chapter 13 - marquette general hospitalww4.mgh.org/emt/emtlib/mistovich_ch13_pec09.pdf · provide...

01/09/2013

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Chapter 13

Patient Assessment

Copyright ©2010 by Pearson Education, Inc.

All rights reserved.

Prehospital Emergency Care, Ninth Edition

Joseph J. Mistovich • Keith J. Karren

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).

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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 SpO2 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).

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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).

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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).

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Multimedia Directory

Slide 30 Initial Assessment Video

Slide 88 Detailed Physical Exam Video

Slide 97 Abdominal Assessment Techniques Video

Slide 112 Assessment of Pain Video

Slide 217 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)

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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

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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 fire-

escape 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?

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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

• 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.”

Upon Arrival

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How would you proceed with the assessment of this patient?

Back to Topics

Section 1 – Scene

Size-Up

Steps of the

Scene Size-Up • Standard

Precautions

• Scene safety

• Mechanism of

injury or nature

of illness

• Number of

patients

• Need for

additional

resources Back to Objectives

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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

Return to Directory

Click here to view a video on the topic of initial assessment.

Initial Assessment

media/PA_initial.htm

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Form a General

Impression of the

Patient

Back to Topics

• First impression

• Stable or unstable

• Chief complaint

(© Mark C. Ide) Back to Objectives

Determine If the Patient Is

Injured or Ill

Back to Objectives

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• 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

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Identify Immediate Life

Threats during the General

Impression

Back to Objectives

Those that you identify as you

approach

Treat obvious life threats.

Establish In-Line

Stabilization

Back to Objectives

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• 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

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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

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Assess the Level of Responsiveness

Alertness and Orientation

Alert

Eyes open and able to speak to you as you approach


Responsiveness to

Verbal Stimulus

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Verbal

Makes an attempt to respond only

when you speak to him


Responsiveness to

Painful Stimulus

• Types of stimuli

• Responses to stimuli Pain

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Extension posturing

Flexion posturing


Unresponsiveness

• Not responsive to verbal or painful stimuli

• Can lead to airway compromise

Unresponsive

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Document the Level of

Responsiveness

• Be specific

• Should take a few

seconds to assess

Document

Assess the Airway

Back to Topics

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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

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• High risk of airway occlusion

• EMS must manage

Open the Airway

• Manual maneuvers

• Suction

• Airway adjuncts

• Manual thrusts

• Positioning of patient

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Indications of Partial Airway

Occlusion

• Snoring

• Gurgling

• Crowing

• Stridor

Assess Breathing

Back to Topics

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Assess Rate and Quality of

Breathing

Look

Back to Objectives

• Inadequate tidal volume

• Abnormal respiratory rate

• Signs of respiratory distress

Look


Breathing

Listen and Feel

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• Absent or inadequate breathing

• Adequate breathing

Listen and Feel


Breathing

Oxygen Therapy in the

Patient with Adequate

Breathing

• Based on

patient’s

condition

• NEVER

withhold

oxygen

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Assess Rate and Quality of Breathing

Adequate Oxygenation Based

on the SpO2 Reading

• SpO2 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

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Assess the Pulse

Back to Objectives

Determine

• Presence

• Approximate rate

• Strength and regularity

Identify Major Bleeding

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• Control major

bleeding only

• Expose

blood-soaked

areas

Assess Perfusion

Assess skin

• Color

• Temperature

• Condition

• Signs of shock

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Establish Patient

Priorities

Back to Topics

• Unstable versus

stable

• Rapid transport

versus secondary

assessment on

the scene

Back to Objectives

Back to Topics

Section 3 – Secondary

Assessment

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• 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

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Return to Directory

Click here to view a video on the topic of a detailed physical exam.

Detailed Physical Exam

Performing the Secondary

Assessment: An Anatomic Approach

Assess the Head

Back to Objectives

• Scalp

• Face

• Ears

• Eyes

• Nose

• Mouth

Head

media/B_Exam_1_Intro.htm

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Assess the Neck

• Cover large lacerations with

occlusive dressings

• Jugular vein distention (JVD)

• Tracheal deviation

Neck



Assess the Chest

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• Inspect for

trauma

• Inspect

chest rise

• Palpate

• Auscultate

Chest



Assess the Abdomen

• Inspect

• Palpate

Abdomen

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Return to Directory

Click here to view a video on abdominal assessment techniques.

Abdominal Assessment Techniques



Assess the Pelvis

• Bleeding

• Priapism

• Palpation of

pelvic wings

Pelvis

media/402_Assessment.htm

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Assess the Lower

Extremities

• Pulses

• Motor function

• Sensation

• Deformity

Lower

Extremities



Assess the Upper

Extremities

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• Deformities

• Pulses

• Motor function

• Sensation

Upper

Extremities



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

Assess the

Posterior

Body

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Assessment: A Body

Systems Approach

Back to Objectives

• Respiratory

• Cardiovascular

• Neurologic

• Musculoskeletal

Assess Baseline Vital Signs

Back to Objectives

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• Breathing

• Pulse

• Skin

• Capillary refill

• Blood pressure

• Pupils

• SpO2

Obtain a History

Back to Objectives

• SAMPLE

• OPQRST

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Return to Directory

Click here to view a video on the topic of the assessment of pain.

Assessment of Pain

Secondary

Assessment:

Trauma Patient

Back to Topics

• Rapid secondary assessment

• Modified secondary assessment

Back to Objectives

media/405_pain.htm

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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

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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

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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

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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

01/09/2013

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• Causes of decreased mental status

• Level of orientation

Perform a Rapid Secondary

Assessment

Back to Objectives

• Inspect

• Palpate

• Auscultate

• Listen

• Smell

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Assessment

Assess the Head

Head

• Scalp and

skull

• Face

• Ears

• Pupils

• Nose

• Mouth


Assessment

Assess the Neck

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Neck

• Trauma

• Midline trachea

• Jugular vein distention


Assessment

Apply a Cervical Spine

Immobilization Collar

Apply a

Cervical Spine

Immobilization

Collar

• Place after assessment of the neck

• Maintain in-line spine immobilization

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Assessment

Assess the Chest

Chest • Expose

• Inspect

• Palpate

• Auscultate


Assessment

Assess the Abdomen

01/09/2013

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Abdomen

• Inspect

• Palpate

• Markle test


Assessment

Assess the Pelvis

Pelvis

• Inspect

• Palpate

01/09/2013

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Assessment

Assess the Extremities

Extremities

• Inspect

• Palpate

• Pulses

• Motor

function

• Sensation


Assessment


01/09/2013

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Posterior Body • Inspect

• Palpate


• Breathing

• Pulse

• Skin

• Pupils

• Blood pressure

• Pulse oximetry

01/09/2013

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Blood Glucose Test

Rule out a hypoglycemic episode.

Obtain a SAMPLE History

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• 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

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Provide Emergency Care

Life-threatening problems must be

managed prior to transport.

Trauma Score

Back to Objectives

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• Respiratory

rate

• Systolic

blood

pressure

• GCS

Back to Topics

Modified Secondary

Assessment: Trauma

Patient with NO

Significant Mechanism

of Injury, Altered

Mental Status, Multiple

Injuries, or Critical

Finding (Stable)

Perform a Modified Secondary

Assessment

Back to Objectives

01/09/2013

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Focuses on injury site and

surrounding areas only

Obtain Baseline Vital Signs

and SAMPLE History

• Baseline vital signs

• SAMPLE

01/09/2013

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Assessment If Indicated

Back to Objectives

If in doubt, conduct a

complete secondary

assessment.

Secondary

Assessment:

Medical Patient

Back to Topics

01/09/2013

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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

• Considered critical

• Rapid secondary

assessment

• Prompt transport

• Look for

environmental clues

Back to Objectives

01/09/2013

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Assessment for the Medical Patient

Assess the Head

Head • Inspect

• Palpate

• Check pupils



Assess the Neck

01/09/2013

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Neck

• Inspect

• JVD

• Accessory

muscle use (© David Effron, MD)



Assess the Chest

Chest • Inspect

• Auscultate

–Crackles

–Wheezing

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Assess the Abdomen

Abdomen

• Inspect

• Palpate

• Markle test



Assess the Pelvic

Region

01/09/2013

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• Inspect

• Palpate

Pelvis



Assess the Extremities

Extremities • Inspect

• CMS

• Palpate

01/09/2013

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• Inspect and

palpate for

discoloration,

edema and

tenderness

• Sacral edema

may indicate

congestive heart

failure

Assess the

Posterior

Body


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• Breathing

• Pulse

• Skin

• Pupils

• Blood pressure

• Pulse oximetry


Blood Glucose Test

Rule out a hypoglycemic episode.

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Position the Patient

• Place in recovery position

• Have suction available

Obtain a SAMPLE History

01/09/2013

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Obtain a SAMPLE history from

those available.


Oxygen via nonrebreather mask or

bag-valve mask if needed

01/09/2013

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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

01/09/2013

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Assess Patient Complaints:

OPQRST

Back to Objectives

• Onset

• Provocation

• Quality

• Radiation

• Severity

• Time

Complete the SAMPLE

History

01/09/2013

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• 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

01/09/2013

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• Assess baseline

vital signs

• Watch for

changes


01/09/2013

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• 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

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Back to Topics

Section 4 –

Reassessment

Purposes of the

Reassessment

Back to Topics

• Detect changes

• Identify missed

injuries

• Adjust care

Back to Objectives

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Detect Any Change in

Condition

Back to Objectives

Detect changes

in the patient’s

condition.

Identify Any Missed Injuries

or Conditions

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• 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

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Return to Directory

Click here to view a video on the topic of Reassessment.

Reassessment

Repeat the Primary

Assessment

Back to Topics

Reassess Mental Status

media/PA_Ongoing.htm

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• Check speech

patterns

• Assess ability to

obey commands

• Repeat GCS

Reassess the Airway and

Reassess Breathing

• Airway patency

• Adequate breathing

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Reassess Circulation

• Pulse

• Bleeding

• Skin

Reestablish Patient

Priorities

01/09/2013

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Readjust the transport

decision as the patient’s

condition changes.

Complete the

Reassessment

Back to Topics

Reassess and Record Vital

Signs

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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

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Check Interventions

• Determine that

interventions

are producing

wanted results

• If not, adjust

treatments

Note Trends in Patient

Condition

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Document changes in

the patient’s condition:

better or worse.

CASE STUDY

Follow-Up

CASE STUDY

#1

Trauma Patient

Follow-Up

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

CASE STUDY

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Primary Assessment

• Insert OPA and BVM

• Gunshot wound to left anterior chest

CASE STUDY


• 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

CASE STUDY CASE STUDY

01/09/2013

81

CASE STUDY

#2

Medical Patient

Follow-Up

CASE STUDY

#2

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


• Symptoms started this morning and

worsened

• No allergies

• Medications relate to history of

emphysema

• Last oral intake was lunch

CASE STUDY

01/09/2013

82


• No unusual events

• BP: 120/90 mmHg; P: 100; RR: 28;

SpO2: 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

CASE STUDY

• 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

Critical Thinking Scenario 1

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83

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?


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?


01/09/2013

84

• 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 Scenario 2

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?


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?


01/09/2013

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9. What does the mental status possibly

indicate?

10.What would you expect the SpO2 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.

http://www.bradybooks.com/

chapter 13 - marquette general hospitalww4.mgh.org/emt/emtlib/mistovich_ch13_pec09.pdf · provide...

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