Trauma Patient Medical Record

Transcription

1 Summarize patient information when entering Emergency Department (ED): Name: Date: p: Trauma Patient Medical Record Glasgow Coma Scale Vital Signs What score do you give the patient? The patient Blood Pressure = is moaning with eyes closed, but he opens them to painful stimuli and also moves his extremities to painful stimuli. Check the numbers you think apply. / Score Pulse = Eye opening spontaneously 4 to speech 3 per minute to pain 2 Skin = Respiration = per minute Temperature = degrees F Motor response obeys commands 6 localizes to pain 5 withdraws from pain 4 Can pulse be obtained carotid, radial, flexion to pain 3 extension to pain 2 Verbal response orientated 5 confused 4 inappropriate 3 incomprehensible 2 What is the total score for this patient? Maximum score 15 femoral and top of both feet? YES NO If no, record areas where can pulse NOT be obtained: Why can pulse not be obtained from an area? Is this patient on any medications administered or taken prior to arrival? YES NO

2 If YES, what class of drugs? Glasgow Coma Scale Patient is sedated. Check the numbers you think apply. Summary of Tests Summarize the results of the x-rays: Score Eye opening spontaneously 4 to speech 3 to pain 2 Summarize the results of the CT scan: Motor response obeys commands 6 localizes to pain 5 withdraws from pain 4 flexion to pain 3 Summarize the results of the FAST scans: extension to pain 2 Verbal response orientated 5 confused 4 inappropriate 3 Record any medications and the amounts given: incomprehensible 2 What is the total score for this patient? Maximum score 15 Record the results of the blood test: Trauma Patient Medical Record Serum potassium Serum sodium Reading Normal Patient Blood Urea Nitrogen CO2 (carbon dioxide) Creatinine Glucose Serum chloride 7-20 mg/dl mmol/l mg/dl mg/dl mmol/l meq/l meq/l Prolactin level for this patient: Results of the toxicology (urine) screening: Drugs detected = List at least three reasons patients should not take medications if they are not prescribed by a doctor:

3 List at least three reasons patients should not take medications if they are not prescribed by a doctor: Outcomes: Summarize what happened with the female patient including the outcomes of investigation: Summarize what happened with the male patient including the outcomes of investigation: List three ways patients can take personal responsibility to prevent prescription drug abuse:

4 Virtual Aortic Aneurysm 1) What is the aorta? What are the four sections of the aorta? Label them on the diagram. Name: 2) What is an aneurysm? Where is our patient s aneurysm? 3) Complete the S and O for your patient: 4) How large is Mr. Bishop s aneurism? Should he have surgery? Normal Abdominal Aorta 5) What do you think cauterize means? 6) Why don t we just cut through the abdominal muscles from side to side? 7) What do you think retract means? Why is retraction necessary? 8) Why do we clamp the iliac arteries? 9) Why do we clamp the aorta below the renal arteries? 10) What is atherosclerosis? 11) Why would we use permanent sutures? 12) Why do we close the aorta around the graft? 13) Why do we use staples instead of the sutures? 14) Would you want to be a cardiothoracic surgeon? Why or why not?

5 Name Date Period Knee Anatomy 1. Label the following diagrams of the knee and the materials for the total knee replacement. Virtual Knee Video Worksheet 2. Who is the patient in the virtual total knee replacement surgery? 3. Who checks the vital signs once the patient is in the operating room? 4. Examine the x- rays. What condition does the patient have that would cause him to have the surgery? 5. What step is taken to prevent wrong surgeries? 6. Why is the tourniquet applied? 7. Why does the surgical area need to be cleaned with betadine? 8. What do you think cauterize means? 9. At what angle does the leg need to be to fully expose the bones of the knee? 10. What are the three bones of the knee joint? 11. With what part of the body is the tibial cutting jig aligned? 12. What kind of cut is used on the femur? patella?

6 13. When placing components on the knee to check for sizing, what order is used? 14. Why is the plastic spacer used? 15. How long does the cement take to harden once the permanent components of the knee are in place? 16. What is the first layer sutured back together after the permanent components are in place? 17. How long does the average patient remain in the hospital? Analysis Questions 1. What is the primary cause of the pain experienced by patients recommended for total knee replacement surgery? a. the existence of bone spurs in the knee b. pulled muscles or tendons c. hairline fractures of the femur and tibia d. lack of cartilage between the bones of the knee 2. How does the surgeon check the alignment of the femoral prosthetic component before using the bone saw? a. by measuring the angle between the end of the femur and the hip bone b. by drilling a hole in the femur and inserting an alignment device c. by attaching a cutting jig d. by checking sight lines between the femur and tibia 3. How does the surgeon check the alignment of the tibial prosthetic component before using the bone saw? a. by measuring the angle between the end of the tibia and the ankle b. by drilling a hole in the tibia and inserting an alignment device down the center of the bone c. by attaching an alignment jig that is lined up with the big toe and the highest point of the tibia d. by checking sight lines between the femur and tibia 4. Which of the knee bones are cut and shaped during total knee replacement? a. femur, tibia, patella b. femur and tibia c. tibia and patella d. femur and patella 5. Why does the surgeon use trial components? a. to make sure the holes drilled in the bones are in the right places b. to test the fit and range of motion allowed by the components without wasting real ones c. to make certain that the patient doesn t react to the materials used in the real components d. to make certain the bones are cut correctly 6. Why is the knee bent side to side during the test of the trial components? a. to add an extra range of motion to the new knee components b. to test the anesthesia to see if the patient is waking up c. to make certain that there is not too much space between components d. to make certain the bones are cut correctly 7. The excess cement that might exist around the permanent components of the knee is: a. cut from around the components and thrown away b. added to the cement already under the components to make sure they stay in place c. saved for the next total knee replacement surgery d. put between the components to make certain no extra movement takes place 8. Physical therapy after total knee replacement surgery typically lasts: a. 1-2 weeks b. 3-8 weeks c weeks d weeks