section 3: patient assessment. chapter 8 patient assessment

Section 3: Patient Assessment

Chapter 8

Patient Assessment

Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

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3: Patient Assessment

Scene Size-up• Describe the importance of recognizing potential

hazards• Describe common hazards found at the scene• Determine if the scene is safe to enter• Discuss identifying the number of patients at the

scene• Explain the need for additional help or assistance

Objectives (1 of 9)


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Initial Assessment• Summarize the reasons for forming a general

impression• Discuss methods of assessing altered mental

status• Discuss methods of assessing the airway• State reasons for managing the cervical spine• Discuss methods for assessing if a patient is

breathing

Objectives (2 of 9)


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• State what care should be provided to a patient with adequate breathing

• State what care should be provided to a patient without adequate breathing

• Describe methods used to obtain a pulse

• Discuss the need for assessing for external bleeding

Objectives (3 of 9)


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• Describe normal and abnormal findings when assessing skin color

• Describe normal and abnormal findings when assessing skin temperature

• Describe normal and abnormal findings when assessing skin condition

• Describe normal and abnormal findings when assessing capillary refill

• Explain the reason for prioritizing a patient for care and transport

Objectives (4 of 9)


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Focused History and Physical Exam: Trauma• Discuss reasons for reconsidering the MOI• State the reasons for performing a rapid

trauma assessment• Describe the rapid trauma assessment and

what should be evaluated• Differentiate when the rapid assessment may

be altered to provide patient care

Objectives (5 of 9)


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Focused History and Physical Exam: Medical Patients

• Describe the need for assessing a patient with a specific complaint and no known history

• Differentiate between the assessment for responsive patients without a history and responsive patients with a history

Objectives (6 of 9)


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• Describe the unique needs of assessing an unresponsive patient

• Differentiate between the assessment performed on an unresponsive patient and other medical patients

Objectives (7 of 9)


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Detailed Physical Exam

• Discuss components of the detailed physical exam

• Explain what additional care is provided during the detailed physical exam

• Distinguish between the detailed exam on a trauma and medical patient

Objectives (8 of 9)


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Ongoing Assessment

• Discuss the reason for repeating the initial assessment

• Describe the components of the ongoing assessment

• Describe trending of assessment components

Objectives (9 of 9)


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Patient Assessment Process• Scene size-up• Initial assessment• Provide spinal

immobilization• Identify and treat life

threats • Focused history and

physical exam

• Provide transport if needed

• Detailed physical exam

• Reassess vital signs

• Ongoing assessment


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The Patient Assessment Process


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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


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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


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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.


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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


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Motor Vehicle Crashes

• Amount of force related to speed

• Injuries can be predicted by:• Position in the car• Use of seat belts• How the body shifts

during the crash


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Falls

• Amount of force related to height of fall

• Note surface that patient landed on

• Attempt to determine how patient landed


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Gunshot and Stab Wounds

• Gunshot wounds• Force is related to caliber

of weapon and distance from gun to the patient

• Stab wounds• Injury can be estimated by

looking at the entrance and length of the weapon


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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.


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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.


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Patient Assessment Process


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Components of the Initial Assessment

• Develop a general impression• Assess mental status• Assess airway• Assess the adequacy of

breathing• Assess circulation• Identify patient priority


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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


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Distinguishing Between Medical and Trauma

• Determination should come after assessment is finished.

• Patients may have traumatic injuries caused by a medical reason.

• Initially assume all patients have both medical and traumatic aspects to their condition.


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Assessing Mental Status• Checking responsiveness

• Assess how well the patient responds to external stimuli.

• Check for orientation• Check the patient’s memory to person,

place, time, and event. If he or she recalls all four, then he or she is fully alert and oriented times four.


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Level of Consciousness

• A Alert

• V Responsive to Verbal stimulus

• P Responsive to Pain

• U Unresponsive


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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


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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


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Assessing Breathing

• Are the patient’s respirations shallow or deep?

• Does the patient appear to be choking?

• Is the patient cyanotic (blue)?

• Is the patient moving air into and out of the lungs as the chest rises and falls?


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Managing Breathing

• If patient is having difficulty breathing reevaluate airway.

• Consider assisting ventilations with a BVM or applying a nonrebreathing mask if patient’s respirations are greater than 24/min or less than 8/min.


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Unresponsive Patients

• Look, listen and feel technique

• Consider spinal cord injury.

• Provide high-flow oxygen.

• Assist ventilations if needed.


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Assessing Circulation (1 of 2)

• Assess the pulse.

• Rate, rhythm and strength

• Assess and control external bleeding.

• Direct pressure

• Evaluate skin color.

• Cyanotic, flushed, pale or jaundiced


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Assessing Circulation (2 of 2)

• Evaluate skin temperature.

• Skin is an organ.

• Evaluate skin condition.

• Dry or moist

• Evaluate capillary refill.

• Should be less than 2 seconds


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Restoring Circulation• Control bleeding and improve

oxygen delivery.

• If unresponsive and pulseless begin CPR.

• Apply and operate the AED as quickly as possible.

• Do not use AED on patients with a catastrophic traumatic injury.


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Identifying Priority Patients• Poor general

impression

• Unresponsive with no gag or cough reflexes

• Difficulty breathing

• Signs of poor perfusion

• Complicated childbirth

• Uncontrolled bleeding

• Severe pain

• Severe chest pain

• Inability to move any part of the body


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Goals of Exam

• Identify the patient’s chief complaint.

• Understand the specific circumstances surrounding the chief complaint.

• Direct further physical examination.


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The Golden Hour


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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 head, chest, or abdomen


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Significant Mechanism of Injury for Children

• Includes the list from the previous slide as well as:

• Fall greater than 2 to 3 times their height

• Bicycle crash


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Hidden Injuries

• Seat belts

• May cause injuries if worn improperly

• Airbags

• Look beneath airbag for bent steering wheel.


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Trauma Assessment

• D Deformities

• C Contusions

• A Abrasions

• P Punctures/ Penetrations

• B Burns

• T Tenderness

• L Lacerations

• S Swelling


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Rapid Trauma Assessment (1 of 3)

• Maintain spinal immobilization while checking patient’s ABCs.

• Assess the head.

• Assess the neck.

• Apply a cervical spine immobilization collar.


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• Assess the chest.

• Assess the abdomen.

• Assess the pelvis.

• Assess all four extremities.


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• Roll the patient with spinal precautions.

• Assess baseline vital signs and SAMPLE history.


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Head, Neck, and Cervical Spine

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

• Check for bleeding.

• Ask about pain or tenderness.


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Chest

• Watch chest rise and fall with breathing.

• Feel for grating bones as patient breathes.

• Listen to breath sounds.


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Abdomen

• Look for obvious injury, bruises, or bleeding.

• Evaluate for tenderness and any bleeding.

• Do not palpate too hard.


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Pelvis

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

• Press gently inward and downward on pelvic bones.


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Extremities

• Look for obvious injuries.• Feel for deformities.• Assess

• Pulse• Motor function• Sensory function


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Back

• Feel for tenderness, deformity, and open wounds.

• Carefully palpate from neck to pelvis.

• Look for obvious injuries.


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Vital Signs

• After rapid assessment, obtain baseline vital signs and a SAMPLE history.

• Vital signs of stable patients should be reassessed every 15 minutes.

• Vital signs of unstable patients should be reassessed every 5 minutes.


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SAMPLE SAMPLE History• S Signs and symptoms

• A Allergies

• M Medications

• P Past medical history

• L Last oral intake

• E Events leading to the episode


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Focused History and Physical Exam

• Assess the chief complaint.• Chest pain• Shortness of breath• Abdominal pain• Any pain associated with bones

or joints• Dizziness

• Obtain baseline vital signs and SAMPLE history


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Documentation• Skin color, temperature, and moisture

• Initial assessment findings

• Baseline and subsequent vital signs and SAMPLE history

• Circulation, sensation and movement in all extremities

• Breath sounds


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Other Considerations• The following patients should receive

a rapid trauma assessment and immediate transport• Significant mechanism of injury• Unresponsive or disoriented• Extremely intoxicated

• Patients whose complaint cannot be identified or understood


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Assessing the Responsive Patient

• Ask general questions to find out the chief complaint.

• Listen to the patient.

• Record the chief complaint in a few of the patient’s words.

• Use OPQRST to gather history of present illness.


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OPQRST (1 of 2)

• O Onset

• When did the problem first start?

• P Provoking factors

• What creates or makes the problem worse?

• Q Quality of pain

• Description of the pain


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OPQRST (2 of 2)

• R Radiation of pain or discomfort

• Does the pain radiate anywhere?

• S Severity

• Intensity of pain on 1-to-10 scale

• T Time

• How long has the patient had this problem?


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SAMPLE History

• Questions to ask:

• Have you ever been told you have a heart condition?

• Have you ever been told you have problems with your lungs?

• Have you ever been told you have seizures?


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Focused Physical Exam

• Investigate problems associated with chief complaint.

• Examine abnormalities.

• Reassess vital signs.

• Make transportation decision.

• Document findings.


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Assessing the Unresponsive Patient

• Perform a rapid medical assessment.• Obtain baseline vital signs.• Obtain SAMPLE history from family if

available.• Provide emergency care and transport.• Document findings.


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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


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Performing the Detailed Physical Exam (1 of 5)

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

eyelids.• Examine the eyes.• Pull the patient’s ear forward to assess

for bruising.


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

• Look for bruising and lacerations about the head.

• Palpate the zygomas.

• Palpate the maxillae.

• Palpate the mandible.


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• Assess the mouth for obstructions and cyanosis.

• Check for unusual odors.

• Look at the neck.

• Palpate the front and the back of the neck.

• Look for distended jugular veins.


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• Look at the chest.

• Gently palpate over the ribs.

• Listen for breath sounds.

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

• Look at the abdomen and pelvis.


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• Gently palpate the abdomen.

• Gently compress the pelvis.

• Gently press the iliac crests.

• Inspect all four extremities.

• Assess the back for tenderness or deformities.


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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?


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Steps of the Ongoing Assessment

• Repeat the initial assessment.

• Reassess and record vital signs.

• Repeat focused assessment.

• Check interventions.


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Review


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The Communication Process

• Do what you can to make the patient comfortable.

• Listen to the patient.• Make eye contact.• Base questions on the

patient's complaint.• Mentally summarize before

starting treatment.

section 3: patient assessment. chapter 8 patient assessment

Documents

patient assessmentobjectives

patient careemergency

edition aaos3

additional care

assistanceemergency

historyemergency care

transportemergency care

breathingemergency care