stopped in both ways
Divided highway traffic control in unaffected lane officers discretion
Crash Procedures STARS
Emergency access
Fuel shut off and location of fuel tank
How to operate safety belts
Oxygen shutoff
Activation of emergency locator transmitter
Landing zone size
36meters by 36 meters
Fixed wing aircraft
necessary due to the distances travelled because of the scattered population
faster over a longer distance than rotary wing, they are pressurized, and they can fly above weather patterns
Rotary wing aircraft
used for shorter distances as they fly slower and are not pressurized which necessitates lower flying altitudes making them more susceptible to weather patterns
rotary wing aircraft can respond directly to the scene and in some jurisdictions transport the patient directly to the receiving facility
Ramp Dangers for aircraft landing
noise
propellers
jet exhaust/engine intake
structural component
smoking
Types of ambulances
Type I, Type II, and Type III
Type I Ambulances
a modular box that is mounted on a truck chassis
allows for higher weight limits and can handle both rough terrain and urban streets
allows for more room in the patient compartment for equipment storage and movement during patient care
Type II Ambulances
manufactured using a modern passenger or cargo van
often used in larger urban centers due to the ease of navigating through heavy traffic
commonly used for interfacility transports
Type III Ambulances
modular with a van chassis
can handle both rough terrain and urban streets
allows for more room in the patient compartment for equipment storage and movement during patient care
more common ambulance types used in Saskatchewan
Routine maintenance of an ambulance includes the following:
Regular oil changes
Yearly safety checks
Tire rotation
Seasonal tire changes
Daily mechanical check
completing daily mechanical and equipment checks
Components of a Mechanical and Safety Check: TIRES
cuts
bruises
wear bars
intervals around the tire
inflation
Components of a Mechanical and Safety Check: UNDER THE HOOD
belts
hoses
fluid leaks
fluid colors
Coolant—Green or yellow Power steering—Clear Brake—Clear or amber Washer fluid—Blue or yellow Transmission—Red or thick black Battery (acid)—Clear or white
Components of a Mechanical and Safety Check: INTERIOR
loose items
seatbelt
steering
brakes
lights and sirens
communications equipment
pt care equipment
Requirements for and ambulance to be fit for service
it must be able to Start, Stop, Steer and Stay Running
Examples of Reasons to Remove an Ambulance from Service
Battery failure Major fluid leaks Brake issues Steering issues Tire damage or wear seatbelt failure
Brake issues
Brake fade—a sensation that you have lost brakes
Brake pull—steering wheel jerks in one direction when braking
remember the following principles of emergency driving when lights and sirens are activated:
Stop at all controlled intersections.
Attempt to make eye contact with all drivers before proceeding.
Change the siren mode or air horn to alert nearby traffic.
Never pass a vehicle on the right. Always keep to the left to pass vehicles as the public
has been trained to pull to the right when they hear an emergency siren.
Never use the right-hand lane during an emergency unless you intend to turn right at the next intersection
When proceeding through intersections:
Make a secondary stop before crossing the intersection.
Have your partner actively involved in watching for other vehicles and driver reactions.
If an intersection is impassable
- power down all lights & sirens.
Never assume the vehicle’s lights, sirens, and air horns provide an absolute right-of-way or privileged immunity to proceed. You are only requesting the right-of-way, you must wait for others to grant it before you may proceed
Ambulance Act
Outlines how the operator may deploy employees and resources
Outlines employee’s responsibility to the employer
Offensive driving
It is driving so that other motorists are aware of your presence and your intentions
defensive driving
observing the presence and intentions of other drivers to avoid accidents. Anticipating other driver’s movements so that you can be prepared if you must take evasive action
If law enforcement/fire service personnel have secured the scene, the ambulance should be parked:
about 30 meters past the accident scene (on the same side of the road)
Uphill (about 60 meters) and upwind if the presence of hazardous materials is suspected
If the scene has not been secured by law enforcement/fire service personnel, the ambulance should be positioned:
approx. 15 meters in front of the scene in a “Fend-Off Position.”
term bariatric is derived from the Greek words
“baros,” meaning weight, and “iatreia,” meaning medical treatment
Bariatric care
branch of medicine that deals with causes, prevention, and treatment of obesity
In determining if a patient meets the definition of a bariatric person, the following elements are evaluated:
Body mass index
Waist circumference/girth and weight distribution
Risk factor for diseases/conditions
BMI categories
Underweight (BMI less than 18.5)
Healthy weight (BMIs 18.5 to 24.9)
Overweight (BMIs 25 to 29.9)
Obese (BMI 30 and over)
Circumference Calculation
waist measurement of greater than 40 inches in males and 35 inches in females is associated with greater health risk
Pear-Shaped
Pear-shaped body types have adipose tissue accumulated below the waist in the buttock and thigh area
These patients may have difficulty bringing their knees together while sitting and the excess weight of the lower extremities may make rolling difficult
Apple-Shaped
Apple-shaped body types have adipose tissue accumulation in the abdominal region
These patients tend to have poor endurance and usually prefer to have their head elevated as breathing may be difficult for them
Rolling, and moving from supine to seated, standing and leaning forward may be difficult due to larger abdominal mass
Bulbous Gluteal (Enlarged Buttock Region)
Bulbous gluteal body types have adipose tissue accumulation in the buttocks
This body type may cause the patient to have difficulty with lying supine
hey may also have trouble sitting and rising from sitting to standing due to the excess bulk
Anasarca
Severe Generalized Edema
usually caused by an overload of the lymphatic system
complication that may be seen in obesity
greater risk for congestive heart failure or positional respiratory distress
Predisposing Physical Conditions related to obesity
improperly use insulin
buildup of plaque in arteries
Higher triglycerides and HDL
Sleep apnea increases vessel wall stiffness
Hypoventilation leading to structurally narrowed airways
Increased asthma-related hormones
Higher cholesterol synthesis leading to increased bile production
Increased volume of gastric and uric fluid
Decreased immune response and deactivation of macrophages
Increased risks of fatal cancers
Altered cartilage and bone metabolism in all joints
Importance of knowing disease risk in obese patients:
To choose appropriate treatments and anticipate problems
Diseases seen in older population now seen in obese younger adults
The stigma of obesity can cloud real disease symptoms
medical complications of obesity
idiopathic intracranial hypertension
stroke
cataracts
coronary heart disease
pancreatitis
cancer
gynecologic abnormalities
ostearthritis
nonalcoholic fatty liver disease
GERD
pulmonary disease
Assessment Challenges for bariatric
Breath sound auscultation
Appropriately sized equipment
Cyanosis
BGL testing
Poor SPO2
By definition, abuse
is any action or inaction which jeopardizes the health, well-being, or assets of an individual.
Physical abuse
Any act or rough treatment directed toward an adult, regardless if physical injury results, including hitting, slapping, and the misuse of physical restraints.
Sexual abuse
Any sexual behaviour directed toward an adult without the adult’s full knowledge and consent, including sexual assault, sexual harassment, or the use of pornography.
Psychological or emotional abuse
Any act that may diminish an adult’s sense of identity, dignity and self-worth including humiliation, intimidation, verbal abuse, threats, infantilization, and isolation.
Medication abuse
The misuse of an adult’s medications and prescriptions including withholding medication and the misuse of chemical restraints.
Financial abuse
The misappropriation of an adult’s funds, resources, or property by fraud, deception, or coercion for purposes not intended by the owner including theft of property or personal effects, unauthorized cashing of pension cheques, selling an adult’s house or furnishings without permission, attempts to change a will, and abusing powers of attorney or property guardianship.
Violation of civil and human rights
The unlawful or unreasonable denial of the fundamental rights and freedoms normally enjoyed by adults, including the denial of information, access to communication, privacy, visitors, religious worship, health care services or the opportunity to provide informed consent to medical treatment as well as interference with the mail, restriction of liberty, or unwarranted confinement in a hospital or institution.
Active neglect
Deliberately withholding basic necessities or care.
Passive neglect
The non-deliberate non-malicious withholding of basic necessities or care because of lack of experience, information, or ability.
Self-abuse
Any self-inflicted act which may cause serious and significant harm to an adult’s health or well-being.
Self-neglect
The failure of an adult to adequately care for his or her needs such that serious and significant harm may come to his or her health, well-being, or assets.
significant challenges that we may encounter while providing care to obese:
Difficulty providing manual ventilation with a BVM due to increased airway resistance, heavy chest due to the presence of adipose tissue and extra supraglottal tissue.
Difficulty performing airway management due to distorted airway anatomy due to larger tongues, adipose tissue, and short thick necks.
An enlarged heart due to the strain that the heart must work under to provide oxygenation to the patient’s tissues.
Hypoventilation may occur due to the inability of the diaphragm to fully move down during inhalation.
Rapid oxygen deoxygenation may occur due to decreased functional residual capacity.
Thick layers of adipose tissue may result in poor visualization and palpation of veins for intravenous cannulation.
Pickwickian syndrome (obesity hypoventilation syndrome) may experience hypoxemia, hypercapnia, and polycythemia.
Laying supine may result in respiratory distress, consider sitting them up if p
When moving a bariatric patient, the following guidelines/recommendations should be considered:
Ask the patient how he or she performs the task
Use gravity whenever possible
Use equipment/assistive devices to ease the load
Additional providers may be required
Depending upon the patient’s body type, the provider may have to support the abdomen
Watch for pinch or pressure points with equipment.
Steps we can take to reduce obesity stigmas
Use people first language. Use the phrase “people living with obesity” rather than “obese people.”
Treat EVERYONE with respect and dignity.
Be aware of the bias that you have so that you can eliminate the use of negative comments and actions.
Don’t get tunnel vision. Not all medical complaints of those living with obesity are related to weight.
culture
generally refers to the customary ways of thinking and behaving and the characteristics of a particular population
It is the combination of race, ethnicity, age, gender, language, education, religion, geography and even economic status.
ethnicity
is concerned with patterns of thought and behaviour such as marriage customs, kinship organization, political and economic systems, religion, folk art, music, and the ways in which these patterns differ in contemporary societies
Cultural Competence, Humility and safety
Working with diverse cultures and understanding the role that culture plays in healing and health
Cultural competence
the ability of systems to provide care to patients with diverse values, beliefs and behaviors, including tailoring delivery to meet patients’ social, cultural, and linguistic needs
providers are encouraged to develop a respectful partnership with each client through client-focused interviewing, exploring similarities and differences between her/his own and each client’s priorities, goals, and capacities
Why is Cultural Competence Important?
Understanding the impact of a patient’s culture on their lives is important when we are trying to help them
cultural humility
being willing to accept and appreciate that we cannot possibly know everything about another’s lived cultural experiences; we are all unique and therefore have unique, complex histories related to our culture.
Developing a respectful curiosity towards each individual’s own cultural understanding
Using the knowledge gained to assist the client in their healing journey.
Cultural Safety
describes a means by which to appreciate diversity in the helping relationship. However, as compared to cultural competence, cultural safety is an end goal.
three key elements of cultural safety
cultural awareness, cultural sensitivity, and cultural safety
Cultural Awareness
Is a beginning step toward understanding that there is a difference. Many people undergo courses designed to sensitize them to formal ritual and practice rather than the emotional, social, economic, and political contexts in which people exist.
Cultural Sensitivity
Alerts practitioners to the legitimacy of difference and begins a process of self-exploration as the powerful bearers of their own life experience and realities and the impact this may have on others.
“Us versus Them” paradigm
reinforces existing power relations that are premised on inequality
It sets the norms of the dominant groups as the “normal” way to do things and then categorizes cultural minority groups as “the others”.
Describe Cultural Diversity
An important aspect of demonstrating respectful care is cultural competency
Multiculturalism
Recognizes and affirms the diversity of people living in society.
Components of Culture
Include language, customs, and material artifacts. Include shared systems of attitudes and feelings, and are learned and transmitted from generation to generation.
Acculturalism
The transfer of one culture from one group to another.
A process of change experienced by members of a minority group as they adapt to a majority group’s culture.
Assimilation
The cultural absorption of a minority group into the main cultural body.
“Colour Blindness”
In counselling, is the belief that “race should not matter” in how individuals are treated. This implies that we ignore racial differences because it should not matter. It is often confused with “race does not matter”
Cultural Barriers
Anything that prohibits or interferes with the ability of one culture to interact in another culture. Some barriers include language, beliefs, appearance, clothing, and customs.
Ethnocultural Competence
The ability to accept, accommodate, and assist people of different cultures in achieving what they desire or need. The ability to successfully communicate with people of other cultures.
Ethnic
[from Ethnos, Greek] Tribe or people with distinctive cultural identities.
Race
Categorizes people into groups based on inherited characteristics, such as skin colour, facial features, hair, etc.
Diversity
A variety, a state of being different refers to multiculturalism—the ideology that includes acceptance of people of a variety of cultural backgrounds.
Prejudice
Pre-judging; making a decision before becoming aware of, for example, relevant facts about a case, event, or person.
Discrimination
The behaviour of treating people unequally.
Stereotype
he generalization of existing characteristics to reduce complexity.
Royal Proclamation, 1763
established a treaty making process between the Crown and the Indian people which recognizes the existence of Indigenous rights such as rights to land—to hunt, fish and gather, self-government, and others
Inuit
generally applies to those Indigenous peoples who occupy the Arctic.
Métis
mixed European and First Nations ancestry
they are not defined by the Government, but rather are self-identified.
Indigenous beliefs and values
developed in response to ecologically specific rhythms, patterns and events derived from their experiences on their traditional territories
Communications challenges related to culture: ATTITUDES TOWARD FEELINGS AND EMOTIONS
How acceptable is it to have feelings and express them? What feelings can or cannot be expressed (e.g., anger, joy)? How are they expressed?
Communications challenges related to culture: BODY LANGUAGE, PERSONAL DISTANCE AND USE OF TOUCH
Is it acceptable, for example, to bow, break bread, make eye contact, greet, place chairs in a certain way, or shake hands?
Communications challenges related to culture: FORMING RELATIONSHIPS
What period of time is considered appropriate to develop rapport, make friends, or discuss a personal issue?
Communications challenges related to culture: GENDER ROLES AND SEXUAL ORIENTATION
What roles do men and women play? Are they equitable? How are men and women expected to relate to each other? How are gays and lesbians viewed? What is the relationship of gays and lesbians to the larger social group?
Communications challenges related to culture: AGE, FAMILY AND SOCIAL GROUP
What privileges or limits do people have at certain ages? What is the role of the family? Who has what responsibilities within the family? How do family members interact with each other? How do they interact with the larger social group? What is the role of the social group? What are the components of the group? How are group members expected to relate to one another?
Communications challenges related to culture: PERSONAL AND SOCIAL BOUNDARIES
What rules define what is private and what is public? What rules govern what may or may not be discussed, and with whom and in what context issues may be discussed? For example, sexuality may be openly discussed with members of both sexes within a family, but not with members of the same sex outside the family.
Communications challenges related to culture: VALUES
What things are valued (e.g., education, material goods, money, relationships, success at work)? To what extent are they valued? For example, is a PhD considered the ultimate accomplishment? If yes, why? Is it because a group has been marginalized that its members feel the need to have their children succeed?
Communications challenges related to culture: TIME
What kind of timekeeping is valued (e.g., punctuality, flexibility)?
Communications challenges related to culture: LANGUAGE, INCLUDING INTONATION AND USE OF HUMOUR AND METAPHORS
Why are certain tones stressed? Why is something funny? Why are certain words or descriptions chosen? Why are certain images or references used?
top 10 problems faced by immigrants
Language barriers Employment opportunities Housing Access to local services Transportation issues Cultural differences Raising children Prejudice Isolation The weather
Transmission oximetry
deploys the LED and photodetector on opposite sides of a tissue bed (e.g., digit, nares, and ear lobe) such that the signal must traverse tissue
Reflectance oximeters
position the LED and photodetector side by side on a single surface and can be placed in anatomic locations without an interposed vascular bed (e.g., forehead)
According to Saskatchewan College of Paramedic, Paramedic Clinical Practice Protocols, SPO2 monitoring should be performed on the following patients:
Patients in respiratory distress.
All critically ill patients.
Patients that require oxygen concentrations of 40% or greater.
Stable patients at risk from sudden deterioration.
Patients that are being intubated or suctioned.
Pulse oximeters have a number of important physiologic and technical limitations that influence bedside use and interpretation
sensor location
motion
signal degradation
physiologic range
dyshemoglobinemia
intravenous dye
