Hx, Exam, and documentation Flashcards
assessment step must include what two things?
ASA classification and diagnosis code
acute vs chronic pain
acute less than 3 months - 6 months
chronic pain greater than 3-6 months
severity level
no 0
mild less than 4
moderate 5/6
severe over 7
normal BP
120/80
elevated BP
120-129/ under 80
HTN stage 1
HTN stage 2
stage I 130-139/ 80-89
stage II over 140 / over 90
adolescence HR, RR, BP, temp
55-105
12 to 20
100 to 120 mmHg
98.6
early adult HR, RR, BP, temp
(20 - 40 years) 70 bpm 16 to 20 120 to 80 mmHg 98.6
middle adult HR, RR, BP, temp
41-60 70 bpm 16-20 120 - 80 mmHG 98.6
late adult HR, RR, BP, temp
depends on pt. physical and health status
papule vs macule
sessile?
papule - rounded
macule - flat
sessile (broad) vs narrow (pedunculated)
ASA I
normal / healthy patient
ASA II
mild systemic disease
examples: current smoker, social alcoholic drinker, pregnant, obesity (30
ASA III
severe systemic disease
functional limitations
one or more moderate/ severe diseases
examples: poorly controlled DM/ HTN, COPD, morbid obesity like BMI over 40, active hepatitis,alcohol dependence or abuse, pacemaker, ESDR with diaylsis, premature infant
ASA IV
constant threat to life
ASA V
not expected to survive without the operation
SOAP note
subjective
objective
assessment
plan
mallampati score
I-IV
Class I: Visualization of the soft palate, fauces, uvula and pillars. No anticipated difficulty. Class II: Visualization of the soft palate, fauces, uvula. No anticipated difficulty. Class III: Visualization of the soft palate and base of the uvula. Anticipate moderate difficulty. Class IV: Soft palate is not visible. Anticipate severe difficulty
sequence to present patient
- age
- gender
- todays planned procedure
- ASA classification
- significant health hx
- dx, meds. controlled?
- any lab values - reported vital signs
- present allergies
- dx of tooth
include intra oral and extra oral exam before this - tx plan of tooth including anesthetics use
procedure code for nitrous
how to pay?
D9230
must pay upfront - 54 dollars
equipment for nitrous
check pressure gauges of each
sign out the tank
connect white house to scavenger system (yellow hose) – turn on and make sure suction is good
connect nasal hood to each hose and put the nasal hood into the scavenger hub
oxygen flow rate on the nitrous machine?
%?
6 L/min
at 100% oxygen
what color is oxygen?
what color is nitrous?
oxygen = green nitrous = blue
do not exceed what ratio with the use of nitrous?
no more than 50%
dial in the middle of the machine
after the procedure adjust flow rate? WHY?
yes back to 100% oxygen for at least 5 minutes
*in order to AVOID diffusion hypoxia
make sure pressure gauges read what after use?
0
