Chapter 13 Patient Assessment Prehospital Emergency Care, Ninth Edition Joseph J. Mistovich Keith J. Karren Copyright 2010 by Pearson Education, Inc. All rights reserved. Objectives 1. Define key terms introduced in this chapter. 2. Explain the importance of developing a systematic patient assessment routine and list the four main components of the patient assessment (slides 26, 28, 85, 209). 3. List the steps of the scene size-up (slides 26-27). 4. State the main purpose of the primary assessment and list the steps of the primary assessment (slides 28-30). 5. Explain how forming and revising a general impression of the patient spans the entire patient assessment process (slides 31-32). 6. Determine if a patient is injured or ill and obtain the chief complaint (slides 33-36). Objectives 7. Identify immediate life threats during the general impression (slides 37-38). 8. Given a variety of patient scenarios, differentiate those who do and do not need spinal stabilization, demonstrate how to establish in-line stabilization, and demonstrate patient positioning for assessment (slides 39-42). 9. Using the AVPU method, assess and document the level of responsiveness (slides 43-56). 10. Determine airway status in responsive patients and those with an altered mental status, demonstrate methods of establishing and maintaining an open airway, and recognize indications of partial airway occlusion (slides 57-65). 1
Objectives 11. Assess the rate and quality of breathing; determine if the patient has absent, inadequate or adequate breathing; provide positive pressure ventilation in the patient with absent or inadequate breathing; and provide oxygenation as determined by the SpO 2 level in the patient who is breathing adequately (slides 66-74). 12. Assess the circulation to include assessing the pulse, identifying and controlling major bleeding, and assessing perfusion through skin color, temperature, and condition and capillary refill, and recognize and begin treatment for shock (slides 75-81). Objectives 13. Discuss establishing patient priorities by evaluating critical findings to the airway, breathing, or circulation to determine if a patient is unstable and a candidate for rapid secondary assessment and immediate transport to the hospital (slides 82-83). Objectives 14. Describe performing the secondary assessment using an anatomical approach, including steps for assessing the following (slides 89-105): a. Head b. Neck c. Chest d. Abdomen e. Pelvis f. Lower extremities g. Upper extremities h. Posterior body 15. Describe performing the secondary assessment using a body systems approach (slides 106-107). 2
Objectives 16. Summarize assessment of the vital signs during the secondary assessment (slides 108-109). 17. Discuss obtaining a history during the secondary assessment, including use of the SAMPLE and OPQRST mnemonics (slides 110-112). 18. List the sequence in which the steps of the secondary assessment are generally performed for a trauma patient and define the following types of physical exam that can be chosen for a trauma patient (slides 113-114): a. Rapid secondary assessment for a trauma patient b. Modified secondary assessment for a trauma patient Objectives 19. List the mechanisms of injury that have a high incidence of producing critical trauma and the special considerations for infants and children (slides 115-118). 20. For the trauma patient with a significant mechanism of injury, discuss how to continue spinal stabilization, reasons to consider requesting advanced life support, and reasons to reconsider transport decisions (slides 120-125). 21. Explain how to use the Glasgow Coma Scale (GCS) to rank the patient s level of consciousness and how to interpret the resulting GCS score (slides 126-127). Objectives 22. Discuss how to conduct a rapid secondary assessment for a trauma patient with significant mechanism of injury, altered mental status, multiple injuries, or critical finding (unstable patient) (slides 128-151). 23. Discuss critical (unstable) findings, possibilities, and emergency care for the trauma patient associated with assessment of the head, neck, chest, abdomen, pelvis, extremities, posterior body, or baseline vital signs (slides 152-155). 24. Explain the purpose and elements of the trauma score (slides 156-157). 3
Objectives 25. Discuss how to conduct a modified secondary assessment for a trauma patient with no significant mechanism of injury, altered mental status, multiple injuries, or critical finding (stable patient) (slides 158-162). 26. Explain circumstances when you should perform a complete, rather than a modified, secondary assessment on a trauma patient with no significant mechanism of injury (slides 163-164). Objectives 27. Name the key differences in the secondary assessment for the responsive medical patient versus the unresponsive medical patient with regard to (slides 165-166): a. Sequence of steps b. Appropriate type of physical exam (modified or rapid) 28. Explain how to conduct a secondary assessment for a medical patient who is not alert or is disoriented, is responding only to verbal or painful stimuli, or is unresponsive (slides 167-192). Objectives 29. Discuss critical (unstable) findings, possibilities, and emergency care for the medical patient with an altered mental status associated with assessment of the head, neck, chest, or pelvic region (slides 193-194). 30. Explain how to conduct a secondary assessment for a medical patient who is alert and oriented (slides 195-207). 31. Explain the purposes of reassessment (slides 208-210). 32. Explain how to conduct and to complete the reassessment (slides 211-235). 4
Multimedia Directory Slide 30 Slide 88 Slide 97 Slide 112 Slide 217 Initial Assessment Video Detailed Physical Exam Video Abdominal Assessment Techniques Video Assessment of Pain Video Reassessment Video Topics Section 1 Scene Size-Up Section 2 Primary Assessment Form a General Impression of the Patient Assess Level of Consciousness (Mental Status) Assess the Airway Assess Breathing Assess Circulation Establish Patient Priorities Topics Section 3 Secondary Assessment Overview of Secondary Assessment: Anatomic and Body Systems Approaches, Baseline Vital Signs, and History Secondary Assessment: Trauma Patient Reevaluate the Mechanism of Injury Rapid Secondary Assessment: Trauma Patient with Significant Mechanism of Injury, Altered Mental Status, Multiple Injuries, or Critical Finding (Unstable) 5
Topics Modified Secondary Assessment: Trauma Patient with NO Significant Mechanism of Injury, Altered Mental Status, Multiple Injuries, or Critical Finding (Stable) Secondary Assessment: Medical Patient Medical Patient Who Is Not Alert or Is Disoriented, Is Responding Only to Verbal or Painful Stimuli, or Is Unresponsive Responsive Medical Patient Who Is Alert and Oriented Topics Section 4 Reassessment Purposes of the Reassessment Repeat the Primary Assessment Complete the Reassessment CASE STUDY #1 Trauma Patient Dispatch 6
EMS Unit 74 Respond to Newton Drive, Greenway Apartments, Building 24 for an unresponsive patient with an unknown problem. Police are at the scene. Time out 1512 Upon Arrival Adult male lying supine below a two-story fireescape ladder Police on scene advise they were called for a domestic incident Neighbors heard fighting and gunfire How would you proceed with the assessment of this patient? 7
CASE STUDY #2 Medical Patient Dispatch EMS Unit 74 Respond to 33 East Sassafras Street for a patient with an unknown problem. Daughter made the call. Time out 1623 Upon Arrival Arrive at a well-kept home in a quiet neighborhood A middle-aged woman hurries out to meet you It s my mother, she says. She can t seem to catch her breath. 8
How would you proceed with the assessment of this patient? Section 1 Scene Size-Up Back to Topics Standard Precautions Scene safety Mechanism of injury or nature of illness Number of patients Need for additional resources Steps of the Scene Size-Up Back to Objectives 9
Section 2 Primary Assessment Back to Topics Steps of the Primary Assessment Form general impression of the patient Assess level of consciousness Assess the airway Assess breathing Assess circulation Establish patient priorities Back to Objectives Initial Assessment Click here to view a video on the topic of initial assessment. Return to Directory 10
Form a General Impression of the Patient Back to Topics First impression Stable or unstable Chief complaint Back to Objectives ( Mark C. Ide) Determine If the Patient Is Injured or Ill Back to Objectives 11
Injured versus ill Blunt trauma Penetrating trauma Clues in environment Obtain the Chief Complaint Chief complaint Original complaint may not be chief complaint People on scene may help for unresponsive patients 12
Identify Immediate Life Threats during the General Impression Back to Objectives Treat obvious life threats. Those that you identify as you approach Establish In-Line Stabilization Back to Objectives 13
For suspected spine injury Neutral in-line position Maintain until you immobilize patient on backboard Position the Patient for Assessment If the patient is prone, roll him to supine for better assessment Establish in-line stabilization first if spine injury is suspected 14
Assess Level of Consciousness (Mental Status) Back to Topics Assess the Level of Responsiveness Back to Objectives A Alert V Verbal P Pain U Unresponsive 15
Assess the Level of Responsiveness Alertness and Orientation Alert Eyes open and able to speak to you as you approach Assess the Level of Responsiveness Responsiveness to Verbal Stimulus 16
Verbal Makes an attempt to respond only when you speak to him Assess the Level of Responsiveness Responsiveness to Painful Stimulus Types of stimuli Responses to stimuli Pain 17
Flexion posturing Extension posturing Assess the Level of Responsiveness Unresponsiveness Unresponsive Not responsive to verbal or painful stimuli Can lead to airway compromise 18
Assess the Level of Responsiveness Document the Level of Responsiveness Document Be specific Should take a few seconds to assess Assess the Airway Back to Topics 19
Determine Airway Status In the Responsive Patient Back to Objectives If the patient is alert and talking without difficulty, assume the airway is patent. Determine Airway Status In the Unresponsive or Severely Altered Mental Status Patient 20
High risk of airway occlusion EMS must manage Open the Airway Manual maneuvers Suction Airway adjuncts Manual thrusts Positioning of patient 21
Indications of Partial Airway Occlusion Snoring Gurgling Crowing Stridor Assess Breathing Back to Topics 22
Assess Rate and Quality of Breathing Look Back to Objectives Inadequate tidal volume Abnormal respiratory rate Signs of respiratory distress Look Assess Rate and Quality of Breathing Listen and Feel 23
Absent or inadequate breathing Adequate breathing Listen and Feel Assess Rate and Quality of Breathing Oxygen Therapy in the Patient with Adequate Breathing Based on patient s condition NEVER withhold oxygen 24
Assess Rate and Quality of Breathing Adequate Oxygenation Based on the SpO 2 Reading SpO 2 greater than 95 percent on room air is indicative of adequate oxygenation After stabilizing airway and breathing, move to circulation Assess Circulation Back to Topics 25
Assess the Pulse Back to Objectives Determine Presence Approximate rate Strength and regularity Identify Major Bleeding 26
Control major bleeding only Expose blood-soaked areas Assess Perfusion Assess skin Color Temperature Condition Signs of shock 27
Establish Patient Priorities Back to Topics Unstable versus stable Rapid transport versus secondary assessment on the scene Back to Objectives Section 3 Secondary Assessment Back to Topics 28
Physical assessment Baseline vital signs Patient history Back to Objectives Overview of Secondary Assessment: Anatomic and Body Systems Approaches, Baseline Vital Signs, and History Back to Topics Inspection, palpation, and auscultation Life threats should be managed as found 29
Detailed Physical Exam Click here to view a video on the topic of a detailed physical exam. Return to Directory Performing the Secondary Assessment: An Anatomic Approach Assess the Head Back to Objectives Head Scalp Face Ears Eyes Nose Mouth 30
Performing the Secondary Assessment: An Anatomic Approach Assess the Neck Neck Cover large lacerations with occlusive dressings Jugular vein distention (JVD) Tracheal deviation Performing the Secondary Assessment: An Anatomic Approach Assess the Chest 31
Chest Inspect for trauma Inspect chest rise Palpate Auscultate Performing the Secondary Assessment: An Anatomic Approach Assess the Abdomen Abdomen Inspect Palpate 32
Abdominal Assessment Techniques Click here to view a video on abdominal assessment techniques. Return to Directory Performing the Secondary Assessment: An Anatomic Approach Assess the Pelvis Pelvis Bleeding Priapism Palpation of pelvic wings 33
Performing the Secondary Assessment: An Anatomic Approach Assess the Lower Extremities Lower Extremities Pulses Motor function Sensation Deformity Performing the Secondary Assessment: An Anatomic Approach Assess the Upper Extremities 34
Upper Extremities Deformities Pulses Motor function Sensation Performing the Secondary Assessment: An Anatomic Approach Assess the Posterior Body Assess the Posterior Body If not already secured to a backboard, roll the patient to the side Inspect the thorax, lumbar area, buttocks and lower extremities Palpate Check for deformity or pain 35
Performing the Secondary Assessment: A Body Systems Approach Back to Objectives Respiratory Cardiovascular Neurologic Musculoskeletal Assess Baseline Vital Signs Back to Objectives 36
Breathing Pulse Skin Capillary refill Blood pressure Pupils SpO 2 Obtain a History Back to Objectives SAMPLE OPQRST 37
Assessment of Pain Click here to view a video on the topic of the assessment of pain. Return to Directory Secondary Assessment: Trauma Patient Back to Topics Rapid secondary assessment Modified secondary assessment Back to Objectives 38
Reevaluate the Mechanism of Injury Back to Topics Significant Mechanisms of Injury Back to Objectives High Incidence of Critical Trauma Ejection Death of an occupant in the same vehicle Fall greater than 20 feet High speed collision Intrusion greater than 12 inches into patient compartment Blast injuries Deformed steering wheel 39
Other Significant Mechanisms for Children Fall greater than ten feet or two to three times the height of the child Bicycle versus motor vehicle Pedestrian versus motor vehicle at medium speed Unrestrained child during a MVC Rapid Secondary Assessment: Trauma Patient with Significant Mechanism of Injury, Altered Mental Status, Multiple Injuries, or Critical Finding (Unstable) Back to Topics Continue Spine Stabilization Back to Objectives 40
Until head and body are secured on a backboard Consider an Advanced Life Support Request Consider ALS but do not delay transport Follow local protocols 41
Reconsider the Transport Decision Don t be afraid to upgrade the transport decision as the patient s status changes. Reassess Mental Status Back to Objectives 42
Causes of decreased mental status Level of orientation Perform a Rapid Secondary Assessment Back to Objectives Inspect Palpate Auscultate Listen Smell 43
Perform a Rapid Secondary Assessment Assess the Head Head Scalp and skull Face Ears Pupils Nose Mouth Perform a Rapid Secondary Assessment Assess the Neck 44
Neck Trauma Midline trachea Jugular vein distention Perform a Rapid Secondary Assessment Apply a Cervical Spine Immobilization Collar Place after assessment of the neck Maintain in-line spine immobilization Apply a Cervical Spine Immobilization Collar 45
Perform a Rapid Secondary Assessment Assess the Chest Expose Inspect Palpate Auscultate Chest Perform a Rapid Secondary Assessment Assess the Abdomen 46
Abdomen Inspect Palpate Markle test Perform a Rapid Secondary Assessment Assess the Pelvis Pelvis Inspect Palpate 47
Perform a Rapid Secondary Assessment Assess the Extremities Inspect Palpate Pulses Motor function Sensation Extremities Perform a Rapid Secondary Assessment Assess the Posterior Body 48
Inspect Palpate Posterior Body Assess Baseline Vital Signs Breathing Pulse Skin Pupils Blood pressure Pulse oximetry 49
Assess Baseline Vital Signs Blood Glucose Test Rule out a hypoglycemic episode. Obtain a SAMPLE History 50
Signs/symptoms Allergies Medication Past pertinent history Last oral intake Events leading to injury Prepare the Patient for Transport Back to Objectives Once immobilized, do not delay transport Limit scene time to ten minutes or less for critical trauma 51
Provide Emergency Care Life-threatening problems must be managed prior to transport. Trauma Score Back to Objectives 52
Respiratory rate Systolic blood pressure GCS Modified Secondary Assessment: Trauma Patient with NO Significant Mechanism of Injury, Altered Mental Status, Multiple Injuries, or Critical Finding (Stable) Back to Topics Perform a Modified Secondary Assessment Back to Objectives 53
Focuses on injury site and surrounding areas only Obtain Baseline Vital Signs and SAMPLE History Baseline vital signs SAMPLE 54
Perform a Rapid Secondary Assessment If Indicated Back to Objectives If in doubt, conduct a complete secondary assessment. Secondary Assessment: Medical Patient Back to Topics 55
Signs and symptoms related to a disease process Back to Objectives Medical Patient Who Is Not Alert or Is Disoriented, Is Responding Only to Verbal or Painful Stimuli, or Is Unresponsive Back to Topics Back to Objectives Considered critical Rapid secondary assessment Prompt transport Look for environmental clues 56
Perform a Rapid Secondary Assessment for the Medical Patient Assess the Head Inspect Palpate Check pupils Head Perform a Rapid Secondary Assessment for the Medical Patient Assess the Neck 57
Neck ( David Effron, MD) Inspect JVD Accessory muscle use Perform a Rapid Secondary Assessment for the Medical Patient Assess the Chest Inspect Auscultate Crackles Wheezing Chest 58
Perform a Rapid Secondary Assessment for the Medical Patient Assess the Abdomen Abdomen Inspect Palpate Markle test Perform a Rapid Secondary Assessment for the Medical Patient Assess the Pelvic Region 59
Pelvis Inspect Palpate Perform a Rapid Secondary Assessment for the Medical Patient Assess the Extremities Extremities Inspect CMS Palpate 60
Perform a Rapid Secondary Assessment for the Medical Patient Assess the Posterior Body Inspect and palpate for discoloration, edema and tenderness Sacral edema may indicate congestive heart failure Assess the Posterior Body Assess Baseline Vital Signs 61
Breathing Pulse Skin Pupils Blood pressure Pulse oximetry Assess Baseline Vital Signs Blood Glucose Test Rule out a hypoglycemic episode. 62
Position the Patient Place in recovery position Have suction available Obtain a SAMPLE History 63
Obtain a SAMPLE history from those available. Provide Emergency Care Oxygen via nonrebreather mask or bag-valve mask if needed 64
Make a Transport Decision Back to Objectives Manage life threats Expedite transport Reassess en route Responsive Medical Patient Who Is Alert and Oriented Back to Topics 65
Assess Patient Complaints: OPQRST Back to Objectives Onset Provocation Quality Radiation Severity Time Complete the SAMPLE History 66
Complete SAMPLE history Obtain additional information for continuance of care Perform a Modified Secondary Assessment Focused or complete If complaint is nonspecific, do a complete assessment 67
Assess Baseline Vital Signs Assess baseline vital signs Watch for changes Provide Emergency Care 68
Contact medical direction if necessary Maintain a patent airway and ventilation Make a Transport Decision Vital signs every Five minutes in critical 15 minutes in noncritical Assess, intervene, and reassess 69
Section 4 Reassessment Back to Topics Purposes of the Reassessment Back to Topics Detect changes Identify missed injuries Adjust care Back to Objectives 70
Detect Any Change in Condition Back to Objectives Detect changes in the patient s condition. Identify Any Missed Injuries or Conditions 71
Possibly find injuries missed on scene Patient may complain of new symptoms Adjust the Emergency Care Steps of Reassessment Repeat primary assessment Reassess and record vital signs Repeat secondary assessment Check interventions Note trends in patient s condition 72
Reassessment Click here to view a video on the topic of Reassessment. Return to Directory Repeat the Primary Assessment Back to Topics Reassess Mental Status 73
Check speech patterns Assess ability to obey commands Repeat GCS Reassess the Airway and Reassess Breathing Airway patency Adequate breathing 74
Reassess Circulation Pulse Bleeding Skin Reestablish Patient Priorities 75
Readjust the transport decision as the patient s condition changes. Complete the Reassessment Back to Topics Reassess and Record Vital Signs 76
Record vital signs and the time they were taken. Repeat Components of the Secondary Assessment for Other Complaints Investigate any new complaints by the patient Readjust assessment to include new areas 77
Check Interventions Determine that interventions are producing wanted results If not, adjust treatments Note Trends in Patient Condition 78
Document changes in the patient s condition: better or worse. CASE STUDY #1 Trauma Patient Follow-Up Follow-Up CASE STUDY Primary Assessment Shirt front, left pants leg soaked in blood Skin is pale, cool, and clammy Right lower leg severely deformed Responds to painful stimuli only Chest is barely rising and falling 79
CASE STUDY Primary Assessment Insert OPA and BVM Gunshot wound to left anterior chest CASE STUDY Secondary Assessment Apply cervical collar; in-line stabilization Decreased breath sounds on the left side of chest Log rolled onto backboard BP: 70/50 mmhg; PERRL; HR: 136 per minute; RR: six (now ten per minute with BVM) CASE STUDY Reassessment Reassess interventions and patient s vital signs every five minutes Radio hospital No change in patient s condition Upon arrival, give oral report, complete written report, and prep ambulance for next call 80
CASE STUDY #2 Medical Patient Follow-Up CASE STUDY Primary Assessment Mrs. Ortega is a 72-year-old female Speaking in short sentences Seated in tripod position Apply nonrebreather mask at 15 lpm Skin pink, warm, and dry Rapid radial pulse CASE STUDY Secondary Assessment Symptoms started this morning and worsened No allergies Medications relate to history of emphysema Last oral intake was lunch 81
CASE STUDY Secondary Assessment No unusual events BP: 120/90 mmhg; P: 100; RR: 28; SpO 2 : 88 percent Hear wheezing without a stethoscope CASE STUDY Reassessment Reassess vital signs every 15 minutes Call hospital Note no changes en route Give oral report to staff Finish care report Clean ambulance Critical Thinking Scenario 1 23-year-old male who fell ~ 20 feet from a balcony at a concert Bystanders state he was talking and moaning right after fall; now won t respond Physical exam: Patient is not alert Blood is coming from his mouth and ears Left arm is angulated, obviously fractured 82
Critical Thinking Questions 1. What would be your first immediate action when you arrive at the patient? 2. What assessment should you conduct first? 3. What are the components of that assessment and in what order would you perform them? 4. What life threats would you assess for and how would you manage them? Critical Thinking Questions 5. What injuries should you suspect in this patient? 6. What baseline vital signs would you assess? 7. Would you perform a rapid secondary assessment or a modified secondary assessment? 8. What does the change in his mental status indicate? Critical Thinking Questions 9. When would you transport? 10.How would you prepare the patient for transport? 11.What would you do while en route to the medical facility? 83
Critical Thinking Scenario 2 78-year-old female with difficulty breathing Daughter states patient has a heart condition and hasn t been feeling well for two days She thought her mother was napping, went to wake her, and she did not respond Patient is supine on the couch, extremely pale and cyanotic Patient presents with snoring respirations Critical Thinking Questions 1. Do you suspect she is a trauma or medical patient? 2. What would be your first immediate action when you arrive at the patient? 3. What assessment should you conduct first? 4. What are the components of that assessment and in what order would you perform them? Critical Thinking Questions 5. What life threats are you assessing for and how would you manage them? 6. Would you collect a SAMPLE history first or do a medical assessment? 7. Would you perform a rapid secondary assessment or a modified secondary assessment? 8. How would you collect a SAMPLE history? 84
Critical Thinking Questions 9. What does the mental status possibly indicate? 10.What would you expect the SpO 2 reading to be? 11.When would you transport? 12.How would you prepare the patient for transport? 13.What would you do while en route to the medical facility? Reinforce and Review Please visit www.bradybooks.com and follow the mybradykit links to access content for the text. 85