LESSON 11 SECONDARY ASSESSMENT

Introduction With no immediate threats to life, obtain the history and conduct a secondary assessment Obtain the patient’s vital signs and perform a physical examination The secondary assessment reveals additional information and problems Continue to reassess the patient to ensure treatment is effective and that the patient’s condition is not worsening

Patient History

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

Taking a History Talk to a responsive patient With an unresponsive patient, talk to family members or others at the scene 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 Look for clues in the environment

SAMPLE S = Signs and symptoms A = Allergies M = Medications P = Pertinent past history L = Last food or drink E = Events

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

Age Variations in History When taking the history and performing the secondary assessment, consider the patient’s life stage For pediatric patients: Assess an infant’s pulse at brachial artery Use capillary refill as an indicator of adequate blood flow in infants and children younger than 6 Use distracting measures and other actions to help gain the child’s trust For geriatric patients: Help the patient obtain eye glasses and hearing aids for improved communication Accept that taking the history may take more time

Secondary Assessment After the history, unless you are now providing critical patient care, continue patient assessment Take the patient’s vital signs Perform a physical examination

Vital Signs Some EMR check patient’s vital signs 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 30-40 100-160 70-100 / 56-70 Child 20-30 70-130 70-120 / 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 (1 cycle = 1 breath)

Assessing Respiration (continued) Count number of breaths in 30 seconds and multiply by 2 Note whether patient is making an effort to breathe, is short of breath or is using accessory muscles of neck and abdomen 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 brachial pulse in a child Always take brachial pulse in an infant Count the beats for 30 seconds and multiply by 2 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 (continued) Pupil characteristics that may indicate a problem: Dilated or constricted pupils Unequal pupils Non-reactive pupils

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

Blood Pressure (continued) Some EMRs are trained to take blood pressure Blood pressure is force of blood pressing against arterial wall from heart’s pumping action Blood pressure indicates level of perfusion

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 the 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 pressure when you feel radial pulse return Record pressure as systolic pressure and include word ‘palpated’ (e.g., “130 palpated” or “130/P”)

Physical Examination Unless you are caring for a life-threatening condition, perform a physical examination Purpose is to find and assess additional signs and symptoms of illness or injury Because patients are often anxious about being examined, provide emotional support

Physical Examination (continued) Information gained from examination 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 examination of responsive medical patient or a trauma patient with only a minor injury

When Performing a Physical Examination 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 Examination (continued) Watch for facial expression or stiffening of body part In responsive patient, begin with area of chief complaint and examine other body areas only as appropriate With unresponsive patient, examine patient from head to toe in a systematic manner If you find life-threatening problem at any time, treat it immediately

When Performing a Physical Examination (continued) Sign: an objective observation or measurement such as warm skin or a deformed extremity Symptom: 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 body Look and palpate for signs and symptoms throughout 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/Penetrations 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? Use of accessory muscles? Equal chest rise?

Check Abdomen Rigidity? Pain? Bleeding?

Back Unless head or spinal injury is suspected, roll patient onto side to examine back If head or 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 spinal injury and don’t move patient

Check Hips and Pelvis Tenderness? Instability? Incontinence? Priapism?

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

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

Reassessment Continue to assess while awaiting additional EMS resources and giving care Calm and reassure patient while reassessing breathing and circulation and repeating vital signs and physical examination Repeat reassessments: Every 15 minutes for a stable patient Every 5 minutes for an unstable patient

Performing Reassessment The primary assessment of responsiveness, breathing and circulation Vital signs The chief complaint

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

Compare Reassessment Results to Baseline Status Level of responsiveness Airway maintenance Adequacy of breathing (rate, depth, effort) Adequacy of circulation (carotid or radial pulse; skin color, temperature and moisture) Chief complaint (pain remains the same, getting worse or getting better) Presence of new or previously undisclosed symptoms

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: Vital signs and physical examination 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