Unit 3 Conscious Patient Assessment

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Unit 3Conscious Patient Assessment

• PE 216 Emergency Response

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Patient Assessment

• The gathering of information to determine a
  possible illness or injury
• Interviews
• Physical Examinations

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Patient Type

• Stable
• Patient is conscious and responsive
• Patients vital signs are within normal limits
  (WNL)
• Re-assess every 15 minutes
• Unstable
• Patient is unconscious or unresponsive, and is
  breathing
• Patients vital signs are unstable (outside normal
  limits) or constantly changing
• Re-assess every 5 minutes

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Patient Type

• Medical Patients
• A patient with an illness and no injuries
• Responsive or unresponsive
• Trauma Patients
• A patient with a physical injury
• Significant and insignificant

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Terms and Definitions

• Patient History
• Gathering information by asking questions and
  listening
• Can interview patient, family, bystanders
• Rapid Physical Exam
• Quick, less detailed head-to-toe assessment of
  critical patients
• Detailed Physical Exam
• Performed on stable patients
• Focuses on a specific injury or complaint

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Terms and Definitions

• Vital Signs
• Pulse (60-100 bpm)
• Respirations (12-20 bpm)
• Blood Pressure (100-140/60-80)
• Symptoms
• Complaints reported by the patient
• Chest pain, nausea, dizziness
• Signs
• Problems which you can visually find
• Dilated pupils, red/dry skin, deformity

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Patient History-SAMPLE

• S- Signs/Symptoms
• A- Allergies
• M- Medications
• P- Past medical history
• L- Last oral intake
• E- Events leading to illness/injury

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Physical Exam Findings

• DCAP-BTLS
• Deformities
• Contusions
• Abrasions
• Punctures
• Burns
• Tenderness
• Lacerations
• Swelling

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Abnormal Findings

• Skin Temperature
• Excessively hot or cold skin could indicate shock
  or environmental illness
• Check by placing the back of your hand on the
  patients forehead
• Skin Color
• Pale Skin- Shock, Heat Exhaustion, Internal
  Injury
• Red Skin- Heat Stroke
• Blue Skin (Cyanosis)- Lack of perfusion
• White/waxy- Frostbite

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Abnormal Findings

• Skin Moisture
• Excessively Dry- Heat Stroke
• Excessively Wet- Head Exhaustion, Heart Attack,
  Shock
• Pupil Reaction
• Test by covering one eye, and shining pen light
  into the other
• Pupils should constrict in the presence of light
• Equal speed, diameter
• Can indicate concussion/head injury

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Abnormal Findings

• Neurovascular Function
• To test neurological, ask patient to
• Wiggle toes
• Squeeze your fingers
• To test vascular, check
• Dorsalis pedis pulse
• Radial Pulse
• If absent, a significant traumatic injury may be
  present to the brain, spinal cord, nerves, or
  arteries

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Rapid Trauma Assessment

• Briefly examine the following
• Neck- distended veins, ID tags
• Chest- equal chest rise, breath sounds
• Abdomen- distention, firmness, rigidity
• Pelvis- incontinence of urine/feces
• Extremities- circulation, sensation, motor
  function, ID tags

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Detailed Physical Exam

• Scalp/Skull
• Eyes
• Ears and Nose
• Mouth
• Cervical Spine
• Chest
• Collarbone/Shoulder
• Ribs

• Abdomen
• Lower back
• Pelvis
• Groin
• Extremities
• Circulation
• Sensation
• Motor Function

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Ongoing Assessment

• Patients condition may change rapidly
• Assessment Intervals
• Stable Patient- every 15 min
• Unstable Patient- every 5 min
• Monitor for changes in
• Consciousness
• ABCs
• Vital Signs