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Section 3: Patient Assessment. Chapter 8 Patient Assessment.
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Transcript of Section 3: Patient Assessment. Chapter 8 Patient Assessment.
Section 3: Patient Assessment
Chapter 8
Patient Assessment
Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS
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3: Patient Assessment
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
Objectives (1 of 9)
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3: Patient Assessment
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
Objectives (2 of 9)
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3: Patient Assessment
• 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
Objectives (3 of 9)
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3: Patient Assessment
• 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
Objectives (4 of 9)
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3: Patient Assessment
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
Objectives (5 of 9)
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3: Patient Assessment
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
Objectives (6 of 9)
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3: Patient Assessment
• Describe the unique needs of assessing an unresponsive patient
• Differentiate between the assessment performed on an unresponsive patient and other medical patients
Objectives (7 of 9)
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3: Patient Assessment
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
Objectives (8 of 9)
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3: Patient Assessment
Ongoing Assessment
• Discuss the reason for repeating the initial assessment
• Describe the components of the ongoing assessment
• Describe trending of assessment components
Objectives (9 of 9)
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3: Patient Assessment
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
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3: Patient Assessment
The Patient Assessment Process
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3: Patient Assessment
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
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3: Patient Assessment
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
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3: Patient Assessment
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.
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3: Patient Assessment
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
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3: Patient Assessment
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
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3: Patient Assessment
Falls
• Amount of force related to height of fall
• Note surface that patient landed on
• Attempt to determine how patient landed
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3: Patient Assessment
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
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3: Patient Assessment
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.
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3: Patient Assessment
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.
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3: Patient Assessment
Patient Assessment Process
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3: Patient Assessment
Components of the Initial Assessment
• Develop a general impression• Assess mental status• Assess airway• Assess the adequacy of
breathing• Assess circulation• Identify patient priority
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3: Patient Assessment
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
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3: Patient Assessment
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.
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3: Patient Assessment
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.
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3: Patient Assessment
Level of Consciousness
• A Alert
• V Responsive to Verbal stimulus
• P Responsive to Pain
• U Unresponsive
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3: Patient Assessment
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
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3: Patient Assessment
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
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3: Patient Assessment
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?
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3: Patient Assessment
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.
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3: Patient Assessment
Unresponsive Patients
• Look, listen and feel technique
• Consider spinal cord injury.
• Provide high-flow oxygen.
• Assist ventilations if needed.
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3: Patient Assessment
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
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3: Patient Assessment
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
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3: Patient Assessment
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.
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3: Patient Assessment
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
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3: Patient Assessment
Patient Assessment Process
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3: Patient Assessment
Goals of Exam
• Identify the patient’s chief complaint.
• Understand the specific circumstances surrounding the chief complaint.
• Direct further physical examination.
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3: Patient Assessment
The Golden Hour
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3: Patient Assessment
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
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3: Patient Assessment
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
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3: Patient Assessment
Hidden Injuries
• Seat belts
• May cause injuries if worn improperly
• Airbags
• Look beneath airbag for bent steering wheel.
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3: Patient Assessment
Trauma Assessment
• D Deformities
• C Contusions
• A Abrasions
• P Punctures/ Penetrations
• B Burns
• T Tenderness
• L Lacerations
• S Swelling
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3: Patient Assessment
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.
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3: Patient Assessment
Rapid Trauma Assessment (2 of 3)
• Assess the chest.
• Assess the abdomen.
• Assess the pelvis.
• Assess all four extremities.
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3: Patient Assessment
Rapid Trauma Assessment (3 of 3)
• Roll the patient with spinal precautions.
• Assess baseline vital signs and SAMPLE history.
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3: Patient Assessment
Head, Neck, and Cervical Spine
• Feel head and neck for deformity, tenderness, or crepitation.
• Check for bleeding.
• Ask about pain or tenderness.
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3: Patient Assessment
Chest
• Watch chest rise and fall with breathing.
• Feel for grating bones as patient breathes.
• Listen to breath sounds.
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3: Patient Assessment
Abdomen
• Look for obvious injury, bruises, or bleeding.
• Evaluate for tenderness and any bleeding.
• Do not palpate too hard.
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3: Patient Assessment
Pelvis
• Look for any signs of obvious injury, bleeding, or deformity.
• Press gently inward and downward on pelvic bones.
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3: Patient Assessment
Extremities
• Look for obvious injuries.• Feel for deformities.• Assess
• Pulse• Motor function• Sensory function
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3: Patient Assessment
Back
• Feel for tenderness, deformity, and open wounds.
• Carefully palpate from neck to pelvis.
• Look for obvious injuries.
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3: Patient Assessment
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.
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3: Patient Assessment
SAMPLE SAMPLE History• S Signs and symptoms
• A Allergies
• M Medications
• P Past medical history
• L Last oral intake
• E Events leading to the episode
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3: Patient Assessment
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
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3: Patient Assessment
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
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3: Patient Assessment
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
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3: Patient Assessment
Patient Assessment Process
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3: Patient Assessment
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.
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3: Patient Assessment
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
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3: Patient Assessment
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?
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3: Patient Assessment
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?
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3: Patient Assessment
Focused Physical Exam
• Investigate problems associated with chief complaint.
• Examine abnormalities.
• Reassess vital signs.
• Make transportation decision.
• Document findings.
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3: Patient Assessment
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.
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3: Patient Assessment
Patient Assessment Process
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3: Patient Assessment
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
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3: Patient Assessment
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.
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3: Patient Assessment
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.
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3: Patient Assessment
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.
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3: Patient Assessment
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.
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3: Patient Assessment
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.
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3: Patient Assessment
Patient Assessment Process
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3: Patient Assessment
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?
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3: Patient Assessment
Steps of the Ongoing Assessment
• Repeat the initial assessment.
• Reassess and record vital signs.
• Repeat focused assessment.
• Check interventions.
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3: Patient Assessment
Review
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3: Patient Assessment
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.