ADVANCED ASSESSMENT. Approach To The Patient Ontario Base Hospital Group OBHG Education Subcommittee
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1 ADVANCED ASSESSMENT Approach To The Patient 2014 Ontario Base Hospital Group
2 ADVANCED ASSESSMENT Approach to the Patient AUTHORS Mike Muir AEMCA, ACP, BHSc Paramedic Program Manager Grey Bruce Huron Paramedic Base Hospital Grey Bruce Health Services, Owen Sound Kevin McNab AEMCA, ACP Quality Assurance Manager Huron County EMS REVIEWERS/CONTRIBUTORS Lori Smith AEMCA, ACP Kitchener Waterloo Wellington Base Hospital Rob Theriault EMCA, RCT(Adv.), CCP(F) Peel Region Base Hospital Donna L. Smith AEMCA, ACP Hamilton Base Hospital References Emergency Medicine
3 SCENE ASSESSMENT INITIAL APPROACH The first step in patient assessment is to STOP and evaluate the scene for the following Environmental Hazards (Is it safe for you, your partner and patient?) Mechanism of Injury (Note the series of events that caused the injury, if applicable) Casualties (How many patients are you working with?) Additional Resources required (ambulance or other emergency services) Personal Protection Equipment (gloves, eye protection) Introduce yourself and your partner Advise patient to limit movement to reduce further harm when appropriate
4 PARAMEDIC ROLES ON SCENE DEFINED
5 ATTENDING PARAMEDIC LEVEL OF DISTRESS ASSESS LOA (AVPU) C SPINE CONTROL IF INDICATED TECHNICAL PARAMEDIC REMOVE EQUIPMENT OFF AND PREPARE STRETCHER ASSESS AIRWAY BREATHING CIRCULATION GATHER CHIEF COMPLAINT CHEST AUSCULTATION INTERVENE IF REQUIRED (OXYGENATION/VENTILATION) ATTACH CARDIAC MONITOR ATTACH SP0 2 MONITOR OBTAIN VITAL SIGNS HISTORY OF CURRENT CONDITION PAST MEDICAL CONDITION MEDICATIONS ALLERGIES PHYSICAL EXAM (PERTINENT TO PATIENT PRESENTATION) OBTAIN BLOOD GLUCOSE REPORT ALL FINDINGS TO PARTNER AS FOUND ASSIST PARTNER IN ANY TREATMENTS TREATMENT DECISION APPROXIMATELY 5 MINUTES
6 ASSESSING THE PATIENT SICK NOT SICK
7 Does the Patient Pass the look Test? first impressions are critical observations and instincts are key elements for a savvy clinician first impressions may lead to load & go
8 DETERMINING LEVEL OF AWARENESS Utilize the AVPU Scale A Alert does the patient look at you when you walk in the room V Does the patient respond to your verbal commands P Does the patient only respond to painful stimulus U Unresponsive (patient does not respond to painful stimuli) ASK closed questions at first to determine LOA What is your name? Where are you? What month is it?
9 Assess C Spine Does the mechanism of injury suggest trauma? Do you have any discomfort in your head or neck region?
10 DETERMINING LEVEL OF DISTRESS (mild, moderate, severe) Evaluate 4 Areas 1) What is patients level of awareness 2) Workload of breathing 3) Position 4) Skin (color, condition, temperature)
11 Assess Airway Patent or not Manageable Correct if needed
12 Assess Breathing Rate Volume Workload Correct if needed (Oxygenation / Ventilation)
13 Circulation Pulses rate, where found (radial, brachial, carotid) Does the pulse match monitor (pulse deficit) Capillary refill
14 Chief Complaint The complaint that troubles the patient the most (Reason for calling the Ambulance) Is the patient complaining of any SOB (always ask)
15 Chest Auscultation Assess all lung fields (optimum is auscultation on the back) Assess for breath sounds apices to bases Equality Adventitious Sounds
16 GATHER HISTORY OF CURRENT CONDITION (Expand upon Chief Complaint and Look for Associated Symptoms) Concentrate on this area ONSET (when did C/C start) ACTIVITY (what were you doing when C/C started) DURATION (length of time of c/c, is it constant, increasing in severity) DESCRIBE CHIEF COMPLAINT (type of discomfort, location, radiation, scale, similar discomforts, aggravating relieving factors) ASSOCIATED COMPLAINTS (always assess chest, head, abdo for pain or discomfort) ANY WEAKNESS OR DIZZINESS ANY NAUSEA OR VOMITING ANY HISTORY OF COUGH COLD OR FEVER, FLU Symptoms ANY RECENT ILLNESSES HOW HAVE YOU BEEN EATING AND DRINKING BOWEL AND URINE OUTPUT
17 Past Medical History (examples) MI, angina, hypertension, diabetic, respiratory disorders, CVA/TIA
18 Medication What medications? Are you taking them regularly? As prescribed? Any new medications? Any over the counter medications? LOOK AT MEDICATIONS WRITE DOWN NAMES & DOSAGES, OR OPTIMALLY, TAKE THEM WITH YOU TO THE HOSPITAL!
19 Allergies Do any pills make you sick? Are you allergic to any medications? What happens to you when you come into contact with the medicine or products that you are allergic to?
20 SECONDARY SURVEY Keep assessment pertinent to call focused on specific organ systems on medical calls compared with trauma calls where a broader assessment is performed Keep it organized as you work your way down from head to toe
21 General Appearance Distress level, LOA, skin color condition, facial expression Neural exam, person, place, time Take an overall view, communicate Visual assessment look first then palpate
22 Head Skin condition, mucous membranes, facial droop, pupil size, equality reaction,unilateral stare( staring to one side only) Take a better look at the airway (possible/potential) problems e.g. dentures, partial plates Discharge from ears or nose (can palpate fontanels lightly)
23 Neck JVD while patient 45 degrees > 3 cm above clavicle= abnormal can block jug to see if distal pressure disappears, lowest pressure in the body, if jug vein needed lift legs tracheal deviation, palpate suprasternal notch, approx. 1 finger either side subcutaneous emphysema palpate C spine for tenderness, step deformity carotid artery palpate both to see if difference in pressure auscultate for Carotid Bruits (swishy sound on auscultation caused by atherosclerosis carotid endarterectomy = removal of plaque, look for scar (contraindication of CSM)
24 Chest Look first CLAPS, Paradoxical movements Auscultate (reassess for changes) Palpate for TICS (tenderness, instability, crepitus, subcutaneous emphysema)
25 Abdomen (proper assessment patient must be supine) Look before touching, masses, bruising, symmetry, discoloration, scarring Size: obvious distention (normal or not) Gas? Bleeding? Do not palpate masses or pulsations Peritonitis: guarding, rigidity Pain near diaphragm: think abdomen as well as chest (heart problem) Child baring years think ectopic pregnancy Look for previous surgeries (scars)
26 Pelvis No need to assess if medical Trauma is critical (large amount of blood loss) needs rapid transport Palpate at least 2 planes for stability, crepitus
27 Extremities If medical go distal Edema: pitting or not, how far up legs, duration, changes Cap refill, sensation, movement equal or not Arms (assess bilateral B/P if chest pain) Dialysis Patient: shunt (never start an I.V in same arm) PICC line?
28 PATCHING FORMAT
29 Patch Format Introduction of yourself, name, medic #, run # How you are patching (cell phone, radio, landline) Make sure they can hear you (confirm reception) Where you are (location, e.g. 25th floor) Age, weight, sex, LOA, level of distress Chief complaint Incident history Vitals, ECG, SpO 2 Exam findings Past medical history, Medications, Allergies Treatment & Response
30 Patch Format (Details) Pulse, respirations, blood pressure, skin, pupils Rhythm on the monitor Physical assessment Head, neck, patency of airway, cyanosis, JVD Chest Breath sounds, trauma Abdomen (assessed not assessed) report findings if any Extremities pulses present, Edema pitting or not location Treatment done so far & response, any change What receiving hospital, amount of time to have patient receive transfer of care Modify patch format to give report at emergency room Follow same structure
31 Question # 1 What is the purpose of obtaining a patient history? A B C D to detect signs of injury to establish priorities of patient care to make the patient feel comfortable to see if you can no service the patient
32 Answer # 1 What is the purpose of obtaining a patient history? A B C D to detect signs of injury to establish priorities of patient care to make the patient feel comfortable to see if you can no service the patient
33 Question # 2 When gathering information from the elderly, it is important to: A B C D speak loudly since most are deaf refer to the patient as dear anticipate numerous medications not expect any variation in the exam
34 Answer # 2 When gathering information from the elderly, it is important to: A B C D speak loudly since most are deaf refer to the patient as dear anticipate numerous medications not expect any variation in the exam
35 Question # 3 From the following list, in which situation is important to determine the last oral intake? A patient with a welding flash burn to the eye B C D patient with a nail through his foot dizzy patient adult with dental pain
36 Answer # 3 From the following list, in which situation is important to determine the last oral intake? A patient with a welding flash burn to the eye B C D patient with a nail through his foot dizzy patient adult with dental pain
37 Question # 4 The approach to the pediatric patient should include: A B C D Establishing a rapport with the parents Calm and confident approach Observing the patient prior to physical examination All of the above
38 Answer # 4 The approach to the pediatric patient should include: A B C D Establishing a rapport with the parents Calm and confident approach Observing the patient prior to physical examination All of the above
39 Question # 5 In which of the following cases is the paramedic most likely to perform a detailed physical examination? A B C D 34 year old patient in status seizure 40 year old shot in the chest 80 year old in cardiac arrest 59 year old weak and diaphoretic
40 Answer # 5 In which of the following cases is the paramedic most likely to perform a detailed physical examination? A B C D 34 year old patient in status seizure 40 year old shot in the chest 80 year old in cardiac arrest 59 year old weak and diaphoretic
41 Well Done! Ontario Base Hospital Group Self directed Education Program
42 SORRY, THAT S NOT THE CORRECT ANSWER
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