Section 3: Patient Assessment

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

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

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

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

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

8
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

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

10
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

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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

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

13
The Patient Assessment Process
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

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

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.

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

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

19
Falls

• Amount of force related to height of fall
• Note surface that patient landed on
• Attempt to determine how patient landed

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

21
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.

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 patients
  condition.

23
Patient Assessment Process
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Components of the Initial Assessment

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

25
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

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.

27
Assessing Mental Status

• Checking responsiveness
• Assess how well the patient responds to external
  stimuli.
• Check for orientation
• Check the patients 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.

28
Level of Consciousness

• A Alert
• V Responsive to Verbal stimulus
• P Responsive to Pain
• U Unresponsive

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

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

31
Assessing Breathing

• Are the patients 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?

32
Managing Breathing

• If patient is having difficulty breathing
  reevaluate airway.
• Consider assisting ventilations with a BVM or
  applying a nonrebreathing mask if patients
  respirations are greater than 24/min or less than
  8/min.

33
Unresponsive Patients

• Look, listen and feel technique
• Consider spinal cord injury.
• Provide high-flow oxygen.
• Assist ventilations if needed.

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

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

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.

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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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Patient Assessment Process
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Goals of Exam

• Identify the patients chief complaint.
• Understand the specific circumstances surrounding
  the chief complaint.
• Direct further physical examination.

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The Golden Hour
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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 head, chest, or abdomen

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

43
Hidden Injuries

• Seat belts
• May cause injuries if worn improperly
• Airbags
• Look beneath airbag for bent steering wheel.

44
Trauma Assessment

• D Deformities
• C Contusions
• A Abrasions
• P Punctures/ Penetrations

• B Burns
• T Tenderness
• L Lacerations
• S Swelling

45
Rapid Trauma Assessment (1 of 3)

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

46
Rapid Trauma Assessment (2 of 3)

• Assess the chest.
• Assess the abdomen.
• Assess the pelvis.
• Assess all four extremities.

47
Rapid Trauma Assessment (3 of 3)

• Roll the patient with spinal precautions.
• Assess baseline vital signs and SAMPLE history.

48
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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Chest

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

50
Abdomen

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

51
Pelvis

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

52
Extremities

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

53
Back

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

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.

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SAMPLE History

• S Signs and symptoms
• A Allergies
• M Medications
• P Past medical history
• L Last oral intake
• E Events leading to the episode

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

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

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

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Patient Assessment Process
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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
  patients words.
• Use OPQRST to gather history of present illness.

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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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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?

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?

64
Focused Physical Exam

• Investigate problems associated with chief
  complaint.
• Examine abnormalities.
• Reassess vital signs.
• Make transportation decision.
• Document findings.

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.

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Patient Assessment Process
67
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

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 patients ear forward to assess for
  bruising.

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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.

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.

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.

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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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Patient Assessment Process
74
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?

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Steps of the Ongoing Assessment

• Repeat the initial assessment.
• Reassess and record vital signs.
• Repeat focused assessment.
• Check interventions.

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Review
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.