8: Patient Assessment

Scene Size-up Objectives (1 of 2)

Cognitive 3-1.1 Recognize hazards/potential hazards. 3-1.2 Describe common hazards found at the scene of a trauma and a medical patient. 3-1.3 Determine if the scene is safe to enter. 3-1.4 Discuss common mechanisms of injury/nature of illness. 3-1.5 Discuss the reason for identifying the total number of patients at the scene. 3-1.6 Explain the reason for identifying the need for additional help or assistance.

Scene Size-up Objectives (2 of 2)

Affective 3-1.7 Explain the rationale for crew members to evaluate scene safety prior to entering. 3-1.8 Serve as a model for others explaining how patient situations affect your evaluation of mechanism of injury or illness. Psychomotor 3-1.9 Observe various scenarios and identify potential hazards.

Initial Assessment Objectives (1 of 7)

Cognitive 3-2.1 Summarize the reasons for forming a general impression of the patient. 3-2.2 Discuss methods of assessing altered mental status. 3-2.3 Differentiate between assessing the altered mental status in the adult, child, and infant patient. 3-2.4 Discuss methods of assessing the airway in the adult, child, and infant patient. 3-2.5 State reasons for management of the cervical spine once the patient has been determined to be a trauma patient.

Initial Assessment Objectives (2 of 7)

3-2.6 Describe methods used for assessing if a patient is breathing. 3-2.7 State what care should be provided to the adult, child, and infant patient with adequate breathing. 3-2.8 State what care should be provided to the adult, child, and infant patient without adequate breathing. 3-2.9 Differentiate between a patient with adequate and inadequate breathing. 3-2.10 Distinguish between methods of assessing breathing in the adult, child, and infant patient.

Initial Assessment Objectives (3 of 7)

3-2.11 Compare the methods of providing airway care to the adult, child, and infant patient. 3-2.12 Describe the methods used to obtain a pulse. 3-2.13 Differentiate between obtaining a pulse in an adult, child, and infant patient. 3-2.14 Discuss the need for assessing the patient for external bleeding. 3-2.15 Describe normal and abnormal findings when assessing skin color. 3-2.16 Describe normal and abnormal findings when assessing skin temperature.

Initial Assessment Objectives (4 of 7)

3-2.17 Describe normal and abnormal findings when assessing skin condition. 3-2.18 Describe normal and abnormal findings when assessing skin capillary refill in the infant and child patient. 3-2.19 Explain the reason for prioritizing a patient for care and transport.

Initial Assessment Objectives (5 of 7)

Affective 3-2.20 Explain the importance of forming a general impression of the patient. 3-2.21 Explain the value of performing an initial assessment.

Initial Assessment Objectives (6 of 7)

Psychomotor 3-2.22 Demonstrate the techniques for assessing mental status. 3-2.23 Demonstrate the techniques for assessing the airway. 3-2.24 Demonstrate the techniques for assessing if the patient is breathing. 3-2.25 Demonstrate the techniques for assessing if the patient has a pulse.

Initial Assessment Objectives (7 of 7)

3-2.26 Demonstrate the techniques for assessing the patient for external bleeding. 3-2.27 Demonstrate the techniques for assessing the patient's skin color, temperature, condition, and capillary refill (infants and children only). 3-2.28 Demonstrate the ability to prioritize patients.

Focused History and Physical Exam: Trauma Objectives (1 of 3)

Cognitive 3-3.1 Discuss the reasons for reconsideration concerning the mechanism of injury. 3-3.2 State the reasons for performing a rapid trauma assessment. 3-3.3 Recite examples and explain why patients should receive a rapid trauma assessment. 3-3.4 Describe the areas included in the rapid trauma assessment and discuss what should be evaluated.

Focused History and Physical Exam: Trauma Objectives (2 of 3)

3-3.5 Differentiate when the rapid assessment may be altered in order to provide patient care. 3-3.6 Discuss the reason for performing a focused history and physical exam. Affective 3-3.7 Recognize and respect the feelings that patients might experience during assessment.

Focused History and Physical Exam: Trauma Objectives (3 of 3)

Psychomotor 3-3.8 Demonstrate the rapid trauma assessment that should be used to assess a patient based on mechanism of injury.

Focused History and Physical Exam: Medical Patients Objectives (1 of 3)

Cognitive 3-4.1 Describe the unique needs for assessing an individual with a specific chief complaint with no known prior history. 3-4.2 Differentiate between the history and physical exam that are performed for responsive patients with no known prior history and responsive patients with a known prior history. 3-4.3 Describe the needs for assessing an individual who is unresponsive.

Focused History and Physical Exam: Medical Patients Objectives (2 of 3)

3-4.4 Differentiate between the assessment that is performed for a patient who is unresponsive or has an altered mental status and other medical patients requiring assessment.

Affective 3-4.5 Attend to the feelings that these patients might be experiencing.

Focused History and Physical Exam: Medical Patients Objectives (3 of 3)

Psychomotor 3-4.6 Demonstrate the patient care skills that should be used to assist a patient who is responsive with no known history. 3-4.7 Demonstrate the patient care skills that should be used to assist a patient who is unresponsive or has an altered mental status.

Detailed Physical Exam Objectives (1 of 2)

Cognitive 3-5.1 Discuss the components of the detailed physical exam. 3-5.2 State the areas of the body that are evaluated during the detailed physical exam.

3-5.3 Explain what additional care should be provided while performing the detailed physical exam.
3-5.4 Distinguish between the detailed physical exam that is performed on a trauma patient and that of the medical patient.

Detailed Physical Exam Objectives (2 of 2)

Affective 3-5.5 Explain the rationale for the feelings that these patients might be experiencing. Psychomotor 3-5.6 Demonstrate the skills involved in performing the detailed physical exam.

Ongoing Assessment Objectives (1 of 2)

Cognitive 3-6.1 Discuss the reason for repeating the initial assessment as part of the ongoing assessment.

3-6.2 Describe the components of the ongoing assessment.

3-6.3 Describe trending of assessment components.

Affective
3-6.4 Explain the value of performing an ongoing assessment.

Ongoing Assessment Objectives (2 of 2)

3-6.5 Recognize and respect the feelings that patients might experience during assessment.

3-6.6 Explain the value of trending assessment components to other health professionals who assume care of the patient. Psychomotor
3-6.7 Demonstrate the skills involved in performing the ongoing assessment.

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

Patient Assessment Process

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

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

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

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.

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

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.

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.

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.

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

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

Patient Assessment Process

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

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

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

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

Assessing Mental Status

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

Testing Responsiveness
A V P U Alert Responsive to Verbal stimulus Responsive to Pain Unresponsive

Testing Orientation
Person Place Time Event

Caring for Abnormal Mental Status

Complete initial assessment. Provide high-flow oxygen. Consider spinal immobilization. Initiate transport. Support ABCs. Reassess.

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

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

Assessing Breathing
Choking Rate Depth Cyanosis Lung sounds Air movement

Assessing Breath Sounds

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

Positioning the Patient

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

Assessing the Pulse

Presence Rate Rhythm Strength

Normal Pulse Rates in Infants and Children

Age Infant: 1 month to 1 year Toddler: 1 to 3 years Preschool-age: 3 to 6 years Range (beats/min) 100 to 160 90 to 150 80 to 140

School-age: 6 to 12 years
Adolescent: 12 to 18 years

70 to 120
60 to 100

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

Assessing Perfusion
Color Temperature Skin condition Capillary refill

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

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

Patient Assessment Process

Goals of the Focused History and Physical Exam

Understand the circumstances surrounding the chief complaint. Obtain objective measurements. Perform physical exam.

Components of Focused History and Physical Exam

Medical history Baseline vital signs Physical exam

Rapid Physical Exam

60-90 second head-totoe exam Performed on: Significant trauma patients Unresponsive medical patients Identifies undiscovered conditions

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

Components of a Rapid Physical Exam (1 of 3)

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

Components of a Rapid Physical Exam (2 of 3)

Assess the chest.
Assess the abdomen. Assess the pelvis.

Components of a Rapid Physical Exam (3 of 3)

Assess all four extremities. Roll the patient with spinal precautions.

Focused Physical Exam

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

Head, Neck, and Cervical Spine

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

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

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

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

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

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

Specific Chief Complaints

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

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

Assessment Steps for Significant MOI

Rapid trauma assessment Baseline vital signs SAMPLE history Reevaluate transport decision

Assessment Steps for Trauma Patients Without Significant MOI

Focused assessment Baseline vital signs SAMPLE history Reevaluate transport decision

Responsive Medical Patients

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

Unresponsive Medical Patients

Rapid medical assessment Baseline vital signs SAMPLE history Reevaluate transport decision

Patient Assessment Process

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

Performing the Detailed Physical Exam (1 of 10)

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

Performing the Detailed Physical Exam (2 of 10)

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

Performing the Detailed Physical Exam (3 of 10)

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

Performing the Detailed Physical Exam (4 of 10)

Palpate the maxillae. Palpate the mandible.

Performing the Detailed Physical Exam (5 of 10)

Assess the mouth and nose for obstructions and cyanosis.

Check for unusual odors.

Performing the Detailed Physical Exam (6 of 10)

Look at the neck. Palpate the front and the back of the neck.

Look for distended jugular veins.

Performing the Detailed Physical Exam (7 of 10)

Look at the chest. Gently palpate over the ribs.

Performing the Detailed Physical Exam (8 of 10)

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

Performing the Detailed Physical Exam (9 of 10)

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

Gently compress the pelvis.

Performing the Detailed Physical Exam (10 of 10)

Gently press the iliac crests. Inspect all four extremities.

Assess the back for tenderness or deformities.

Patient Assessment Process

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?

Steps of the Ongoing Assessment

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