1. Section 3: Patient Assessment

2. Chapter 8
Patient Assessment

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

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

39. 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

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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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

51. 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

52. 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

53. 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

54. 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

55. 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

56. 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

57. 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

58. 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

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

60. 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

61. 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

62. 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

63. 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

64. 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

65. 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

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

67. 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

68. 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

69. 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

70. 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

71. 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

72. 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

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

74. 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

75. 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

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

77. 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