PHYSICAL ASSESSMENT: A REFRESHER FOR PHARMACISTS

Transcription

1 PHYSICAL ASSESSMENT: A REFRESHER FOR PHARMACISTS FRIDAY/3:30-5:00PM ACPE UAN: L01-P 0.15 CEU/1.5 hr Activity Type: Application-Based Learning Objectives for Pharmacists: Upon completion of this CPE activity participants should be able to: 1. Perform physical assessments in practice with enhanced confidence and accuracy. 2. Interpret physical assessment results and their implications on patient care. 3. Compose appropriate care plans for patients based on physical assessment results. Speaker: Ellina Seckel, PharmD, BCACP Dr. Ellina Seckel is the Associate Chief of Pharmacy, Ambulatory and Specialty Care at the Madison VA. Seckel received her PharmD degree from the University of Nebraska Medical Center. She completed PGY1 ambulatory care and PGY2 pharmacy administration residencies at the Madison VA. In her current role, Seckel is responsible for 25 pharmacists in more than 20 clinics across multiple departments. She also maintains her own patient care practice, and provides clinical support to 2 primary care teams. Last year, Seckel was recognized as a national VA Gold Status Fellow for outcomes showing the impact of using pharmacists to open access to care. In addition to VA work, Seckel enjoys being highly involved in ASHP. Seckel is the current Vice Chair for the SAG on Clinical Practice Advancement, ASHP PAI workshop presenter in South Dakota, Missouri, Pennsylvania, and Florida, Midyear Networking Session facilitator, and is in the 2017 Pharmacy Leadership Academy class. Speaker Disclosure: Ellina Seckel reports no actual or potential conflicts of interest in relation to this CPE activity. Off-label use of medications will not be discussed during this presentation.

2 Physical Assessment: A Refresher for Pharmacists Ellina Seckel, PharmD, BCACP Disclosure Dr. Seckel reports no actual or potential conflicts of interest associated with this presentation Represent myself, not my employer 1

3 Learning Objectives Upon successful completion of this activity, participants should be able to: - Perform physical assessments in practice with enhanced confidence and accuracy - Interpret physical assessment results and their implications on patient care - Compose appropriate care plan for patients based on physical assessment results Pharmacist Practice Advancement USA Today: VA Treats Patients Impatience with Clinical Pharmacists 2

4 Approaching the Patient Introduce yourself (to everyone in the room) Sit down Don t interrupt (12 seconds) 3

5 2/5/18 General Appearance 4

6 2/5/18 Scary Breathing Scary Colors 5

7 2/5/18 Scary Neurologic Symptoms Blood Pressure 6

8 2/5/18 Heart Rate Fast or Slow Regular or irregular Proper Cuff Size is Important 7

9 Proper Positioning is Important 8

10 Bell/Diaphragm The chest-piece usually consists of two sides that can be placed against the patient for sensing sound; a diaphragm (plastic disc) or bell (hollow cup). The bell transmits low frequency sounds, while the diaphragm transmits higher frequency sounds. Low frequency intestinal sounds and often murmurs High frequency lung sounds Performing a Manual Blood Pressure Exam Position the patient - One arm resting on table at about heart level - Feet flat on floor - Butt to back of chair Tell the patient - I won t talk to you, you don t talk to me - Take a few deep breaths and relax Place cuff on corresponding bare arm, cuff should be ~2-3 inches above antecubital fold Place diaphragm over artery - NOT under cuff Pump up to ~20-30 mmhg above patient s normal systolic Release valve slowly First sound you hear = systolic Sound disappears = diastolic 9

11 Measuring Orthostatic BP 1. Have the patient lie down for 5 minutes. 2. Measure blood pressure and pulse rate. 3. Have the patient stand. 4. Repeat blood pressure and pulse rate measurements within 1 minute. A drop in BP of 20 mm Hg, or in diastolic BP of 10 mm Hg, orexperiencing lightheadedness or dizziness is considered abnormal. PRACTICE! 10

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13 2/5/18 Normal Heart Sounds Where to Put Your Listener: APT-M 12

14 Listening to Normal Sounds order=1&courseid=22 Murmurs Innocent (normal heart) - Common in newborns and children - Occurs when blood flows more rapidly than normal through the heart; i.e. w/ fever or pregnancy - seid=22 Abnormal - Congenital heart disease in children - Acquired heart valve problems 13

15 Abnormal Murmurs Stenosis - courseid=26 (mild aortic stenosis) - courseid=26 (severe aortic stenosis) Regurgitation - courseid=26 (mitral regurgitation) Describing Heart Murmurs How loud is it? - Rated on a scale from 1 to 6, with 6 being the loudest When does it occur? What affects the sound? (position, exercise) Where is it best heard? Does it radiate? What is the pitch? - high-, medium- or low-pitched 14

16 2/5/18 Performing the Exam Stethoscope always UNDER shirt/gown - Do not listen over clothing Tell patient to breath in and out normally In through nose, out through mouth Place stethoscope APT-M Keys to performing a sensitive yet thorough exam: - Explain what you're doing (and why) before doing it - Expose minimum amount of skin necessary Examining heart and lungs of female patients: - Ask patient to remove bra prior - Enlist patient's assistance, asking them to raise their breast to a position that enhances your ability to listen to and palpate the heart Don t rush, be conscientious PRACTICE! 15

17 CHF - Volume Overload Shortness of breath Weight gain Crackles upon auscultation Hypertension Edema Third heart sound Ascites Abnormalities in renal function Lower extremity edema 16

18 Grading Lower Extremity Edema 17

19 Inspiration and Expiration Look and Listen 18

20 2/5/18 Look Lips Body position Accessory muscle use The Look of COPD 19

21 Pattern of Breathing I:E Ratio Normal Less than 1:2 COPD 1:3 or greater 20

22 Where to Put Your Listener Things to Listen For Wheezing Crackles Diminished breath sounds Asymmetric sounds 21

23 Performing the Lung Exam Stethoscope always UNDER shirt/gown - Do not listen over clothing Ask patient to lean forward slightly Ask patient to take a deep breath in and out - In through nose, out through mouth Move stethoscope from side to side at same level to compare 22

24 ADA Guidelines Physical examination - Height, weight, and BMI; growth and pubertal development in children and adolescents - Blood pressure determination, including orthostatic measurements when indicated - Fundoscopic examination - Thyroid palpation - Skin examination (e.g., for acanthosis nigricans, insulin injection or infusion set insertion sites) - Comprehensive foot examination Inspection Palpation of dorsalis pedis and posterior tibial pulses Presence/absence of patellar and Achilles reflexes Determination of proprioception, vibration, and monofilament sensation Neuropathy Numbness - My feet are numb and feel dead - I don t feel pain in my feet, even when I have blisters or injuries - I m unsteady when I walk Tingling - My feet tingle - I feel pins and needles Pain or Increased Sensitivity - I have burning, stabbing, shooting pain in my feet - It hurts to have bed covers on my feet 23

25 Neuropathy Long-standing elevated blood sugars cause nerve damage ADA recommends comprehensive DFE every year - Shoes and socks should be removed at every patient visit for diabetes Screening for loss of protective sensation Diabetic Foot Exam (DFE) Inspection - Toenails, infections, ulcers, cuts, callous, look in between toes - Can patient look at own feet? Palpation of dorsalis pedis and posterior tibial pulses Determination of monofilament sensation 24

26 Performing the Inspection/Palpation Exam Gloves will limit sensation - May make patient feel as if you think they are too gross to touch Please do use gloves if hygiene is an issue or any abrasions, cuts, ulcers, etc Always use hand sanitizer/wash hands Goal of palpation is to assess pattern over time Dorsalis pedis (on top) Posterior tibial (inside) Palpation 25

27 Performing the Monofilament Exam Request patient removes shoes/socks on both feet - They may need assistance 10g monofilament First demonstrate on patient s arm - It s going to feel like this Instruct patient to close eyes Patient to verbalize location when feel something Discard monofilament after each use 26

28 PRACTICE! 27

29 Lipohypertrophy Lipoatrophy 28

30 Acanthosis Nigricans 29

31 Ear Pearly grey, shiny, translucent w/ no bulging or retraction Smooth consistency Landmarks Cone shaped light reflection Short process, malleus and umbo clearly visible 30

32 Performing the Ear Exam Turn otoscope on (light should shine) Twist the largest otoscope cap on Adults: pull top of ear up and back - Don t pull too hard!! Slowly enter otoscope into ear - Don t rush!! Don t go too far!! Rest hand on side of patient s head Look for pearly ear drum 31

33 Nose 32

34 Performing the Nose Exam Ask patient to lean head back Gently push top of nose back Use otoscope (new cap) to shine light Look for obstructions Throat 33

35 Throat 34

36 Performing the Throat Exam Ask patient to lean head back slightly Ask patient to stick tongue out and say Ahhhh May use tongue depressor Use otoscope to shine light Look for pink mucosa vs red, inflamed tissue or white abnormalities PRACTICE! 35

37 Take Home Points Pharmacists play an important role in physical assessment Practice! Look for abnormalities and changes over time Be gentle and respectful Questions? Let s Chat! ellinaseckel@gmail.com 36