Division 2 Patient Assessment Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Chapter 11, Physical Exam Techniques (cont.) Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal System Consists of 206 bones and associated muscles, tendons, ligaments, and cartilage Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

General Approach Inspection Range of motion (ROM) Palpation Muscular and neurological exams Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

The Extremities A complete examination of the extremities includes wrists and hands, elbows, shoulders, ankles and feet, knees, and hips. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

General Inspection Observe how the patient moves as he goes into the room or moves to stretcher. General appearance. Body proportions. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Examination of the Musculoskeletal System Observe, inspect, and palpate the joints, structure, and movement. Note: Compare strength Range of motion Crepitus Pain Swelling Deformity Symmetry Tissue changes Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Range of Motion Active: Patient moves his joint. Passive: You move the patient’s joint. Watch for decreased or increased movement of the joint compared to the other side as well as the norm. Watch for pain with movement. Listen for crepitus or “popping.” Watch for abnormal movements. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assess the elbow’s range of motion. Passive range of motion Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Palpation Palpate for swelling. Palpate for warmth. Palpate each area of the structure in turn, evaluating for pain and abnormalities as compared to the other side. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

The Spinal Column Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

The Vertebrae Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessing the Spine Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Inspect the Spine: Spinal Curvatures Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Palpate the spine: Check the entire spine Check for tenderness or stepoff Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

The Peripheral Vascular System The peripheral vascular system delivers oxygenated blood to the tissues of the extremities. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessing a Peripheral Pulse Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessing the Peripheral Vascular System Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Palpate the radial artery. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Palpate the brachial artery. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Palpate and compare the femoral arteries. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Palpate the popliteal pulse. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Palpate the dorsalis pedis pulse. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Palpate the posterior tibial pulse. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Palpate for edema. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessing for Edema Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pitting Edema Scale Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

The Nervous System A neurological exam attempts to answer the following questions: Are the findings symmetrical or unilateral? If unilateral, where do they originate? It the problem in the brain, spinal cord, or peripheral nerve after it leaves the spinal cord Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Five Areas of Neurological Exam Mental status and speech Cranial nerves Motor system Sensory system Reflexes Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Mental Status Level of consciousness Alert Verbal Painful Unresponsive Orientation: Person, place, time, events Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Speech and Behavior Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

The Cranial Nerves Refer to Mike Yee’s lecture and book Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessing the Cranial Nerves Some of your eye, head, and neck exam already incorporate testing of cranial nerves such as pupil reactivity and eye movement, tongue movement, facial symmetry Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Test the oculomotor, trochlear, and abducens nerves by evaluating your patient's extraocular movements. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Test motor function of the trigeminal nerve by palpating the temporal and masseter muscles. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Test sensory function of the trigeminal nerve with sharp and dull objects. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Test the glossopharyngeal and vagus nerves with a tongue blade. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Test the spinal accessory nerve by having your patient shrug her shoulders against resistance. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

The Peripheral Nerves Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Muscle Tone Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessing the Motor System Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Test your patient’s grip. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Test arm strength. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Test for pronator drift. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Test for coordination with rapid alternating movements. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Test coordination with point-to-point testing. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assess coordination with heel-to-shin testing. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Muscle Strength Scale Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Knowing basic landmarks enables you to locate spinal cord lesions. Dermatome Chart Knowing basic landmarks enables you to locate spinal cord lesions. Not going to talk much about sensation other than to see if it’s symmetrical Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

A reflex arc depicts muscle tension over time. Circuit of sensory nerve to spinal cord to motor nerve Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Reflex Scale Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Reflex figures show grade on a scale of 0 to 4+. These are the areas where all the reflexes are and how they record their findings Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pediatric Physical Exam Techniques Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Introduction Specific techniques same as adult Inspection Palpation Percussion Auscultation Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Physical Examination of Infants and Children Children are not just small adults and you cannot treat them as if they are. Different age groups have specific fears and characteristics. Position yourself at the child’s level, use a soft voice, and smile a lot. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Infants (newborn to 1 year) Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Have parents hold young children while you examine them. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Toddler (1–3 years) Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Preschooler (3–6 years) Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

School Age (6–12 years) Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Adolescent (13–18 years) Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pediatric Anatomy and Physiology Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Fontanelles of the Infant’s Skull Dehydration: sunken Head injury, meningitis, or elevated intracranial pressure: Bulging (anything that causes elevated intracranial pressure Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

General Impression Skin Respiration Hydration Mental status Cry and social interaction Psychosocial conditions Behavior Development Relationship to parent and examiner and general condition Skin – Recognize jaundice, petechiae, purpura, urticaria, and other rashes. Recognize common skin findings associated with child abuse and assess skin turgor. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Head, Eyes, and Ears Fontanelles: Head size and shape. Fullness Turgor Head size and shape. Assess eyes for red light reflex. Assess hydration of the mucous membranes. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Neck Short in infancy Nuchal rigidity in meningitis Clavicles – fracture Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Normal Vital Signs for Various Pediatric Age Groups Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Auscultation – Lungs Bell or diaphragm Breath sounds harsher in infants and young children Distinguish lower from transmitted upper airway sounds Abnormalities Decreased sounds Rales Wheeze Stridor Rate Place the stethoscope along the young patient’s mid-axillary line. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Auscultation – Cardiac Apical pulse Functional (normal) murmur in 1/2 to 2/3 of kids No cardiac symptoms Change with position Systolic – never diastolic ½ to 2/3 of the kids can have normal murmurs. A murmur in kids is normal if the child has no associated symptoms, the intensity of the murmur changes with position, and it happens only in systolic phase Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Perfusion Assess capillary refill. Sinus arrhythmia common. Premature ventricular contractions common. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Abdomen Warm hands; palpate gently. If abdomen tense, try flexing legs at hip. Palpate for tenderness and masses. If newborn, evaluate number of umbilical vessels. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Gradually increase the pressure when palpating a young patient’s abdomen. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

The most important characteristic of a physical assessment is thoroughness. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Recording Examination Findings After you perform the history and physical examination, it is time to record the findings on your patient’s chart or permanent medical record. The patient record is only as good as the accuracy, depth, and detail you provide. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Summary Techniques of Inspection, Palpation, Auscultation, and Percussion Evaluation of Mental Status Examination of the Body Regions Special Considerations Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ