Patient Assessment

Introduction Patient assessment involves systematic evaluation or appraisal of the condition of the patient. Needs critical First Responder skills Act quickly to ensure scene is safe and care for immediate threats to life Care provided is based on patient assessment

Scene Size-Up While going to scene, consider factors that may affect safety for you, bystanders, and patient Dispatcher’s information may alert you to hazards or special precautions Begin scene size-up before you exit your vehicle and while approaching the patient

BSI Precautions Put on medical exam gloves as you approach patient Observe scene/patient to determine whether to use other personal protective equipment: Protective eyewear Gown and mask Turn-out gear Follow standard precautions

Scene Safety Observe for any hazards As you enter the scene While approaching the patient

Vehicle Crash Hazards Traffic hazards Downed wires Risk of fire or explosion Unstable vehicles Hazardous materials

Potential Violence Crime scenes Potentially violent patient or bystanders Guard dogs, wild animals

Environmental Dangers Unstable surfaces Water, ice Weather extremes Hazards within Structures Low-oxygen areas Toxic substances, fumes Risk of collapse Risk of fire or explosion

Hazards Within Structures Low-oxygen areas Toxic substances, fumes Risk of collapse Risk of fire or explosion

Principles of Scene Safety Enter scene only if it is safe If unsafe, make it safe or stay away Protect bystanders and other rescuers from hazards Protect patient from environmental threats

Mechanism of Injury (MOI) Nature of Injury (NOI) What specifically caused the injury? Was there an impact with a blunt or sharp object? What body area received the impact? What organs may be injured? How much force may have been involved? Might the force have been transferred from one body area to another?

Examples of Mechanism of Injury Vehicle collision may cause head /spinal injuries Fall from a height may cause extremity fractures Blunt impact to abdomen may cause closed injury/ internal bleeding Diving incident may cause spinal injury Gunshot may cause extensive internal damage not apparent from the appearance of the outside wound Fall forward onto a hand may transfer force up arm and cause shoulder dislocation

Consider Nature of Illness Consider nature of illness during scene size-up Don’t stop to talk to family/bystanders until you are sure there is no immediate threat to life Observe patient’s position/demeanor for clues Use all your senses If patient is unresponsive, move immediately to initial assessment If patient is responsive, ask patient, family members, or bystanders why EMS was called

Number of Patients Determine how many patients are involved Observe for clues and ask those present if everyone is accounted for Be certain you know how many patients are involved Call for additional help immediately for multiple patients If more patients than responders, triage patients first

Additional Resources Consider these factors: Number of patients and types/seriousness of injuries Possible need for air transport Potential for fire or explosion Potential presence of hazardous materials Need for extrication Need for law enforcement or traffic control Damage to power lines or other utilities

Initial Assessment Performed when you reach patient to identify any immediate threats to life Rapid means to determine patient’s general condition and set initial priorities for care Begin with your initial impression of patient Check patient’s responsiveness, airway, breathing, and circulation status

General Impression Is the patient ill or injured? What is chief complaint? Does patient’s appearance give clues about his/ her condition? Are there signs of a serious problem? Note patient’s sex and approximate age

You may notice immediately whether patient is responsive Responsive means a person is conscious and awake Responsiveness

Patients who cannot talk may be able to move and thereby signal responsiveness

Patients who cannot talk/move may be paralyzed but still able to respond with purposeful eye movements or other signs Responsiveness

Assessing Responsiveness Begin by speaking to the patient: If patient isn’t speaking or moving, tap gently and ask, “Are you okay?” Be careful not to move patient in any way Always suspect a spinal injury and take steps to stabilize head and neck

Unresponsiveness Unresponsiveness may be sign of life-threatening problem or may result from a less urgent problem Continue the initial assessment Unresponsiveness is considered life-threatening emergency

Degree of Responsiveness Assessed with AVPU scale AVPU scale useful for noting changes in a patient’s responsiveness while providing care and for communicating this information Make mental note of level of responsiveness or write it down along with time A change in level of responsiveness, generally indicates a serious condition

Degree of Responsiveness AVPU Scale A = Alert V = Responds to Verbal stimuli P = Responds to Pain U = Unresponsive to all stimuli

Degree of Responsiveness continued Responsiveness in Pediatric Patients Infants/young children may respond differently from older children/adults Look for age-appropriate responses Assess unresponsive infant by flicking bottom of feet and noting response

ABCs identifies immediate life threats that must be corrected before patient assessment continues. Checking the ABCs

A = Airway B = Breathing Checking the ABCs After checking responsiveness, initial assessment continues by checking ABCs: C = Circulation A = Airway B = Breathing Checking the ABCs

Airway Airway is route air moves from mouth and nose through pharynx to lungs Airway may be blocked by a foreign body, swollen airway tissues, or tongue Airway must be patent Confirm that it is open Take action to open it Clear an obstruction

Airway continued If patient is talking, crying, or coughing, the airway is open Patient with weak, wheezing cough may have partially blocked airway

Opening the Airway Open airway with head tilt–chin lift or jaw thrust

Tilting head back, lift chin to move tongue away from opening of throat Use your fingers, not your thumb, to lift chin Do not press deeply into the soft tissues of chin Ensure mouth stays open Head Tilt–Chin Lift

Jaw Thrust With possible spinal injury, lift jaw upward, using both hands Jaw thrust is more difficult and fatiguing but is effective If lips close, open lower lip with your gloved thumb When in doubt, use jaw thrust If jaw thrust does not open airway, switch to head tilt–chin lift method

Trauma or Vomiting With head trauma/vomiting, inspect mouth for blood, loose teeth, vomit, or any other obstruction Use a gloved finger or suction if needed to clear airway

Avoid Unnecessary Movement Don’t immediately roll unresponsive person onto his/her back to open airway Movement may cause additional injury Determine whether airway is open by looking, listening, feeling for breathing without moving patient

Avoid Unnecessary Movement continued Patient who is breathing has an open airway Don’t move patient unless necessary If cannot determine whether patient is breathing, move into supine position to open airway, check for breathing Support head/neck when moving trauma patient

Breathing

Check Breathing In a responsive adult, check for adequate breathing Inadequate Breathing Difficult or labored breathing Wheezing or gurgling sounds with breathing Pale skin or a blue color of lips/nail beds Respiratory rate ≤8 or ≥30 breaths/minute

Check for Breathing Look, Listen, Feel Look for rise and fall of chest Listen for breathing Feel for breath Look, Listen, Feel

If No Breathing Detected If no signs of breathing within 10 seconds, assume the person is not breathing Lack of breathing may be caused by an obstructed airway or other causes You must immediately give ventilations

Assessing a Child’s Breathing It is difficult to assess a child’s adequacy of respiration Check instead for presence/absence of breathing Check the same as in an unresponsive adult

Circulation

Circulation After checking breathing, check for circulation If patient’s heart has stopped or patient is bleeding profusely, vital organs are not receiving enough oxygen to sustain life If patient is responsive or breathing, heart is beating

In responsive adult or child, check radial pulse Pulse Check

In an unresponsive adult, check carotid pulse Pulse Check

In an unresponsive child, check either carotid pulse or femoral pulse In an infant, use the brachial pulse in the inside of the upper arm Pulse Check

Pulse Check in Initial Assessment Do not take time to count pulse, note whether it is irregular, very slow or very fast—signs that patient may not be stable Lack of pulse along with absence of adequate breathing signifies heart has stopped or is not beating effectively enough to circulate blood If patient lacks a pulse and is not breathing adequately, start CPR

Check for Serious Bleeding Look for life-threatening bleeding Arterial bleeding usually most serious Bleeding from vein is generally slower Don’t remove clothing to check for bleeding, but look for blood-saturated clothing and blood pooling During initial assessment, don’t address minor bleeding or wounds Control serious bleeding immediately with direct pressure

Skill: Initial Assessment of an Unresponsive Patient

Patient Priority Initial assessment determines whether a critical condition is present and what steps you need to take Unresponsiveness or any problem with the airway, breathing, or circulation is a high priority Continue to reassess and treat life-threatening conditions while waiting for additional EMS resources Call EMS unit to update patient’s condition

Report to EMS After the Initial Assessment Provide this information: Number of patients Patient age and gender Patient’s chief complaint Patient’s level of responsiveness Patient’s airway, breathing, and circulation status Ask responding unit their estimated time of arrival Continue to care for patient accordingly

Physical Exam

Physical Examination Follows the initial assessment Question patient, family members, bystanders Purpose is to find/assess signs/symptoms of illness or injury

Physical Examination continued Information gained from exam and history may help you care for patient and be of value to arriving EMS personnel Complete rapid trauma assessment of unresponsive patient or a patient with a significant MOI Perform focused physical exam of responsive medical patient or a trauma patient with only a minor injury

When Performing a Physical Exam Allow responsive patient to remain in position he/she finds most comfortable Ask responsive patient for consent to do physical examination Don’t start with a painful area

When Performing a Physical Exam continued Watch for facial expression/stiffening of body part In responsive patient, begin with area of chief complaint and examine other body areas only as appropriate With an unresponsive patient, examine patient from head to toe in a systematic manner

When Performing a Physical Exam Continued A sign is an objective observation or measurement such as warm skin or a deformed extremity A symptom is a subjective observation reported by the patient, such as pain or nausea

Use Systematic Head-To-Toe Approach Begin at head because injuries here are more likely to be serious than injuries elsewhere. With responsive children, begin at feet and work up the body. Look and palpate for signs and symptoms throughout the body, Compare one side of body to other when appropriate.

DOTS for Trauma Patients D = Deformities O = Open injuries T = Tenderness (pain) S = Swelling

DCAP-BTLS Memory Aid D = Deformities C = Contusions A = Abrasions P = Punctures B = Burns T = Tenderness L = Lacerations S = Swelling

Check Head and Neck Skull Eyes Ears Nose Breathing Mouth Neck

Check Chest Deformity? Wounds? Tenderness? Bleeding? Even breathing?

Check Abdomen Rigidity? Pain? Bleeding?

Back Unless head/spinal injury is suspected, roll patient onto side to examine back If head/neck injury is suspected, don’t move patient but slide your gloved hand under back Sweep entire lower back, looking at fingertips of your gloved hands for any bleeding Treat any tenderness, swelling, or deformity of lower part of spine as a sign of a spinal injury and don’t move patient

Check Hips and Pelvis Pain? Deformity?

Check Lower Extremities Bleeding? Deformity? Pain? Normal movement, sensation, temperature? Check Lower Extremities

Check Upper Extremities Bleeding? Deformity? Pain? Medial alert ID? Normal movement, sensation, temperature?

Vital Signs Some First Responders check patient’s vital signs in the physical examination Vitals signs assessed include: Breathing rate, rhythm, depth, and ease Pulse rate, rhythm, and strength Skin color, temperature, and condition Pupil size, equality, and reaction to light Blood pressure

Importance of Vital Signs Vital signs reveal additional information about condition Changes in vital signs, from the baseline vital signs, are important and should be documented Changes may show deterioration or improvement with treatment Vital signs vary significantly among different individuals Vital signs are affected by stress, activity, and other variables

Normal Vital Signs Patient Normal Respiratory Rate at Rest Normal Pulse Rate at Rest Normal Blood Pressure (systolic/diastolic) Infant 20 - 30 80 - 150 84-106 / 56-70 Child 18 - 30 70 - 130 98-124 / 50-80 Adult 12 - 20 60 - 100 118-140 / 60-90

Assessing Respiration Don’t tell a responsive patient that you are assessing breathing Count respirations while holding wrist draped across chest as if taking a pulse. Observe or feel for the chest rising and falling (one cycle equals one breath)

Assessing Respiration continued Count number of breaths in 30 seconds and multiply by two Note whether patient is making an effort to breathe, is short of breath, or is using abdominal muscles in breathing

Characteristics of Respiratory Distress Gasping or wheezing Very fast or slow respiratory rate Very shallow or very deep breathing Shortness of breath, difficulty speaking

Assessing Pulse Have a responsive patient sit or lie down Take a radial pulse in an adult or child. If no radial pulse, take carotid pulse in an adult or a brachial pulse in a child. Always take a brachial pulse in an infant Count the beats for 30 seconds and multiply by two Note strength of pulse (strong or weak) Note rhythm of pulse (regular or irregular)

Characteristics of Possible Circulation Problem Very fast or very slow pulse Very weak or strong, bounding pulse Very weak and fast pulse (thready pulse)—may indicate shock Irregular rhythm—may indicate a cardiac problem Unequal pulses at different sites

Assessing Skin Temperature and Condition Assess skin temperature using back of hand on skin Assess skin color Assess skin moisture In a young child, assess capillary refill

Skin Characteristics That May Indicate a Problem Skin temperature Unusual coloration Skin condition Capillary refill time ≥2 seconds may indicate shock or diminished blood flow

Assessing Pupils Assess size of patient’s pupils Assess the pupils for equality Assess reactivity to light

Assessing Pupils Pupil Characteristics That May Indicate a Problem Dilated or constricted pupils Unequal pupils Non-reactive pupils

Blood Pressure Some First Responders are trained to take blood pressure Blood pressure is force of blood pressing against arterial wall from heart’s pumping action

Blood Pressure When heart contracts, pressure is higher (systolic pressure) Pressure falls lower when heart relaxes between beats (diastolic pressure) Blood pressure is recorded as systolic pressure over diastolic pressure

Skill: Measuring Blood Pressure by Auscultation

Repeated Blood Pressure It is difficult to interpret blood pressure because of wide variation among individuals Repeated measurements may show a possible trend in patient’s condition A drop in blood pressure in shock usually develops as a late sign

Measuring Blood Pressure by Palpation If you don’t have a stethoscope or scene is noisy, measure systolic blood pressure by palpation While palpating radial pulse, inflate cuff 30 mmHg beyond the point where you stop feeling pulse While watching gauge, open valve to slowly deflate cuff Note the pressure when you feel radial pulse return Record pressure as systolic pressure and include the word palpated (e.g., “130 palpated” or “130/Palp”)

Patient History

Patient History Patient’s history is gained from patient or others Although history focuses on specific injury or chief complaint, it should be complete With responsive medical patients, you may take history before performing physical exam With trauma patients and any unresponsive patient, perform physical exam first

Taking a History Talk to a responsive patient With an unresponsive patient, talk to family members or bystanders about what they know or saw Look for medical alert insignia or other medical identification. In the home, look for medication bottles and a Vial of Life

Taking a History continued With trauma patient, assess forces involved When taking history of a responsive patient with a sudden illness, ask fully about the patient’s situation to learn possible causes

SAMPLE SAMPLE S Signs and symptoms A Allergies M Medications P Previous problems L Last food or drink E Events SAMPLE

Additional Guidelines for History If patient is unresponsive, ask family members or bystanders Check scene for clues of what may have happened Consider environment Consider patient’s age When additional EMS personnel arrive, give them information you gathered

Ongoing Assessment

Ongoing Assessment Continue to assess while awaiting additional EMS resources and giving care Calm and reassure patient while reassessing ABCs and repeating physical examination Repeat initial assessment: Every 15 minutes for a stable patient Every 5 minutes for an unstable patient

Performing the Ongoing Assessment Reassess mental status Maintain an open airway Monitor breathing for rate and quality Reassess pulse for rate and quality Monitor skin color, temperature, and condition Repeat the physical exam as needed

Importance of Ongoing Assessment Check that your interventions are effective Perform additional treatments as needed

Hand-Off Report Give EMS hand-off report with detailed information about the patient’s: Age and gender Chief complaint Responsiveness Airway and breathing status Circulation status

Hand-Off Report continued Also include: Physical exam findings Results of SAMPLE history Interventions provided and the patient’s response to them You may also complete a written report containing the same information