Patient Assessment

1
Patient Assessment

• Initial Assessment - main purpose is to identify
  and treat immediately life-threatening conditions.

2
Initial Assessment Sequence

• Form general impression of the patient.
• Assess mental status.
• Assess airway.
• Assess breathing.
• Include exposing the chest.
• Assess circulation.
• Establish priorities.

3
General Impression of the Patient

• Definition - The general impression is formed to
  determine priority of care and is based on the
  EDTs immediate assessment of the environment and
  the patients chief complaint.
• Determine if ill i.e., medical or injured
  (trauma).
• If injured
• Identify mechanism of injury.
• Age
• Sex
• Race

4
Establish In-line Stabilization

• Suspected injury to patient.
• Bring patients head into neutral in-line position
  and maintain until secured to backboard.
• Decreases chance of spinal cord damage.
• If patient is prone.
• Quickly assess back and log-roll onto spine
  board.
• Eliminates the need for a second log-roll.

5
Assess Patients Mental Status

• Begin by speaking to the patient. State name,
  tell the patient that you are an Emergency
  Medical Technician and explain that you are here
  to help.
• Levels of mental status.
• Alert.
• Responds to Verbal stimuli.
• Responds to Painful stimuli.
• Purposeful movement ( grabs your hand to avoid
  pain)
• Nonpurposeful movement (posturing pg. 161)
• Unresponsive - no gag or cough.

6
Assess the Patients Airway Status

• Responsive patient - Is the patient talking or
  crying.
• If yes, assess for adequacy of breathing.
• If no, open the airway.
• Unresponsive patient - Is the airway open?
• Open the airway. Note position of patient, age,
  and size.

7
Assess the Patients Airway Status

• For medical patients, perform the head-tilt,
  chin-lift.
• Clear
• Not clear - Clear the airway.
• For trauma patients or those with unknown nature
  of illness, the cervical spine should be
  stabilized / immobilized and jaw thrust maneuver
  performed.
• Stabilize a sitting patient head from behind and
  a supine patients head from the top.
• Clear
• Not clear - Clear the airway.

8
Assess Breathing

• Determine if breathing is adequate or inadequate.
• Determine the need for early oxygen therapy if
  breathing is adequate.
• Provide positive pressure ventilation with
  supplemental oxygen for inadequate breathing.

9
Assess Breathing

• Best method to assess breathing rate and quality.
• Look.
• Listen.
• Feel.

10
Assess Breathing/Look

• Inadequate tidal volume.
• Poor chest rise and fall.
• Abnormal respiratory rate.
• Breathing faster or slower than normal.
• 12 to 20 adult
• 15 to 30 child
• 25 to 50 infant
• Retractions.
• Nasal flaring.
• Excessive abdominal muscle use.
• Tracheal tugging.
• Cyanosis
• Asymmetrical chest wall movement

11
Assess Breathing/Listen and Feel

• Absence of breathing (apnea).
• Inadequate breathing.
• Unresponsive patient with a rate of 24 or times per minute should be assisted with a BVM
  and 15lpm. supplemental oxygen.
• All responsive patients breathing 24 or should receive high flow oxygen. 15lpm
  nonrebreather mask.
• Dyspnea - difficulty breathing.
• Assess the chest.

12
Assess Circulation

• Pulse.
• Skin color, condition, and temperature.
• Capillary refill in infants and children.
• Hemorrhage scan.
• If major bleeding, it must be controlled.
• Capillary refill in infants and children.
• Less than 6 years of age.

13
Establish Patient Priority

• Load and Go Criteria
• Poor general impression.
• Unresponsive patient (Decreased LOC).
• Responsive not obeying commands.
• Difficulty breathing or apnea.
• Pulseless patient.
• Shock/Hypoperfusion
• Open wound to chest or or flail segment.
• Chest pain with BP less than 100 systolic.
• Severe pain anywhere.
• Complicated childbirth.
• Hyper or hypothermia.
• Severe allergic reaction.
• Poisoning or overdose of unknown substance.

14
Focused History and Physical Exam Trauma
Patient

• Purpose is to identify any additional injuries or
  conditions that may also be life-threatening.

15
Trauma Patient

• In the trauma patient the physical exam and vital
  signs are done before the history because the
  most significant information will usually come
  from the physical exam.

16
Reconsider Mechanism of Injury

• Ejection from vehicle.
• Death in same passenger compartment.
• Falls (of more than 20 feet or 3 times the
  patients height).
• Roll over of vehicle.
• High-speed vehicle collision.
• Vehicle-pedestrian collision.
• Motorcycle crash.
• Unresponsive or altered mental status.
• Penetrations of the head, chest, or abdomen.

17
Hidden Injuries

• Seat belts.
• If buckled, may have produced injuries.
• If patients had seat belts on, it does not mean
  they do not have injuries.

18
Hidden Injuries

• Airbags.
• May not be effective without seatbelt
• Patients can hit wheel after deflation
• Lift the deployed airbag and look at the
  steering wheel for deformation.
• Lift and look under the bag after the patient has
  been removed.
• Any visible deformation of the steering wheel
  should be regarded as an indicator of potentially
  serious internal injury, and appropriate action
  should be taken.

19
Infant and Children Considerations

• Falls greater than 10 feet.
• Bicycle collision.
• Vehicle in medium-speed collision.
• Unrestrained child or infant.

20
Remember to

• Continue spinal stabilization.
• Consider ALS request.
• Reconsider transport decision.
• Reassess mental status.
• Is patient A0X3.
• Person.
• Place.
• Time.

21
Performing the Rapid Trauma Assessment

• Inspect (look).
• Auscultate (listen).
• Palpate (feel).
• Use you sense of smell to detect any unusual
  odors on patient such as alcohol, feces, urine.

22
Look, Listen, and Feel For

• Deformities.
• Contusions.
• Abrasions.
• Punctures / penetrations.
• Burns.
• Tenderness.
• Lacerations.
• Swelling.

23
Assess the Head For

• Deformities.
• Contusions.
• Abrasions.
• Punctures / penetrations.
• Burns.
• Tenderness.
• Lacerations.
• Swelling.
• Crepitation

24
Assess the Neck For

• Deformities.
• Contusions.
• Abrasions.
• Punctures / penetrations.
• Burns.
• Tenderness.
• Lacerations.
• Swelling.
• Crepitation.
• Jugular vein distention (JVD), Tracheal
  deviation, Subcutaneous emphysema and a medical
  alert tag.
• Apply cervical Collar

25
Assess the Chest For

• Deformities.
• Contusions.
• Abrasions.
• Punctures / penetrations.
• Burns.
• Tenderness.
• Lacerations.
• Swelling.
• Crepitation.
• Paradoxical motion.
• Auscultate breath sounds
• Apices-mid-clavicular bilaterally.
• Bases-mid-axillaery bilaterally.

26
Assess the Abdomen For

• Deformities.
• Contusions.
• Abrasions.
• Punctures / penetrations.
• Burns.
• Tenderness.
• Lacerations.
• Swelling/Distention.
• Firm.
• Soft.

27
Assess the Pelvis For

• Deformities.
• Contusions.
• Abrasions.
• Punctures / penetrations.
• Burns.
• Tenderness.
• Lacerations.
• Swelling.
• If no pain noted, gently compress the pelvis, in
  and down at the same time, without rocking, to
  determine tenderness or motion.

28
Assess All Four Extremities For

• Deformities.
• Contusions.
• Abrasions.
• Punctures / penetrations.
• Burns.
• Tenderness.
• Lacerations.
• Swelling.
• Distal pulse.
• Sensation.
• Motor function.

29
Assess the Back For

• Roll the patient with spinal precautions and
  assess back for.
• Deformities.
• Contusions.
• Abrasions.
• Punctures / penetrations.
• Burns.
• Tenderness.
• Lacerations.
• Swelling.

30
Remaining Exam

• Assess baseline vital signs.
• Assess a SAMPLE history.
• Perform any interventions and transport.

31
Patients with no Significant MOI.

• Cut Finger.
• Perform focused history and physical exam of
  injuries based on the components of the rapid
  assessment.
• The focused assessment is performed on the
  specific injury site.
• Assess baseline vital signs.
• Obtain SAMPLE history.

32
Focused History and Physical Exam Medical
Patient
33
Unresponsive Medical Patient

• Perform rapid assessment.
• Assess the head.
• Assess the neck.
• Assess the chest.
• Assess the abdomen.
• Assess the pelvis.
• Assess the extremities.
• Assess the posterior body.
• Assess baseline vital signs.
• Position patient to protect airway.
• Obtain Sample history from bystanders, family,
  friends prior to leaving.
• Look for any medical alert bracelets.

34
Responsive Medical Patient

• Assess complaints and signs and symptoms.
• O-P-Q-R-S-T.
• Onset.- When and how did symptoms begin?
• Provocation.- What makes the symptom worse?
• Quality.- How would you describe the pain?
• Radiation.- Where do you feel the pain?
• Severity.- How bad is the pain?
• Time.- How long have you had the symptom?

35
Responsive Medical Patient

• Assess SAMPLE history.
• Performs rapid assessment.
• Assess the head if necessary.
• Assess the neck if necessary.
• Assess the chest if necessary.
• Assess the abdomen if necessary.
• Assess the pelvis if necessary.
• Assess the extremities if necessary.
• Assess the posterior body if necessary.
• Assess baseline vital signs.
• Provide emergency medical care based on signs and
  symptoms in consultation with medical direction.

36
Detailed Physical Exam

• Patient with a cut finger would not require the
  detailed physical exam.

37
Detailed Physical Exam

• Done only after all life-threatening injuries
  have been effectively managed.
• Usually performed in the back of the ambulance en
  route to the hospital.
• Before you start reassess your initial
  assessment.

38
Detailed Physical Exam

• Amore detailed assessment of the patient.
• Assess the head, DCAPBTLS.
• Scalp, DCAPBTLS.
• Ears, nose for blood or Cerebral Spinal Fluid
  (CSF). Behind ears for battles signs.
• Mouth, blood, loose teeth, blood.
• Eyes, PEARL, equal or unequal, blood in chamber.
• Facial bones, DCAPBTLS.

39
Assess the Neck

• Never remove the c-collar after it has been
  applied.
• DCAPBTLS.
• JVD, Tracheal deviation, subcutaneous emphysema,
  Medical alert tag.

40
Assess the Chest

• DCAPBTLS.
• Paradoxical motion.
• Breath sounds.
• Present.
• Equal.
• Absent.

41
Assess the Abdomen

• DCAPBTLS.
• Firm.
• Soft.
• Distended.

42
Assess the Pelvis

• DCAPBTLS.
• Press in and down without rocking.

43
Assess All Four Extremities

• DCAPBTLS.
• PMS.
• Pulse.
• Motor function.
• Sensation.

44
Assess the Back

• Patient should not be removed from the backboard,
  reach as far back as you can without moving the
  patient.
• DCAPBTLS.
• Reassess baseline vital signs.

45
Ongoing Assessment
46
Ongoing Assessment

• Repeat initial assessment.
• For stable patient, repeat and record vitals
  every 15 minutes.
• For an unstable patient, repeat and record vitals
  at a minimum of every 5 minutes.
• Reassess mental status.
• Maintain open airway
• Monitor breathing for rate and quality.
• Reassess pulse for rate and quality.
• Re-establish patient priorities.

47
Ongoing Assessment

• Reassess and record baseline vital signs.
• Repeat focused assessment regarding patient
  complaint orinjuries.
• Check interventions.
• Assure adequacy of oxygen delivery/artificial
  ventilation.
• Assure management of bleeding.
• Assure adequacy of other interventions.