•PASS YOUR

PREVIOUS/NEW
RECITATION
CARDS
 HEALTH CARE I CLASS
SCHEDULE
• FEB 21
– SUBMISSION OF ASSIGNMENT 3.1 AND 3.2
(handwritten and by partner):
• Partner 1: 10 leading causes of morbidity in the
Philippines AND Recent epidemic diseases in the
Philippines
• Partner 2: 10 leading causes of mortality in the
Philippines AND Recent pandemic diseases in the
world
– LECTURE 2: COMMON
DISEASES/DISORDERS AND TREATMENT
INTRODUCTION
TO CLINICAL
SERVICE

Ruby Ann S. David, RND

 INTERDISCIPLINARY
TEAMWORK
• Different professional team that provides
“direct” care:
– Doctors
– Nurses
– Pharmacists
– Dietitians
– Medical technologist
– Administrative
• Ward clerk/secretary – encoder
 Hierarchy of physicians
• RANK THE PHYSICIANS IN
ASCENDING ORDER OF
SUPERIORITY(1 as lowest)
• ____ THE ATTENDING
PHYSICIAN
• ____ THE RESIDENT
• ____ THE INTERN
• ____ THE FELLOW
 • 1ST year resident
• works in a temporary
Hierarchy of
position as an OJT trainee;
physicians similar to an
THE apprenticeship.
INTERN • Are not yet doctors
 • aka house officer / senior house officer
in UK)

Hierarchy of • person who has received a medical

degree (MD) and who practices
physicians medicine under the supervision of
fully licensed physicians, usually in a
THE hospital or clinic.
RESIDENT • a member of the house staff who has
completed at least 1 year of
postgraduate medical education.
• Doctor who’s beginning their post
graduate training after medical
school
– may follow the internship year or include
the internship year as the first year of
residency.
 • Fellowship is the period of medical
training in a relevant sub-specialty,
Hierarchy of and during this time the physician
physicians is known as a “fellow”.
• a doctor who goes beyond their
THE typical expected residency
FELLOW training into a subspecialty that
allows them to obtain a
specialized certificate in the area
that they're focusing on.
– may or may not be active members of a
team (house staff) and may not be
obligated to teach medical students
 • called simply “The Attending”; staff
physician practicing his/her specialty
• All major therapeutic decisions
Hierarchy of made about the care of these patients
physicians are ultimately passed by the
THE attending.
– is morally and legally responsible for the
ATTENDING care of all patients whose charts are marked
PHYSICIAN with the attending’s name.
• has completed postgraduate
education and is now a member of
the teaching faculty.
– this person is responsible for teaching and
evaluating house staff and medical
students.
 ROUNDS
• Rounds are meetings of all members of the
service for discussing the care of the patient.
These occur daily and are of three kinds:
– MORNING ROUNDS (work rounds)
– ATTENDING ROUNDS
– EVENING ROUNDS (check-out rounds)
 ROUNDS
• MORNING ROUNDS or WORK ROUNDS
• take place anywhere from 6:30 to 9:00 AM on most
services
• and are attended by residents, interns, and students.
• time for discussing:
– what happened to the patient during the night
– the progress of the patient’s evaluation and/or therapy
– the laboratory and radiologic tests to be ordered for the patient
– talking with and evaluating the patient
 ROUNDS
• ATTENDING ROUNDS
• These vary greatly depending on the service and on the nature of
the attending physician. The same people who gathered for
morning rounds will be here, with the addition of the attending.
• significant new laboratory, radiographic, and physical findings
are described (often by the student caring for the patient); and
new patients are formally presented to the attending (again, often
by the medical student).
– most important priority for the student on attending rounds is to know the
patient.
 ROUNDS
• EVENING ROUNDS or Check-out rounds
• between 3:00 and 7:00 PM on most days
• the patients are seen by the entire team a second time are
typically done only on surgical services and pediatrics.
• Other services, such as, medicine, often will have check-out
with the resident on call for the service that evening
(sometimes called “card rounds”).
• Orders are again written
• laboratory work desired for early the next day is requested
• list of work to be done that night and a list of patients who need
close supervision.
 ROUNDS
• BEDSIDE ROUNDS
• the same as any other rounds except that tact is at a premium
• patients whose case presentations were made at the bedside
which were usually made in a conference room.
 CLINICAL WRITE-UPS
• Identification
– Name, age, sex, referring physician,
and the informant (eg, patient,
relative, old chart) and the informant’s
reliability
• chief complaint
– State, in patient’s own words, the
current problem
• history of the present illness
(HPI)
• past medical history
– Current medications (Rx or OTC);
vitamins, and herbals; allergies;
surgeries; hospitalizations; blood
transfusions; other illnesses
• family history
• psychosocial history
– Stressors (financial, significant
relationships, work or school, health)
and support (family, friends,
significant other, clergy); life-style
risk factors (alcohol, drugs, tobacco,
caffeine; diet; and exposure to
environmental agents; and sexual
practices)
• Review of system (ROS)
• physical examination
• Database: laboratory and x-ray data
• Problem-list
• Assessment: clinical impression
• Plan: Additional laboratory tests,
medical treatment, consults, etc.
 Review of systems (ROS)
• General: Weight loss, weight gain,
fatigue, weakness, appetite, fever,
chills, night sweats
• Skin: Rashes, pruritus, bruising,
dryness, skin cancer or other
lesions
• Head: Trauma, headache,
tenderness, dizziness, syncope
• Eyes: Vision, glasses, last
prescription change, photophobia,
blurring, diplopia, spots or floaters,
inflammation, discharge, dry eyes,
excessive tearing, history of
cataracts or glaucoma
• Ears: Hearing changes, tinnitus,
pain, discharge, vertigo, history of
ear infections
• Nose: Sinus problems, epistaxis,
obstruction, polyps, changes in or
loss of sense of smell
• Throat: Bleeding gums; dental
history (last checkup, etc);
ulcerations or other lesions on
tongue, gums, buccal mucosa
• Respiratory: Chest pain; dyspnea;
cough; amount and color of
sputum; hemoptysis; history of
pneumonia, influenza, etc.
 Review of systems (ROS)
• Cardiovascular. Chest pain,
orthopnea, dyspnea on exertion,
paroxysmal nocturnal
dyspnea,murmurs, palpitations
• Gastrointestinal. Dysphagia,
heartburn, nausea, emesis,
hematemesis, indigestion, abdominal
pain, diarrhea, constipation, melena,
hemorrhoids, change in stool shape
and color, jaundice, fatty food
intolerance, flatulence
• Gynecologic: abortions; age at
menarche; last menstrual period
(frequency, duration, flow);
dysmenorrhea; spotting; menopause
• Gynecologic: contraception; sexual
history, frequency of intercourse,
number of partners, sexual orientation
and satisfaction, and dyspareunia.
• Genitourinary. dysuria; hematuria;
polyuria; nocturia; discharge; sterility;
impotence; polydipsia; and sexual
history
• Endocrine. Polyuria, polydipsia,
polyphagia, temperature intolerance,
glycosuria/glucosuria, hormone
therapy, changes in hair or skin texture
• Musculoskeletal. Arthralgia, arthritis,
joint swelling, redness, tenderness,
back pain, musculoskeletal trauma,
gout
 PHYSICAL EXAMINATION
• Physical assessment techniques:
– INSPECTION  examination to detect significant signs that
involves senses of sight, smell and hearing. (begins at the 1st
encounter) **vital signs/HEENT etc
– PALPATION  examining the body by using sense of touch to
assess the characteristics of body structures. (requires positioning:
erect, sitting, prone, supine/dorsal, dorsal recumbent, lithotomy,
sim’s, knee-chest/genupectoral) **vital signs, lymph
nodes/HEENT/breast etc
– PERCUSSION  tapping of a particular area of the body with the
fingertips or a percussion hammer in order to elicit the character and
density of the sound in the underlying tissue. **chest/back (signs of
stenosis) etc
– AUSCULTATION  listening to the sounds created in various
body organs to detect variations/abnormalities.
**ROS  interviewing and observation (signs and symptoms)
 Physical examination equipments
• Thermometer • Watch
• Stethoscope • Gloves and lubricant
• Sphygmomanometer • Reflex hammer
• Otoscope • Drapes and patient’s
• Ophthalmoscope gown
• Penlight • Weighing scale
• Tongue depressor • Height scale
• Tape measure • Eye charts
 CHARTWORK
• Admit: Admitting team, room
number
• Attending: The name of the
attending physician, the person
legally responsible for the
patient’s care. Also include the
resident’s and intern’s names.
• Diagnosis: List admitting
diagnosis or procedure if post-
op orders.
• Condition: Stable, critical, etc
• Vitals: Determine frequency
of vital signs (temperature,
pulse, blood pressure, central
venous pressure, pulmonary
capillary wedge pressure,
weight, etc)
• Activity: Specify bedrest, up
ad lib, ambulate qid,
bathroom privileges, etc
• Allergies: Note any drug
reactions or food or
environmental allergies.
 CHARTWORK
• Nursing Procedures
– Bed Position. Elevate head of
bed 30 degrees, etc
– Preps. Enemas, scrubs,
showers
– Respiratory Care.
– Dressing Changes, Wound
Care. Change dressing bid,
etc
– Notify House Officer If.
Temperature >101°F, BP
<90 mm Hg, etc
• Diet: NPO, clear liquid,
regular, etc
• Ins and Outs: Refers to all
“tubes” a patient may have.
– Record Daily I&O.
• IV Fluids. Specify type and rate.
• Drains. Suctions
• Medications: (eg, diuretic,
antibiotics, hormones, etc) and
symptomatic drugs as needed (eg,
pain medications, laxatives,
“sleepers”). Include dose frequency
and special instructions, ie, take
with food.
• Labs: ECGs, x-rays, nuclear
scans, consultation requests, etc.
 Clinical notes
• Problem-oriented progress notes (list more than 1 problem and its
corresponding SOAP)
• SOAP
– Subjective
• How the patient feels, any complaints
– Objective
• How the patient looks
• Vital signs
• Physical examination
• Laboratory data, etc
– Assessment: (for each problem)
• Evaluation of the data and any conclusions that can be drawn
– Plan: (for each problem)
• Any new lab tests or medications
• Changes or additions to orders
• Discharge or transfer plans
 APPLYING NUTRITION CARE
PROCESS in SOAP
• NUTRITION
ASSESSMENT (ABCD)
• NUTRITION
DIAGNOSIS (analysis,
interpretation)
• NUTRITION CARE
PLAN
• NUTRITION
MONITORING AND
EVALUATION
APPLYING NUTRITION CARE
PROCESS in SOAP
– Subjective
• ________________________
• ________________________
– Objective
• ________________________
• ________________________
– Assessment:
• ________________________
• ________________________
– Plan:
• ________________________
• ________________________
• ________________________
 PRECAUTIONS in writing
nutrition care plan
• qd = daily (this is a dangerous abbreviation and
should not be used
• q6h = every 6 h
• qid = four times a day. (Note that qid and q6h are
NOT the same orders: qid means that the
medication is given four times a day while awake
(eg, 8 AM, 12 noon, 6 PM, and 10 PM); q6h means
that the medication is given four times a day but by
the clock (eg, 6 AM, 12 noon, 6 PM, 12 midnight).
 Dangerous Practices
• 1. NEVER use a trailing zero.
• Correct: 1 mg
• Dangerous: 1.0 mg. If the decimal is not seen, a 10-fold
overdose can occur.
• 2. NEVER leave a decimal point “naked.”
• Correct: 0.5 mL
• Dangerous: .5 mL. If the decimal point is not seen, a 10-
fold overdose can occur.
• 3. NEVER abbreviate a drug name because the
abbreviation may be misunderstood or have multiple
meanings.
 Dangerous Practices
• 4. NEVER abbreviate U for units as it can easily
be read as a zero, thus “6 U regular insulin” can be
misread as 60 units. The order should be written as “6
units regular insulin.”
• 5. NEVER use qd (abbreviation for once a day).
When poorly written, the tail of the “q” can make it
read qid or four times a day.
 SENTINEL AND ADVERSE
EVENTS
• SENTINEL EVENT • ADVERSE EVENT
– Unexpected occurrence – Unforeseen and/or
involving death or undesirable occurrence
serious injury or risk. involving the health of a
patient
 HOSPITAL EMERGENCY
CODES
• Use to alert staff to various emergency
situations. (color or number)
• Why need for code?
– It is intended to convey essential information
quickly and with a minimum of misunderstanding
to staff, while preventing stress or panic among
visitors to the hospital.
 HOSPITAL EMERGENCY
CODES
• Every institution have their own code standards:
• Code blue  cardiac arrest; requires immediate CPR
(code white for pediatric patient)
• Code 99 and code 45 (similar to code blue and white)
• Code red  fire/ total evacuation
– Fire: Dr. Fire, Dr. Pyro, Dr. Firestone
• Code triage  patient influx