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Transcript of Paramedic Care: Principles & Practice Volume 3: Patient Assessment CHAPTER Fourth Edition Patient...
Paramedic Care: Principles & Paramedic Care: Principles & PracticePractice
Volume 3: Patient AssessmentVolume 3: Patient Assessment
CHAPTER
Fourth EditionFourth Edition
Patient Assessmentin the Field
7
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Standard
• Assessment
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Competency
• Integrate scene and patient assessment findings with knowledge of epidemiology and pathophysiology to form a field impression.
• This includes developing a list of differential diagnoses through clinical reasoning to modify the assessment and formulate a treatment plan.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Introduction
• Patient assessment: problem-oriented evaluation of patient; establishing priorities of care.
• Patient's condition determines components you use; how to use them.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Introduction
• Proficiency in performing patient assessment will determine your ability to deliver highest quality of prehospital advanced life support (ALS).
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Scene Size-Up
• First stage of every emergency call.
• Ensure safe environment.• Take necessary precautions for personal protection.
• Determine what resources needed.• Locate all patients.• Assess mechanism of injury (MOI) or nature of medical illness.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Primary Assessment
• Determine whether patient “looks dead or doesn't look dead.”
• If patient looks dead, quickly assess responsiveness and breathing.
• If pulse absent, begin chest compressions immediately.
• If patient shows signs of life, conduct primary assessment (ABC).
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Primary Assessment
• Steps of Primary Assessment– Form general impression– Stabilize cervical spine as needed– Assess baseline mental status– Assess airway– Assess breathing– Assess circulation– Assign priority
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Manually stabilize the head and neck on first patient contact.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Primary Assessment
• Should take less than 1 minute, unless you intervene with lifesaving measures.
• Do not delay transport for detailed assessments and procedures.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Vital signs, followed by focused history and physical exam.
• Based on primary assessment and patient's chief complaint.
• Includes monitoring technology.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Types of Patients– Major trauma patient with significant injury or altered mental status
– Minor trauma patient with isolated injury
– Responsive medical patient– Unresponsive medical patient
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• The Major Trauma Patient– Primary assessment.– Rapid secondary assessment.– Package patient.– Rapid transport to emergency department.
– Perform reassessment and treatments en route.
– MOI could be life-threatening.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Predictors of Serious Internal Injury– Fall from more than 20 feet– Automobile crash with intrusion– Ejection from vehicle– Death in same passenger compartment– Automobile–pedestrian collision– Automobile–bicycle collision– Motorcycle crash
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• MOIs can result from seat belts, air bags, child safety seats.
• Look for hidden internal injuries.• Physical signs of trauma confirm index of suspicion.
• If in doubt, transport patient to medical facility without delay; always best to err on side of precaution.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment– To identify all other life-threatening conditions.
– Assess patient systematically; avoid tunnel vision.
– Maintain spinal immobilization throughout rapid trauma exam.
– Reconsider decision to transport; things can change unexpectedly.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment– Assess mental status using AVPU mnemonic.
– Compare findings with baseline mental status from initial assessment.
– Pay special attention to head, neck, chest, abdomen, pelvis.
– Major concern: internal injuries beneath superficial wounds.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment– Deformities, contusions, abrasions, penetrations, burns, tenderness, lacerations, swelling.
– Assess head for injuries and crepitus.– Simple scalp laceration can cause life-threatening hemorrhage.
– Altered mental status and abnormality in structure of skull: serious emergency.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment– Inspect and palpate neck for injuries and crepitus; significant blood loss quickly.
– Examine jugular veins for abnormal distention.
– Inspect and palpate trachea.– Inspect and palpate neck for subcutaneous emphysema.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment– Palpate posterior neck for evidence of spinal trauma.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–1Rapid Secondary Assessment—
The Head and Neck
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–1 Rapid Secondary Assessment—The Head and Neck7-1a The first step in the rapid secondary assessment is to palpate the head.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–1 Rapid Secondary Assessment—The Head and Neck7-1b Periodically examine your gloves for blood.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–1 Rapid Secondary Assessment—The Head and Neck7-1c Inspect and palpate the anterior neck. Pay particular attention to tracheal deviation and subcutaneous emphysema.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–1 Rapid Secondary Assessment—The Head and Neck7-1d Inspect and palpate the posterior neck. Note any tenderness, irregularity, or edema.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment– Look for signs of acute respiratory distress.
– Quickly inspect and then palpate chest.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment– Be careful when palpating ribs; look for erythema caused by impact to ribs.
– Suspect major damage to underlying organs, especially vascular structures, when ribs broken.
– Observe for equal, symmetrical, effortless chest rise.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment– Flail chest greatly reduces air movement.
– Inspect patient's chest and back for open wounds.
– Seal any open wounds with occlusive dressing; tape dressing on three sides.
– Auscultate both lungs quickly at midaxillary line for air movement.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–2 Rapid Secondary Assessment—The Chest7-2c Seal any sucking chest wound with tape on three sides.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment– Tension pneumothorax: life-threatening condition.
– Inspect and palpate abdomen for injuries and crepitus.
– Note areas of bruising and guarding.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–2Rapid Secondary Assessment—
The Chest
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–2 Rapid Secondary Assessment—The Chest7-2a Palpate the clavicles.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–2 Rapid Secondary Assessment—The Chest7-2b Stabilize a flail chest.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–2 Rapid Secondary Assessment—The Chest7-2c Seal any sucking chest wound with tape on three sides.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–2 Rapid Secondary Assessment—The Chest7-2d Perform needle decompression to relieve tension pneumothorax if authorized.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment– Inspect and palpate abdomen for injuries and crepitus.
– Note areas of bruising and guarding.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment– Bruising over umbilicus (Cullen's sign).
– Bruising over flanks (Grey Turner's sign).
– Both signs indicate intraabdominal hemorrhage; immediate transport to medical facility for surgery.
– Test for rebound tenderness.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment– Examine pelvis for injuries and crepitus; stable pelvic ring.
– Evaluate pelvic ring at iliac crests and symphysis pubis.
– Immobilize pelvis before transport to prevent movement and possible circulatory catastrophe.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–3 Rapid Secondary Assessment—The Chest7-3a Assess the integrity of the pelvis by gently pressing medially on the pelvic ring.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment– Inspect and palpate all four extremities for injuries and crepitus.
– Splint fractures en route to hospital.– Evaluate distal neurovascular function.
– Inability to feel and move both legs indicates complete spinal cord disruption.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–3 Rapid Secondary Assessment—The Chest7-3f Assess distal sensation and motor function.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment– Diminished sensation, paresthesias, or diminished motor ability indicates partial disruption.
– Weakness or disability on only one side of body suggests brain injury due to stroke or head injury.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–3Rapid Secondary Assessment—The Pelvis and Extremities
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–3 Rapid Secondary Assessment—The Chest7-3a Assess the integrity of the pelvis by gently pressing medially on the pelvic ring.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–3 Rapid Secondary Assessment—The Chest7-3b Compress the pelvis posteriorly.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–3 Rapid Secondary Assessment—The Chest7-3c Palpate the legs.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–3 Rapid Secondary Assessment—The Chest7-3d Palpate the arms.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–3 Rapid Secondary Assessment—The Chest7-3e Palpate the dorsalis pedis pulse to evaluate distal circulation in the leg.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–3 Rapid Secondary Assessment—The Chest7-3f Assess distal sensation and motor function.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment– Check for MedicAlert tags.– Log-roll patient onto side to inspect posterior body; note tenderness in spinal area.
– History: chief complaint, history of present illness, past history, current health status.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Inspect and palpate the posterior body.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• SAMPLE History– Symptoms– Allergies– Medications– Pertinent past medical history– Last oral intake– Events leading up to the incident
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• The Minor Trauma Patient– Isolated injury; no significant MOI; no signs of systemic involvement.
– Does not require extensive history or comprehensive physical exam.
– Ensure hemodynamic status via primary assessment.
– Secondary assessment on specific isolated injury.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• The Responsive Medical Patient– History takes precedence over physical exam.
– Physical exam: identifies signs of medical complications rather than injury.
– Conscious, alert patients can tell you about their illness.
– Chief complaint: pain, discomfort, or dysfunction; patient requested help.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Begin treatment while you assess your responsive medical patient.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• The Responsive Medical Patient– Present problem: circumstances surrounding chief complaint.
– Follow acronym OPQRST–ASPN.– Past medical history: insights into chief complaint and field diagnosis.
– Family/social history: history of serious disease may be “red flag” in the case.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• OPQRST–ASPN– Onset– Provocation/Palliation– Quality– Region/Radiation– Severity– Time– Associated Symptoms– Pertinent Negatives
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• The Responsive Medical Patient– Review of systems: system-by-system list of questions more specific than those asked during basic history.
– Begin focused physical exam based on information elicited from patient.
– Cardiac chest pain/respiratory distress, altered mental status, acute abdomen.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• The Unresponsive Medical Patient– Begin with primary assessment.– Rapid head-to-toe exam.– Brief history from family or friends.
– Airway protected.– Assess head, neck, chest, abdomen, pelvis, extremities, posterior aspect of body.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• The Unresponsive Medical Patient– Assess baseline vital signs.– Perform additional tests.– Consider unresponsive patient unstable.
– Expedite transport to hospital.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Reassessment
• Patient condition can change suddenly.
• Reassess mental status, airway patency, breathing adequacy, circulation, any deterioration.
• Every 15 minutes for stable patients.
• Every 5 minutes for unstable patients.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–4Reassessment
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–4 Reassessment7-4a Reevaluate the ABCs.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–4 Reassessment7-4b Take all vital signs again.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–4 Reassessment7-4c Perform your focused assessment again.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–4 Reassessment7-4d Evaluate your interventions' effects.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Reassessment
• Mental Status– Recheck mental status by performing AVPU exam frequently during transport.
– Falling level of response indicates direct or indirect brain pathology.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Reassessment
• Airway Patency– Can change instantly.– Endotracheal intubation best way to secure airway in patients with no gag reflex.
– Be prepared for the worst.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Reassessment
• Breathing Rate and Quality– Sudden increase in rate or respiratory effort suggests deterioration.
– Subtle increases in respiratory rate can suggest developing problem.
– Decrease in rate and effort could mean treatments are effective.
– Requires constant reevaluation.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Reassessment
• Pulse Rate and Quality– Rising pulse rate: shock, hypoxia, cardiac dysrhythmia.
– Falling rate: terminal stage of shock or rise in intracranial pressure.
– Sudden change in rate or regularity: cardiac dysrhythmia.
– Loss of peripheral pulses: decompensating shock.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Reassessment
• Skin Condition– Reflects body's hemodynamic status.
– Reevaluate skin color, temperature, condition.
• Transport Priorities– Depending upon patient status, you may need to either upgrade or downgrade transport decision.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Reassessment
• Vital Signs– Reassessing vital signs reveals trends.
– Reevaluate critical patients every 5 minutes.
• Secondary Assessment– Repeat focused assessment as chief complaint dictates.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Reassessment
• Effects of Interventions– Know expected therapeutic benefits of interventions; evaluate whether they worked.
• Management Plans– Evaluate whether care is working. – If not, consider another management plan.
– Be flexible to change course of action.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Clinical Decision Making
• Critical Thinking– Form concept– Interpret data– Apply principles– Evaluate results– Reflect on incident
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Clinical Decision Making
• Form a Concept– Assess general environment and immediate surroundings.
– Conduct initial assessment.– Chief complaint, history of present illness, past history, current health status.
– Conduct focused physical exam.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Clinical Decision Making
• Interpret the Data– Consider all data.– Determine most common and statistically probable conditions that fit patient's initial presentation.
– Differential field diagnosis.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Clinical Decision Making
• Apply the Principles– Devise management plan that covers all contingencies.
• Evaluate the Results– Reassess patient's condition and effects of protocol interventions.
– Determine whether treatment improving patient's condition and status.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Clinical Decision Making
• Reflect on the Case– Discuss field diagnosis and care with emergency physician.
– Compare field diagnosis with physician's diagnosis.
– Conduct run critique with your crew.
– With every patient contact, your experience grows and clinical judgment improves.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Patient assessment is key to providing effective prehospital emergency medical care.
• Primary assessment, secondary assessment, vital signs, reassessment.
• Primary assessment: identify and treat life-threatening airway, breathing, circulation problems.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Secondary assessment: identify signs and symptoms surrounding chief complaint.
• Problem-oriented approach; easily modified to match patient's clinical situation.
• Reassessment: reevaluate patient for changes in status en route to hospital.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Trauma patient with significant MOI: primary assessment, rapid secondary assessment, rapid transport.
• Patient with isolated, minor trauma: physical exam focused on particular problem or area.
• Responsive medical patient: primary and secondary assessment; focused on chief complaint, vital signs.
©2013 Pearson Education, Inc.Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Unresponsive medical patient: primary assessment; rapid secondary assessment and rapid transport.
• You will be expected to use clinical judgment when deciding which assessment tools to use.