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Patient Assessment Chapter 8

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

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Patient Assessment Process

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

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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 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

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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 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

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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. 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.

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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 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

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Nature of Illness Search for clues to determine the nature of illness. Often described by the patients chief complaint Gather information from the patient and people on scene. Observe the scene Search for clues to determine the nature of illness. Often described by the patients chief complaint Gather information from the patient and people on scene. Observe the scene

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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. 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.

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Number of Patients Determine the number of patients and their condition. Assess what additional resources will be needed. Triage to identify severity of each patients condition. Determine the number of patients and their condition. Assess what additional resources will be needed. Triage to identify severity of each patients condition.

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

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

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Patient Assessment Process

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

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Develop a General Impression Occurs as you approach the scene and the patient Assessment of the environment Patients chief complaint Presenting signs and symptoms of patient Occurs as you approach the scene and the patient Assessment of the environment Patients chief complaint Presenting signs and symptoms of patient

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Obtaining Consent Introduce self. Ask patients name. Obtain consent. Introduce self. Ask patients name. Obtain consent.

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

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

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Testing Responsiveness AAlert VResponsive to Verbal stimulus PResponsive to Pain UUnresponsive AAlert VResponsive to Verbal stimulus PResponsive to Pain UUnresponsive

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Testing Orientation Person Place Time Event Person Place Time Event

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

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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 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

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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 Obvious trauma, blood, or other obstruction Noisy breathing such as bubbling, gurgling, crowing, or other abnormal sounds Extremely shallow or absent breathing

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

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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 Breathing faster than 20 breaths/min Breathing slower than 12 breaths/min Breathing too shallow Decreased level of consciousness Respiratory distress Poor skin color

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Positioning the Patient Position of comfort Sitting up with feet dangling High Fowlers position Spinal precautions if possible spinal injury Position of comfort Sitting up with feet dangling High Fowlers position Spinal precautions if possible spinal injury

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Assessing the Pulse Presence Rate Rhythm Strength Presence Rate Rhythm Strength

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Normal Pulse Rates in Infants and Children AgeRange (beats/min) Infant: 1 month to 1 year100 to 160 Toddler: 1 to 3 years90 to 150 Preschool-age: 3 to 6 years80 to 140 School-age: 6 to 12 years70 to 120 Adolescent: 12 to 18 years60 to 100

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

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Assessing Perfusion Color Temperature Skin condition Capillary refill Color Temperature Skin condition Capillary refill

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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 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

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

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Patient Assessment Process

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

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

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

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

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Components of a Rapid Physical Exam

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Maintain spinal immobilization while checking patients ABCs. Assess the head. Assess the neck. Apply a cervical spine immobilization collar. Maintain spinal immobilization while checking patients ABCs. Assess the head. Assess the neck. Apply a cervical spine immobilization collar.

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

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

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Focused Physical Exam Used to evaluate patients chief complaint Performed on: Trauma patients without significant MOI Responsive medical patients Used to evaluate patients chief complaint Performed on: Trauma patients without significant MOI Responsive medical patients

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

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

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

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

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

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

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

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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 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

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

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

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

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

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Patient Assessment Process

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Detailed Physical Exam More in-depth exam based on focused physical exam Should only be performed if time and patients condition allows Usually performed en route to the hospital More in-depth exam based on focused physical exam Should only be performed if time and patients condition allows Usually performed en route to the hospital

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Performing the Detailed Physical Exam

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

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Pull the patients ear forward to assess for bruising. Use the penlight to look for drainage or blood in the ears. Pull the patients ear forward to assess for bruising. Use the penlight to look for drainage or blood in the ears.

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

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Palpate the maxillae. Palpate the mandible Palpate the maxillae. Palpate the mandible

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

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

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

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

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

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

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Patient Assessment Process

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Ongoing Assessment Is treatment improving the patients condition? Has an already identified problem gotten better? Worse? What is the nature of any newly identified problems? Is treatment improving the patients condition? Has an already identified problem gotten better? Worse? What is the nature of any newly identified problems?

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