Secondary Patient Assessment Reporting & Documentation

Firefighter Prehospital Care Program Module 7 & 8

Firefighter Prehospital Care Program Firefighter Prehospital Care Program Module 7 & 8Module 7 & 8

Document 1.3

Secondary Assessment -Objectives

• Conduct a more thorough examination than in the primary assessment

• Head to toe examination• Identify and treat any missed life threatening

conditions (treat as soon as found)• Identify and treat non-life threatening conditions after

the secondary assessment is complete• Obtain vital signs• Establish dialogue with patient and family, collect

information and reassure• Verify chief complaint, obtain list of allergies,

medications, and medical history• Report to paramedics

Overview• Complete history, vital signs, and head to toe

examination• Reassess ABCs and look again for life threats• Treat life threats as soon as found• Treat other problems after the secondary survey• Report to paramedics

Patient Interview

hName

hAge

hChief Complaint (CC)

h Incident History

hS.A.M.P.L.E.

S.A.M.P.L.E.S - Signs and symptoms

A - Allergies

M - Medications

P - Previous medical history

L - Last oral intake

E - Events leading up to incident

Pain AssessmentO - Onset

P - Provocation

Q - Quality

R - Radiation

S - Severity

T - Time

Baseline AssessmentLevel of Consciousness (LOC)

hA.V.P.U

hPatient Alert to surroundings

hResponsive to Verbal stimulation

hResponsive to Painful stimulation

hUnresponsive to painful stimulation

hGlasgow Coma Scale (GCS)

Level of Awareness (LOA)

h Person / Place / Time

Baseline Vital SignsPulse:

h Rate (measure beats for 30 seconds and X 2)

hRhythm - regular or irregular

hVolume – weak or full

Normal Values:hAdult 60 - 90 bpm

hChild 80 - 150 bpm

hInfant 120 - 150 bpm

Baseline Vital SignsRespirations:

Rate (measure beats for 30 seconds and X 2)

Rhythm – regular or irregular

Volume – shallow or full

Normal Values:

hAdult 12 - 20

hChild 15 - 30

hInfant 25 - 50

Baseline Vital Signs

Skin:h Colour

h Temperature

h Condition

Blood Pressure (BP)h2 main techniques:

Palpation & auscultation

hSystolic reading(when heart is contracting)diastolic reading (betweenheartbeats)

hFollow along with the slides…

Blood Pressure Cuff Parts

Cuff

Pressure gauge

Inflation bulb

Air bladder(hidden inside cuff)

Step 1:Choose an appropriately sized cuff

• The cuff air bladdershould go about 80% of the way around the arm

• A wrong sized cuff will give a wrong reading; you may omit taking a BP if you don’t have the right cuff size The bladder takes up only

part of the cuff!

Step 2: Apply the cuff• Find the brachial artery

(between the tendon of the biceps and the humerus)

• Wrap the cuff securely around the upper arm with the “artery” marking pointing to the brachial artery pulse

• Make sure clothing is not caught under the cuff

Step 3: Inflate the cuff• Find the radial or

brachial pulse• Inflate the cuff until

you can no longer feel the pulse (this occurs at about the systolic blood pressure level)

• Inflate the cuff another 20 mmHg above that

Step 4: Apply the Stethoscope

• Place the diaphragm of the stethoscope over where the brachial pulse had been palpated

Step 5: Deflate the cuff• Deflate the cuff slowly

(2 mmHg/second)• Record the systolic

pressure when you first hear a “thud-thud-thud”

• Record the diastolic pressure when you lose the sounds or they become very quiet

Blood Pressure by PalpationhFind the radial pulsehApply the cuff as beforeh Inflate the cuff until the

radial pulse is lost; then inflate it another 20 mmHg

hDeflate cuff slowlyhSystolic pressure is when

radial pulse returnshDiastolic pressure is not

obtainedhRecord only systolic

reading

Normal Blood Pressure ValuesSystolic:

Adult: age + 100 (up to 150 mmHg)

Child : 2 x age + 80

Diastolic:

Adult: 65 - 90 mmHg

Child: 50 - 80 mmHg

Low or High Blood Pressures• Low blood pressures (below 90/60 in adults)

suggest shock (lack of blood flow to vital organs)

• Long term high blood pressures (above 160/100) can damage organs (heart, kidneys, brain); Sometimes this takes years

• Short term high blood pressures also occur with pain, fright, emotional upset

• Patients who ask about their blood pressure should be encouraged to ask their physicians about any concerns they may have

Pupils

hAre the Pupils Equal And Reactive to Light (PEARL) ?

hPupils may be dilated, constricted, or mid-size

Assess the headhObserve for discharge

(blood or fluid)

hAssess pupil size

hObserve for “Battle’s Sign”

hCLAPS-D and TICS-D

hReassess airway

Assess the neckhCLAPS-D

hTICS-D

hDistended neck veins (JVD)

hTracheal Deviation

Assess the chest & back

hCLAPS-D

hTICS-D

hAuscultation

* Reassess Critical Interventions

Assess the abdomenhPulsating Masses

hPalpate 4 quadrants

hCLAPS-D and TICS-D

hRigidity

hTenderness

Assess the pelvishCLAPS-D and TICS-D

hObserve for incontinence and / or blood

hStability in 3 planes

If any instability or crepitus is found, there should be no further assessment of the pelvis at any point

• Priapism?

Assess the lower extremities

hCLAPS-D

hTICS-D

hCirculation (skin colour and pulse in foot)

hSensation to touch

hMovement

Assess the upper extremitieshCLAPS-D

hTICS-D

hCirculation (skin colour and pulse)

hSensation

hMovement

Medical Report

• Patient’s name

hPatient’s age

hChief complaint

hIncident history

hTreatment

hVitals

hAssessment findings

hResponse to treatment

What we found

What we did

What we have now

What we found

What we did

What we have now

Pocket Medical Report• No patient name to be recorded on this form• Available to assist crews with assessment and reporting skills• PMR Given to TEMS crew with no copy required by TFS• Use PMR as a guide – not a mandatory TFS form

TORONTO FIRE SERVICES & SOCPC POCKET MEDICAL REPORT Incident address Age M Please read important information on the back of this form F Chief Complaint Incident History Primary/Secondary Survey Airway/Breathing/Circulation Level of consciousness (A V P U) Details Head/Neck Chest/Abdomen Pelvis/Extremities Past Medical History

Cardiac Respiratory Details Stroke Diabetes Seizures

Medications List (use reverse side) or collect medications & send with patient Allergies ASA Codeine Sulpha Penicillin Other? Time Pulse Blood Pressure Respirations 1st set / hr / ---------------------------------------------------------------------------------------------- 2nd set / hr / Treatment

CPR and defibrillation Oxygen C-spine support Splinting Wound dressing

Document 1.13

Important Instructions Due to patient confidentiality issues DO NOT include the patient’s name on the Pocket Medical Report. The patient’s name, if available, should be collected as it will be required for completion of the TFS ‘A’ form.

Summary

• A head to toe examination• Identified and treated any life threatening

conditions missed during the primary survey• Identified and treated non-life threatening

conditions after completion of the secondary survey

• Obtained and recorded vital signs, including blood pressure

• Establishing a dialogue with patient and family to collect information, confirm the chief complaint, and identify any other medical issues

• Organizing and delivering a patient report

In this module we have discussed and/or practiced:

Any Questions ?

Photography credits:

Michael FeldmanKirk FudgeUri RateneksBill SaultNatasha Skvorets