Hints To Malignant Melanoma

 

HINTS TO MALIGNANT MELANOMA

Even if you have carefully practiced sun safety all summer, it's important to continue being vigilant about your skin in fall, winter, and beyond. Throughout the year, you should examine your skin head-to-toe once a month, looking for any suspicious lesions. Self-exams can help you identify potential skin cancers early, when they can almost always be completely cured.

First, for a successful self-exam, you obviously need to know what you're looking for.  As a general rule, to spot either melanomas or non-melanoma skin cancers (such as basal cell carcinoma and squamous cell carcinoma), take note of any new moles or growths, and any existing growths that begin to grow or change significantly in any other way.  Lesions that change, itch, bleed, or don't heal are also alarm signals.

It is so vital to catch melanoma, the deadliest form of skin cancer, early that physicians have developed two specific strategies for early recognition of the disease: the ABCDEs and the Ugly Duckling sign.  

A- ASYMMETRY

If you draw a line through this mole, the two halves will not match.

B - Border

The borders of an early melanoma tend to be uneven. The edges may be scalloped or notched.

C - Color

    Having a variety of colors is another warning signal. A number of different shades of brown, tan or black could appear. A melanoma may also become red, blue or some other color.

D - Diameter

Melanomas usually are larger in diameter than the size of the eraser on your pencil (1/4 inch or 6 mm), but they may sometimes be smaller when first detected.


 

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5 Areas for Listening to the Heart

  

5 AREAS FOR LISTENING TO THE HEART

There are five important areas used for listening to heart sounds. These are: Aortic area, Pulmonic area, Tricuspid area, Mitral Area (Apex), ERB's point.

A common notation for a sound heard at an auscultatory site is to use the first initial of the site and the number 1 or 2 to describe the first or second heart sound respectively. Thus T1 denotes the first heart sound at the tricuspid area; M2 denotes the second sound at the mitral area, etc. In general both the first and second sounds can be heard at all sites, but some pathologic and normal sounds are heard best at one site or another. Gallops are often best heard at the apex as is M1 and T1. T1 is slightly louder at the tricuspid position. The A2 and P2 are best heard at the aortic and pulmonic sites respectively with the A2 sound being the major component of the second sound heard at the apex. 

The first heart sound consists of four components. The most notable components are two large, high amplitude deflections, M1 - related to mitral valve closure - and T1 - related to tricuspid valve closure. The second heart sound consists of high frequency deflections relating to the closure of aortic and pulmonic valves. Transit time through the lungs causes a delay between generation of these two sounds causing the aortic sound to be noted some 40-85 milliseconds before the pulmonic sound (A2 and P2 respectively). Variability of the pulmonary vascular impedance with respirations causes prolongation of the time period between A2 and P2 with inspiration and a decrease in the interval with expiration.

Sounds related to mitral and tricuspid valves (atrioventricular valves) opening and closing can de defined relatively easily at the apex. At this point, opening snaps and nonejection sounds can also be heard. Sounds related to the second heart sound include the opening and the closing of aortic and pulmonic valves (semilunar valves), and early ejection clicks.
Two low frequency deflections are associated with these two deflections and are largely inaudible to the human ear. M1 and T1 are usually only separated by 20 to 30 milliseconds except in a few cases where unusual splitting of the two sounds are noted.

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Tools On Physical Assessment

 

TOOLS ON PHYSICAL ASSESSMENT

Inspection/Observation

    Observe the overall appearance of the child: alert, orientated, active/hyperactive/drowsy, irritable.
    Colour(centrally and peripherally): pink, flushed, pale, mottled, cyanosed , clubbing
    Respiratory rate, rhythm and depth (shallow, normal or deep)
    Respiratory effort (Work of Breathing WOB): mild, moderate, severe, inspiratory: expiratory ratio, shortness of breath
    Use of accessory muscles (UOAM): intercostal/subcostal/suprasternal/supraclavicular/substernal retractions, head bob, nasal flaring
    Symmetry and shape of chest
    Tracheal position, tracheal tug
    Audible sounds: vocalisation, wheeze, stridor, grunt, cough - productive/paroxysmal
    Monitor for oxygen saturation

Auscultation

    Listen for absence /equality of breath sounds
    Auscultate lung fields for bilateral adventitious noises e.g.: wheeze, crackles etc

To assess bowel sounds, vascular sound; in pregnancy, FHT’s are heard.

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Palpation

    Bilateral symmetry of chest expansion
    Skin condition – temperature, turgor and moisture
    capillary refill (central/peripheral)
    Fremitus (tactile)
    Subcutaneous emphysema

Percussion

To identify organ size and detect fluid, gas or masses.

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Secondary Assessment History

SECONDARY  ASSESSMENT HISTORY

AMPLE history.

A    Allergies
M   Medications (Anticoagulants, insulin and cardiovascular medications especially)
P    Previous medical/surgical history
L    Last meal (Time)
E    Events /Environment surrounding the injury; ie. Exactly what happened

 Secondary Survey

Pitfalls:

1. Head and face
    a. Posterior scalp lacs/compound skull fractures
    b. Pupil changes since primary survey
    c. Visual deficits

2. Neck
    a. Injuries under the hard collar are not seen
    b. In line immobilisation while the collar is off

3. Chest
    a. Clinical rib #s and sternal #s are missed
        i. many do not show on the chest X-ray
        ii. they can compromise the patient
        iii. X-ray 'proof' is not required

4. Abdomen
    a. Pain or tenderness or bruising requires further investigation
    b. The inaccessible abdomen with appropriate mechanism requires
         investigation.
        i. FAST or DPL in the unstable
        ii. CT in stable patients
    c. Vaginal examination in female patients with pelvic fractures or
         vaginal bleeding. In pregnancy this examination should be deferred
         to an obstetric specialist.
    d. A nasogastric tube is contraindicated in the presence of facial
         fractures (an orogastric tube should be inserted)
    e. a urinary catheter should only be inserted if there is no blood at
         the urethral meatus, no perineal bruising, and rectal examination is
         normal.

5. Back
    a. Log roll takes 5 people, 3 body, one head, one examining
    b. Inspection and palpation
    c. Perform the rectal examination at this time.

6. Extremities
    a. Inspect and palpate each limb for tenderness, crepitation, or
         abnormal movement.
    b. If the patient is cooperative ask him or her to move the limbs in
         response to command in preference to passive movement in the
         first instance.
    c. Adequately splint any injuries.
    d. Reassess after splints, traction or manipulation

7. Neurological examination
    a. Repeat the Glasgow Coma Scale - record scores for E, V and M
         as well as the total score
    b. Re-evaluate the pupils
    c. Look for any localising/lateralising signs
    d. Look for signs of cord injury

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Pain Measurement Scale

 

PAIN MEASUREMENT SCALE

This tool was originally created with children to help them communicate about their pain.  Now it is used around the world with people ages 3 and older, improving assessment so pain management can be addressed.

To use this scale, your doctor should explain that each face shows how a person in pain is feeling. That is, a person may feel happy because he or she has no pain (hurt), or a person may feel sad because he or she has some or a lot of pain.

    Face 0 is very happy because he or she doesn't hurt at all.
    Face 1 hurts just a little bit.
    Face 2 hurts a little more.
    Face 3 hurts even more.
    Face 4 hurts a whole lot.
    Face 5 hurts as much as you can imagine, although you don't have to be crying to feel this bad.

You should point to each face using the words to describe the pain intensity. You should then choose the face that best describes how you feel.

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PQRST Pain Assessment Method

 PQRST PAIN ASSESSMENT METHOD

Since pain is subjective, self-report is considered the Gold Standard and most accurate measure of pain. The PQRST method of assessing pain is a valuable tool to accurately describe, assess and document a patient’s pain. The method also aids in the selection of appropriate pain medication and evaluating the response to treatment.

Nurses can help patients more accurately report their pain by using these very specific PQRST assessment questions:

P = Provocation/Palliation

What where you doing when the pain started? What caused it? What makes it better or worse? What seems to trigger it? Stress? Position? Certain activities?

What relieves it? Medications, massage, heat/cold, changing position, being active, resting?

What aggravates it? Movement, bending, lying down, walking, standing?
Q = Quality/Quantity

What does it feel like? Use words to describe the pain such as sharp, dull, stabbing, burning, crushing, throbbing, nauseating, shooting, twisting or stretching.
R = Region/Radiation

Where is the pain located? Does the pain radiate? Where? Does it feel like it travels/moves around? Did it start elsewhere and is now localized to one spot?
S = Severity Scale

How severe is the pain on a scale of 0 to 10, with zero being no pain and 10 being the worst pain ever? Does it interfere with activities? How bad is it at its worst? Does it force you to sit down, lie down, slow down? How long does an episode last?
T = Timing

When/at what time did the pain start? How long did it last? How often does it occur: hourly? daily? weekly? monthly? Is it sudden or gradual? What were you doing when you first experienced it? When do you usually experience it: daytime? night? early morning? Are you ever awakened by it? Does it lead to anything else? Is it accompanied by other signs and symptoms? Does it ever occur before, during or after meals? Does it occur seasonally?
Documentation

In addition to facilitating accurate pain assessment, careful and complete documentation demonstrates that you are taking all the proper steps to ensure that your patients receive the highest quality pain management. It is important to document the following:

    Patient’s understanding of the pain scale. Describe the patient’s ability to assess pain level using the 0-10 pain scale.
    Patient satisfaction with pain level with current treatment modality. Ask the patient what his or her pain level was prior to taking pain medication and after taking pain medication. If the patient’s pain level is not acceptable, what interventions were taken?
    Timely re-assessment following any intervention and response to treatment. Quote the patient’s response.
    Communication with physician. Always report any change in condition.
    Patient education provided and patient’s response to learning. Don’t write “patient understands” without a supportive evaluation such as patient can verbalize, demonstrate, describe, etc.

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Pain Assessment Mnemonics

PAIN ASSESSMENT

SOCRATES is a mnemonic acronym used by emergency medical services, doctors, nurses and other health professionals to evaluate the nature of pain that a patient is experiencing.

The acronym is used to gain an insight into the patient's condition, and to allow the Health Care Provider to develop a plan for dealing with it.
    *Site - Where is the pain? Or the maximal site of the pain.
    *Onset - When did the pain start, and was it sudden or gradual? Include also whether if it is progressive or regressive.
   *Character - What is the pain like? An ache? Stabbing?
   * Radiation - Does the pain radiate anywhere? (See also Radiation.)
    *Associations - Any other signs or symptoms associated with the pain?
    *Time course - Does the pain follow any pattern?
    *Exacerbating/Relieving factors - Does anything change the pain?
    *Severity - How bad is the pain?

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