Section 3: Patient Assessment

Chapter 8 Patient Assessment

Objectives (1 of 9) Scene Size-up Describe the importance of recognizing potential hazards Describe common hazards found at the scene Determine if the scene is safe to enter Discuss identifying the number of patients at the scene Explain the need for additional help or assistance Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Objectives (2 of 9) Initial Assessment Summarize the reasons for forming a general impression Discuss methods of assessing altered mental status Discuss methods of assessing the airway State reasons for managing the cervical spine Discuss methods for assessing if a patient is breathing Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Objectives (3 of 9) State what care should be provided to a patient with adequate breathing State what care should be provided to a patient without adequate breathing Describe methods used to obtain a pulse Discuss the need for assessing for external bleeding Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Objectives (4 of 9) Describe normal and abnormal findings when assessing skin color Describe normal and abnormal findings when assessing skin temperature Describe normal and abnormal findings when assessing skin condition Describe normal and abnormal findings when assessing capillary refill Explain the reason for prioritizing a patient for care and transport Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Objectives (5 of 9) Focused History and Physical Exam: Trauma Discuss reasons for reconsidering the MOI State the reasons for performing a rapid trauma assessment Describe the rapid trauma assessment and what should be evaluated Differentiate when the rapid assessment may be altered to provide patient care Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Focused History and Physical Exam: Medical Patients Objectives (6 of 9) Focused History and Physical Exam: Medical Patients Describe the need for assessing a patient with a specific complaint and no known history Differentiate between the assessment for responsive patients without a history and responsive patients with a history Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Objectives (7 of 9) Describe the unique needs of assessing an unresponsive patient Differentiate between the assessment performed on an unresponsive patient and other medical patients Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Detailed Physical Exam Objectives (8 of 9) Detailed Physical Exam Discuss components of the detailed physical exam Explain what additional care is provided during the detailed physical exam Distinguish between the detailed exam on a trauma and medical patient Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Objectives (9 of 9) Ongoing Assessment Discuss the reason for repeating the initial assessment Describe the components of the ongoing assessment Describe trending of assessment components Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Patient Assessment Process Scene size-up Initial assessment Provide spinal immobilization Identify and treat life threats Focused history and physical exam Provide transport if needed Detailed physical exam Reassess vital signs Ongoing assessment Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

The Patient Assessment Process Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Body Substance Isolation Assumes all body fluids present a possible risk for infection Protective equipment Latex or vinyl gloves should always be worn Eye protection Mask Gown Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Scene Safety Potential Hazards Fire or smoke Hazardous materials Other dangers at crash or rescue scenes Crime scenes Oncoming traffic Unstable surfaces Leaking gasoline Downed electrical lines Potential for violence Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Scene Safety Park in a safe area Speak with law enforcement first if present. The safety of you and your partner comes first! Next concern is the safety of patient(s) and bystanders. Request additional resources if needed to make scene safe. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Mechanism of Injury Helps determine the possible extent of injuries on trauma patients Evaluate: Amount of force applied to body Length of time force was applied Area of the body involved Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Motor Vehicle Crashes Amount of force related to speed Injuries can be predicted by: Position in the car Use of seat belts How the body shifts during the crash Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Falls Amount of force related to height of fall Note surface that patient landed on Attempt to determine how patient landed Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Gunshot and Stab Wounds Gunshot wounds Force is related to caliber of weapon and distance from gun to the patient Stab wounds Injury can be estimated by looking at the entrance and length of the weapon Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Nature of Illness Search for clues to determine the nature of illness. Often described by the patient’s chief complaint Gather information from the patient and people on scene. Observe the scene. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Number of Patients Determine the number of patients and their condition. Assess what additional resources will be needed. Triage to identify severity of each patient’s condition. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Patient Assessment Process Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Components of the Initial Assessment Develop a general impression Assess mental status Assess airway Assess the adequacy of breathing Assess circulation Identify patient priority Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Develop a General Impression Occurs as you approach the scene and the patient Assessment of the environment Patient’s chief complaint Presenting signs and symptoms of patient Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Distinguishing Between Medical and Trauma Determination should come after assessment is finished. Patients may have traumatic injuries caused by a medical reason. Initially assume all patients have both medical and traumatic aspects to their condition. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Assessing Mental Status Checking responsiveness Assess how well the patient responds to external stimuli. Check for orientation Check the patient’s memory to person, place, time, and event. If he or she recalls all four, then he or she is fully alert and oriented times four. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Level of Consciousness A Alert V Responsive to Verbal stimulus P Responsive to Pain U Unresponsive Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Assessing the Airway Look for signs of airway compromise: Two- to three-word dyspnea Use of accessory muscles Nasal flaring and use of accessory muscles in children Labored breathing Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Signs of Airway Obstruction in the Unconscious Patient Obvious trauma, blood, or other obstruction Noisy breathing such as bubbling, gurgling, crowing, or other abnormal sounds Extremely shallow or absent breathing Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Assessing Breathing Are the patient’s respirations shallow or deep? Does the patient appear to be choking? Is the patient cyanotic (blue)? Is the patient moving air into and out of the lungs as the chest rises and falls? Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Managing Breathing If patient is having difficulty breathing reevaluate airway. Consider assisting ventilations with a BVM or applying a nonrebreathing mask if patient’s respirations are greater than 24/min or less than 8/min. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Unresponsive Patients Look, listen and feel technique Consider spinal cord injury. Provide high-flow oxygen. Assist ventilations if needed. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Assessing Circulation (1 of 2) Assess the pulse. Rate, rhythm and strength Assess and control external bleeding. Direct pressure Evaluate skin color. Cyanotic, flushed, pale or jaundiced Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Assessing Circulation (2 of 2) Evaluate skin temperature. Skin is an organ. Evaluate skin condition. Dry or moist Evaluate capillary refill. Should be less than 2 seconds Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Restoring Circulation Control bleeding and improve oxygen delivery. If unresponsive and pulseless begin CPR. Apply and operate the AED as quickly as possible. Do not use AED on patients with a catastrophic traumatic injury. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Identifying Priority Patients Poor general impression Unresponsive with no gag or cough reflexes Difficulty breathing Signs of poor perfusion Complicated childbirth Uncontrolled bleeding Severe pain Severe chest pain Inability to move any part of the body Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Patient Assessment Process Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Goals of Exam Identify the patient’s chief complaint. Understand the specific circumstances surrounding the chief complaint. Direct further physical examination. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

The Golden Hour Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Significant Mechanism of Injury Ejection from vehicle Death in passenger compartment Fall greater than 15´-20´ Vehicle rollover High-speed collision Vehicle-pedestrian collision Motorcycle crash Unresponsiveness or altered mental status Penetrating trauma to head, chest, or abdomen Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Significant Mechanism of Injury for Children Includes the list from the previous slide as well as: Fall greater than 2 to 3 times their height Bicycle crash Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Hidden Injuries Seat belts May cause injuries if worn improperly Airbags Look beneath airbag for bent steering wheel. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Trauma Assessment D Deformities C Contusions A Abrasions P Punctures/ Penetrations B Burns T Tenderness L Lacerations S Swelling Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Rapid Trauma Assessment (1 of 3) Maintain spinal immobilization while checking patient’s ABCs. Assess the head. Assess the neck. Apply a cervical spine immobilization collar. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Rapid Trauma Assessment (2 of 3) Assess the chest. Assess the abdomen. Assess the pelvis. Assess all four extremities. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Rapid Trauma Assessment (3 of 3) Roll the patient with spinal precautions. Assess baseline vital signs and SAMPLE history. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Head, Neck, and Cervical Spine Feel head and neck for deformity, tenderness, or crepitation. Check for bleeding. Ask about pain or tenderness. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Chest Watch chest rise and fall with breathing. Feel for grating bones as patient breathes. Listen to breath sounds. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Abdomen Look for obvious injury, bruises, or bleeding. Evaluate for tenderness and any bleeding. Do not palpate too hard. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Pelvis Look for any signs of obvious injury, bleeding, or deformity. Press gently inward and downward on pelvic bones. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Extremities Look for obvious injuries. Feel for deformities. Assess Pulse Motor function Sensory function Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Back Feel for tenderness, deformity, and open wounds. Carefully palpate from neck to pelvis. Look for obvious injuries. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Vital Signs After rapid assessment, obtain baseline vital signs and a SAMPLE history. Vital signs of stable patients should be reassessed every 15 minutes. Vital signs of unstable patients should be reassessed every 5 minutes. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

SAMPLE History S Signs and symptoms A Allergies M Medications P Past medical history L Last oral intake E Events leading to the episode Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Focused History and Physical Exam Assess the chief complaint. Chest pain Shortness of breath Abdominal pain Any pain associated with bones or joints Dizziness Obtain baseline vital signs and SAMPLE history Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Documentation Skin color, temperature, and moisture Initial assessment findings Baseline and subsequent vital signs and SAMPLE history Circulation, sensation and movement in all extremities Breath sounds Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Other Considerations The following patients should receive a rapid trauma assessment and immediate transport Significant mechanism of injury Unresponsive or disoriented Extremely intoxicated Patients whose complaint cannot be identified or understood Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Patient Assessment Process Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Assessing the Responsive Patient Ask general questions to find out the chief complaint. Listen to the patient. Record the chief complaint in a few of the patient’s words. Use OPQRST to gather history of present illness. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

OPQRST (1 of 2) O Onset When did the problem first start? P Provoking factors What creates or makes the problem worse? Q Quality of pain Description of the pain Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

OPQRST (2 of 2) R Radiation of pain or discomfort Does the pain radiate anywhere? S Severity Intensity of pain on 1-to-10 scale T Time How long has the patient had this problem? Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

SAMPLE History Questions to ask: Have you ever been told you have a heart condition? Have you ever been told you have problems with your lungs? Have you ever been told you have seizures? Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Focused Physical Exam Investigate problems associated with chief complaint. Examine abnormalities. Reassess vital signs. Make transportation decision. Document findings. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Assessing the Unresponsive Patient Perform a rapid medical assessment. Obtain baseline vital signs. Obtain SAMPLE history from family if available. Provide emergency care and transport. Document findings. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Patient Assessment Process Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Detailed Physical Exam More in-depth exam based on focused physical exam Should only be performed if time and patient’s condition allows Usually performed en route to the hospital Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Performing the Detailed Physical Exam (1 of 5) Visualize and palpate using DCAP-BTLS. Look at the face. Inspect the area around the eyes and eyelids. Examine the eyes. Pull the patient’s ear forward to assess for bruising. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Performing the Detailed Physical Exam (2 of 5) Use the penlight to look for drainage or blood in the ears. Look for bruising and lacerations about the head. Palpate the zygomas. Palpate the maxillae. Palpate the mandible. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Performing the Detailed Physical Exam (3 of 5) Assess the mouth for obstructions and cyanosis. Check for unusual odors. Look at the neck. Palpate the front and the back of the neck. Look for distended jugular veins. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Performing the Detailed Physical Exam (4 of 5) Look at the chest. Gently palpate over the ribs. Listen for breath sounds. Listen also at the bases and apices of the lungs. Look at the abdomen and pelvis. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Performing the Detailed Physical Exam (5 of 5) Gently palpate the abdomen. Gently compress the pelvis. Gently press the iliac crests. Inspect all four extremities. Assess the back for tenderness or deformities. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Patient Assessment Process Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Ongoing Assessment Is treatment improving the patient’s condition? Has an already identified problem gotten better? Worse? What is the nature of any newly identified problems? Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Steps of the Ongoing Assessment Repeat the initial assessment. Reassess and record vital signs. Repeat focused assessment. Check interventions. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Review Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

The Communication Process Do what you can to make the patient comfortable. Listen to the patient. Make eye contact. Base questions on the patient's complaint. Mentally summarize before starting treatment. Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS