1. Patient Assessment
Chapter 8

2. Patient Assessment Scene size-up Initial assessment
Focused history and physical exam
Vital signs
History
Detailed physical exam
Ongoing assessment

3. Patient Assessment Process

4. Scene Size Up Dispatch information Inspection of scene Scene hazards
Safety concerns
Mechanism of injury
Nature of illness/chief complaint
Number of patients
Additional resources needed

5. 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
Turnout gear

6. Scene Safety: Potential Hazards
Oncoming traffic
Unstable surfaces
Leaking gasoline
Downed electrical lines
Potential for violence
Fire or smoke
Hazardous materials
Other dangers at crash or rescue scenes
Crime scenes

7. 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.

8. 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

9. 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

10. The Importance of MOI/NOI
Guides preparation for care to patient
Suggests equipment that will be needed
Prepares for further assessment
Fundamentals of assessment are same whether emergency appears to be related to trauma or medical cause.

11. 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.

12. Additional Resources Medical resources Nonmedical resources
Additional units
Advanced life support
Nonmedical resources
Fire suppression
Rescue
Law enforcement

13. C-Spine Immobilization
Consider early during assessment.
Do not move without immobilization.
Err on the side of caution.

14. Patient Assessment Process

15. Initial Assessment Develop a general impression. Assess mental status.
Assess airway.
Assess the adequacy of breathing.
Assess circulation.
Identify patient priority

16. 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

17. Obtaining Consent
Introduce self.
Ask patient’s name.
Obtain consent.

18. Chief Complaint Most serious problem voiced by the patient
May not be the most significant problem present

19. Assessing Mental Status
Responsiveness
How the patient responds to external stimuli
Orientation
Mental status and thinking ability

20. Testing Responsiveness
A Alert
V Responsive to Verbal stimulus
P Responsive to Pain
U Unresponsive

21. Testing Orientation
Person
Place
Time
Event

22. Caring for Abnormal Mental Status
Complete initial assessment.
Provide high-flow oxygen.
Consider spinal immobilization.
Initiate transport.
Support ABCs.
Reassess.

23. 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

24. 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

25. Assessing Breathing Choking Rate Depth Cyanosis Lung sounds
Air movement

26. High-Flow Oxygen Administration
Breathing faster than 20 breaths/min
Breathing slower than 12 breaths/min
Breathing too shallow
Decreased level of consciousness
Respiratory distress
Poor skin color

27. Positioning the Patient
Position of comfort
Sitting up with feet dangling
High Fowler’s position
Spinal precautions if possible spinal injury

28. Assessing the Pulse
Presence
Rate
Rhythm
Strength

29. Normal Pulse Rates in Infants and Children
Age
Range (beats/min)
Infant: 1 month to 1 year
100 to 160
Toddler: 1 to 3 years
90 to 150
Preschool-age: 3 to 6 years
80 to 140
School-age: 6 to 12 years
70 to 120
Adolescent: 12 to 18 years
60 to 100

30. Assessing and Controlling External Bleeding
Assess after clearing the airway and stabilizing breathing.
Look for blood flow or blood on floor/clothes.
Controlling bleeding
Direct pressure
Elevation
Pressure points

31. Assessing Perfusion
Color
Temperature
Skin condition
Capillary refill

32. Priority Patients Difficulty breathing Poor general impression
Unresponsive with no gag reflex
Severe chest pain
Signs of poor perfusion
Complicated childbirth
Uncontrolled bleeding
Responsive but unable to follow commands
Severe pain
Inability to move any part of the body

33. Transport Decision Patient condition Availability of advanced care
Distance to transport
Local protocols

34. Patient Assessment Process

35. Focused History and Physical Exam
Understand the circumstances surrounding the chief complaint.
Obtain objective measurements.
Perform physical exam.

36. Components of Focused History and Physical Exam
Medical history
Baseline vital signs
Physical exam

37. Rapid Physical Exam 60-90 second head-to-toe exam Performed on:
Significant trauma patients
Unresponsive medical patients
Identifies undiscovered conditions

38. DCAP-BTLS D Deformities B Burns C Contusions T Tenderness A Abrasions
L Lacerations
P Punctures/ Penetrations
S Swelling

39. Components of a Rapid Physical Exam

40. Maintain spinal immobilization while checking patient’s ABCs.
Assess the head.
Assess the neck.
Apply a cervical spine immobilization collar.

41. Assess the chest. Assess the abdomen. Assess the pelvis.
Include presence of
lung sounds
Assess the abdomen.
Assess the pelvis.

42. Assess all four extremities.
Include:
P- Pulse
M- Motor
S- Sensation
Roll the patient with spinal precautions.

43. Focused Physical Exam Used to evaluate patient’s chief complaint
Performed on:
Trauma patients without significant MOI
Responsive medical patients

44. Head, Neck, and Cervical Spine
Feel head and neck for deformity, tenderness, or crepitation.
Check for bleeding.
Ask about pain or tenderness

45. Chest Watch chest rise and fall with breathing.
Feel for grating bones as patient breathes.
Listen to breath sounds.

46. Abdomen Look for obvious injury, bruises, or bleeding.
Evaluate for tenderness and any bleeding.
Do not palpate too hard.

47. Pelvis Look for any signs of obvious injury, bleeding, or deformity.
Press gently inward and downward on pelvic bones.

48. Extremities Look for obvious injuries. Feel for deformities. Assess
Pulse
Motor function
Sensory function

49. Posterior Body Feel for tenderness, deformity, and open wounds.
Carefully palpate from neck to pelvis.
Look for obvious injuries.

50. Specific Chief Complaints
Chest pain
Shortness of breath
Pain associated with bones or joints
Abdominal pain
Dizziness

51. 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 the head, chest, or abdomen

52. Assessment Steps for Significant MOI
Rapid trauma assessment
Baseline vital signs
SAMPLE history
Reevaluate transport decision

53. Assessment Steps for Trauma Patients Without Significant MOI
Focused assessment
Baseline vital signs
SAMPLE history
Reevaluate transport decision

54. Responsive Medical Patients
History of illness
SAMPLE history
Focused assessment
Vital signs
Reevaluate transport decision

55. Unresponsive Medical Patients
Rapid medical assessment
Baseline vital signs
SAMPLE history
Reevaluate transport decision

56. Patient Assessment Process

57. 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

58. Performing the Detailed Physical Exam

59. Visualize and palpate using DCAP-BTLS.
Look at the face.
Inspect the area around the eyes and eyelids.
Examine the eyes.

60. Pull the patient’s ear forward to assess for bruising.
Use the penlight to look for drainage or blood in the ears.

61. Look for bruising and lacerations about the head.
Palpate the zygomas.

62. Palpate the maxillae.
Palpate the mandible

63. Assess the mouth and nose for obstructions and cyanosis.
Check for unusual odors.

64. Look at the neck.
Palpate the front and the back of the neck.
Look for distended jugular veins.

65. Look at the chest.
Gently palpate over the ribs

66. Listen for breath sounds.
Listen also at the bases and apices of the lungs.

67. Look at the abdomen and pelvis.
Gently palpate the abdomen.
Gently compress the pelvis.

68. Gently press the iliac crests.
Inspect all four extremities.
Assess the back for tenderness or deformities

69. Patient Assessment Process

70. 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?

71. Steps of the Ongoing Assessment
Repeat the initial assessment.
Reassess and record vital signs.
Repeat focused assessment.
Check interventions