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Patient Assessment. Chapter 8. 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

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Patient assessment

Patient Assessment

Chapter 8


Patient assessment1

Patient Assessment

  • Scene size-up

  • Initial assessment

  • Focused history and physical exam

    • Vital signs

    • History

  • Detailed physical exam

  • Ongoing assessment


Patient assessment process

Patient Assessment Process


Scene size up

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

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

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

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

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

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


The importance of moi noi

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

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.


Additional resources

Additional Resources

  • Medical resources

    • Additional units

    • Advanced life support

  • Nonmedical resources

    • Fire suppression

    • Rescue

    • Law enforcement


C spine immobilization

C-Spine Immobilization

  • Consider early during assessment.

  • Do not move without immobilization.

  • Err on the side of caution.


Patient assessment process1

Patient Assessment Process


Initial assessment

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

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


Obtaining consent

Obtaining Consent

  • Introduce self.

  • Ask patient’s name.

  • Obtain consent.


Chief complaint

Chief Complaint

  • Most serious problem voiced by the patient

  • May not be the most significant problem present


Assessing mental status

Assessing Mental Status

  • Responsiveness

    • How the patient responds to external stimuli

  • Orientation

    • Mental status and thinking ability


Testing responsiveness

Testing Responsiveness

  • AAlert

  • VResponsive to Verbal stimulus

  • PResponsive to Pain

  • UUnresponsive


Testing orientation

Testing Orientation

  • Person

  • Place

  • Time

  • Event


Caring for abnormal mental status

Caring for Abnormal Mental Status

  • Complete initial assessment.

  • Provide high-flow oxygen.

  • Consider spinal immobilization.

  • Initiate transport.

  • Support ABCs.

  • Reassess.


Assessing the airway

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

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

Assessing Breathing

  • Choking

  • Rate

  • Depth

  • Cyanosis

  • Lung sounds

  • Air movement


High flow oxygen administration

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

Positioning the Patient

  • Position of comfort

    • Sitting up with feet dangling

    • High Fowler’s position

  • Spinal precautions if possible spinal injury


Assessing the pulse

Assessing the Pulse

  • Presence

  • Rate

  • Rhythm

  • Strength


Normal pulse rates in infants and children

Normal Pulse Rates in Infants and Children


Assessing and controlling external bleeding

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

Assessing Perfusion

  • Color

  • Temperature

  • Skin condition

  • Capillary refill


Priority patients

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

Transport Decision

  • Patient condition

  • Availability of advanced care

  • Distance to transport

  • Local protocols


Patient assessment process2

Patient Assessment Process


Focused history and physical exam

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

Components of Focused History and Physical Exam

  • Medical history

  • Baseline vital signs

  • Physical exam


Rapid physical exam

Rapid Physical Exam

  • 60-90 second head-to-toe exam

  • Performed on:

    • Significant trauma patients

    • Unresponsive medical patients

  • Identifies undiscovered conditions


Dcap btls

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

Components of a Rapid Physical Exam


Patient assessment

  • Maintain spinal immobilization while checking patient’s ABCs.

  • Assess the head.

  • Assess the neck.

  • Apply a cervical spine immobilization collar.


Patient assessment

  • Assess the chest.

    • Include presence of

      lung sounds

  • Assess the abdomen.

  • Assess the pelvis.


Patient assessment

  • Assess all four extremities.

    • Include:

      • P- Pulse

      • M- Motor

      • S- Sensation

  • Roll the patient with spinal precautions.


Focused physical exam

Focused Physical Exam

  • Used to evaluate patient’s chief complaint

  • Performed on:

    • Trauma patients without significant MOI

    • Responsive medical patients


Head neck and cervical spine

Head, Neck, and Cervical Spine

  • Feel head and neck for deformity, tenderness, or crepitation.

  • Check for bleeding.

  • Ask about pain or tenderness


Chest

Chest

  • Watch chest rise and fall with breathing.

  • Feel for grating bones as patient breathes.

  • Listen to breath sounds.


Abdomen

Abdomen

  • Look for obvious injury, bruises, or bleeding.

  • Evaluate for tenderness and any bleeding.

  • Do not palpate too hard.


Pelvis

Pelvis

  • Look for any signs of obvious injury, bleeding, or deformity.

  • Press gently inward and downward on pelvic bones.


Extremities

Extremities

  • Look for obvious injuries.

  • Feel for deformities.

  • Assess

    • Pulse

    • Motor function

    • Sensory function


Posterior body

Posterior Body

  • Feel for tenderness, deformity, and open wounds.

  • Carefully palpate from neck to pelvis.

  • Look for obvious injuries.


Specific chief complaints

Specific Chief Complaints

  • Chest pain

  • Shortness of breath

  • Pain associated with bones or joints

  • Abdominal pain

  • Dizziness


Significant mechanism of injury

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

Assessment Steps for Significant MOI

  • Rapid trauma assessment

  • Baseline vital signs

  • SAMPLE history

  • Reevaluate transport decision


Assessment steps for trauma patients without significant moi

Assessment Steps for Trauma Patients Without Significant MOI

  • Focused assessment

  • Baseline vital signs

  • SAMPLE history

  • Reevaluate transport decision


Responsive medical patients

Responsive Medical Patients

  • History of illness

  • SAMPLE history

  • Focused assessment

  • Vital signs

  • Reevaluate transport decision


Unresponsive medical patients

Unresponsive Medical Patients

  • Rapid medical assessment

  • Baseline vital signs

  • SAMPLE history

  • Reevaluate transport decision


Patient assessment process3

Patient Assessment Process


Detailed physical exam

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


Performing the detailed physical exam

Performing the DetailedPhysical Exam


Patient assessment

  • Visualize and palpate using DCAP-BTLS.

  • Look at the face.

  • Inspect the area around the eyes and eyelids.

  • Examine the eyes.


Patient assessment

  • Pull the patient’s ear forward to assess for bruising.

  • Use the penlight to look for drainage or blood in the ears.


Patient assessment

  • Look for bruising and lacerations about the head.

  • Palpate the zygomas.


Patient assessment

  • Palpate the maxillae.

  • Palpate the mandible


Patient assessment

  • Assess the mouth and nose for obstructions and cyanosis.

  • Check for unusual odors.


Patient assessment

  • Look at the neck.

  • Palpate the front and the back of the neck.

  • Look for distended jugular veins.


Patient assessment

  • Look at the chest.

  • Gently palpate over the ribs


Patient assessment

  • Listen for breath sounds.

  • Listen also at the bases and apices of the lungs.


Patient assessment

  • Look at the abdomen and pelvis.

  • Gently palpate the abdomen.

  • Gently compress the pelvis.


Patient assessment

  • Gently press the iliac crests.

  • Inspect all four extremities.

  • Assess the back for tenderness or deformities


Patient assessment process4

Patient Assessment Process


Ongoing 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?


Steps of the ongoing assessment

Steps of the Ongoing Assessment

  • Repeat the initial assessment.

  • Reassess and record vital signs.

  • Repeat focused assessment.

  • Check interventions


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