PATIENT ASSESSMENT PROCESS * Scene size-up * Initial assessment * Focused history and physical exam * Detailed physical exam * Ongoing assessment
A. SCENE SIZE-UP
- how you prepare for a specific situation
- includes dispatch information and must be combined with inspection of scene
Helps identify: scene hazards, safety concerns, MOI, NOI and number of patients you may have, as well as additional resources
BODY SUBSTANCE ISOLATION
- Assumes all body fluids present a possible risk for infection
Personal Protective Equipment (PPE) - Latex or vinyl gloves, Eye protection, Mask, Gown * Reduces your personal risk for injury or illness SCENE SAFETY
Information provided by dispatch may help in determining potential hazards
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
Scene Safety
1. Park in a safe area
- allows rapid access to your patient and your equipment (infront of the scene)
2. Speak with law enforcement first
- ask to accompany you if the victim is a suspect in a crime
3. Do not enter until a professional rescuer has made the scene safe
- Carefully evaluate scene & request specific help to manage the scene threats
Professional Rescuer: law enforcement, firefighters, utility workers, hazardous materials crew
* Remember that hazards do not need to be dramatic situations but could be as simple as a hole in the ground
CONSIDER MOI/NOI
MECHANISM OF INJURY
- how a traumatic injuries occur
With traumatic injury, the body has been exposed to some force or energy that has resulted in a temporary injury, permanent damage or even death
- 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
1. BLUNT TRAUMA – force of the injury occurs over a broad area and skin is usually not broken
* However, tissues and organs below the area of impact may be damaged
2. PENETRATING TRAUMA – force of the injury occurs at a small point of contact between the skin and the object
* The object pierces the skin and creates an open wound that carries a high potential for infection
SIGNIFICANT MECHANISM OF INJURY FOR CHILDREN
Includes the list from the next slide as well as: * Fall greater than 2 to 3 times their height * Bicycle crash
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
HIDDEN INJURIES * Seat belts - May cause injuries if worn improperly * Airbags - Look beneath airbag for bent steering wheel.
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
Falls * Amount of force related to height of fall * Note surface that patient landed on * Attempt to determine how patient landed
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
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.
Examples: seizures, heart attacks, diabetic problems, and poisonings
DETERMINE THE NUMBER OF PATIENTS
- this evaluation of critical in determining your need for additional resources
Multiple patients
- establish incident command, call for additional units, begin triage
Triage – process of sorting patients based on severity of each patient’s condition
* The most experienced should be assigned to perform triage
CONSIDER ADDITIONAL RESOURCES
- some situations may require more ambulances whie others may have needs for specific additional help (Ex. BLS units or ALS for severely injured)
Additional resources: Fire department, law enforcement, specialized search and rescue team, or HazMat team
CONSIDER C-SPINE IMMOBILIZATION
- if an injury is suspected, consider early spinal immobilization
* Without proper spinal immobilization, lifelong paralysis may occur
B. INITIAL ASSESSMENT * Approach and form a general impression * Assess mental status * Assess airway * Assess the adequacy of breathing * Assess circulation * Identify patient priority and make transport decision
GOAL: To identify and initiate treatment of immediate or potential life threats
LIFE THREATENING CONDITIONS
- obtained from visual appearance of the patient
- current MOI or NOI
- obvious problems with the patient’s ABC
APPROACH AND FORM GENERAL IMPRESSION
GENERAL IMPRESSION
- note person’s age, gender, race, level of distress and overall appearance
- note patient’s position and whether the patient is moving or still
* Woman complaining of abdominal pain may have more serious implications than a man with the same complaint because of the complexity of the female reproductive system
1. Approach the scene and the patient
- As you approach, make sure that the patient sees you coming to avoid surprising the patient making injuries worse
- place yourself at lower position to show respect & help pt feel comfortable
2. Introduce yourself
- Ex. “Hello, my name is John Smith, Im an EMT. I’m here to help you”
- Ask the patient his or her name and address
3. Obtain consent to care
- “May I look at your leg? It seems to be injured”
- Treatment for unresponsive patients is based on implied consent
* If the patient wakes up, explain who you are, what you are doing, and why you are doing it
4. Determine Chief complaint
- it is the most serious thing the patient is concerned about (symptoms)
- something observable by the EMT-B (signs)
- answers the questions “What happened?” or “How may I help you?”
- it gives you a referrence point to begin your assessment process
ASSESS MENTAL STATUS
1. CHECKING RESPONSIVENESS
Level of Consciousness * A Alert * V Responsive to Verbal stimulus * P Responsive to Pain * U Unresponsive
2. CHECK FOR ORIENTATION
- person, place (long-term memory), time (intermediate memory) , and event (short-term memory)
* If he or she recalls all four, then he or she is fully alert and oriented x four.
CAUSES (Altered mental status):
- head trauma, hypoxemia, hypoglycemia, stroke, cardiac problems, drug use
If positive: rapidly complete initial assessment, provide high- flow supplemental oxygen, consider spinal immobilization and initiate transport
ASSES THE AIRWAY
RESPONSIVE PATIENTS
- patients of any age who are talking and crying have an open airway
UNRESPONSIVE PATIENTS (or with decreased LOC)
- immediately assess patency of airway
If clear: continue assessment
If not clear: head tilt-chin lift or jaw-thrust manuever
* Suction and use airway adjunct as necessary
CAUSES OF AIRWAY OBSTRUCTION
1. Relaxation of tongue muscles
2. Dentures, blood clots, vomitus, mucus, food or other foreign objects
SIGNS OF AIRWAY OBSTRUCTION
1. Obvious trauma, blood or other obstruction
2. Noisy breathing (normal breathing is quiet)
3. Extremely shallow or absent breathing
SPINAL CONSIDERATIONS
- airway managemetn and spinal immmobilizatio must be performed simultaneously
If patient has no spinal injury: place patient in a recovery position or side- lying position as soon as possible
ASSESS BREATHING
MANAGEMENT (Difficulty of Breathing)
1. Reevaluate airway
2. Oxygen should be administered to patients who are having difficulty of breathing
* Ventilations with a BVM or nonrebreathing mask at 15L/min if patient’s respirations are greater than 24/min or less than 8/min.
3. Positive pressure ventilations performed on patients who are apneic or with slow and shallow breathing
Shallow respiration – little movement of the chest wall Deep respiration – causes great deal of chest rise and fall
* Any patient with decreased LOC, respiratory distress or poor skin color should also receive high-flow oxygen
SIGNS OF INADEQUATE BREATHING * Two- to three-word dyspnea * Use of accessory muscles (presence of retractions) * Nasal flaring and see-saw breathing * Labored breathing
Normal respiratory rates: 12 to 20 breaths/min
Goal of initial assessment: to identify and treat ABC as quickly as possible Unresponsive Patients: Look, listen and feel technique
ASSESS CIRCULATION
1. ASSESS THE PULSE
- Feel for radial artery or carotid artery in the neck
If no pulse: begin CPR
AED – indicated for use on medical patients at least 8 years old weighing more than 55 lbs, unresponsive, no breathing and pulseless
* Special pediatric pads for 1 to 7 years old
If with pulse but no breathing: provide ventilations
Adult: 12 breaths/min Infant and Child: 20 breaths/min
* Continue to monitor pulse
Responsive patient
- Absence of palpable pulse in a responsive patient is not caused by cardiac arrest so NEVER begin CPR or use AED on responsive patient
NORMAL PULSE RATES
Infant – 100 to 160 bpm
Toddler – 90 to 150 bpm
Pre-school – 80 to 140 bpm
School age – 70 to 120 bpm
Adolescent – 60 to 100 bpm
Adult – 60 to 90 bpm
Geriatric – 100 bpm
2. ASSESS AND CONTROL BLEEDING
Signs of blood loss: active bleeding from wounds or blood on clothes
Bleeding from large vein – steady flow
Bleeding from artery – spurting flow of blood
CONTROLLING BLEEDING:
1. Direct pressure with gloved hand
* helps blood to coagulate or clot naturally
2. Sterile bandage over wound
3. Elevate extremity if bleeding is from arms and legs
4. Arterial pressure points (if direct pressure/elevation is not successful)
3. ASSESS PERFUSION
a. COLOR
Pinkish: normal skin color
Alert: Cyanosis (blue), flushed (red), pale (white) or jaundiced (yellow)
Check: fingernail beds, sclera, conjunctiva, mucous membranes of the mouth
b. TEMPERATURE
Cool, pale, clammy skin – with poor perfusion, the body pulls blood away from the surface of the skin and diverts to the core of the body
c. SKIN CONDITION
Warm and dry: normal
Cold, moist and clammy: suggests shock (hypoperfusion)
d. CAPILLARY REFILL.
- Should be less than 2 seconds
Other conditions may also slow CRT: patients age, exposure to cold environment (hypothermia), frozen tissue (frost bite), and vasoconstriction
IDENTIFYING PRIORITY PATIENTS &
MAKE TRANSPORT DECISION
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
* Protecting the patient’s spine and identifying fractured extremities are integral part of packaging and transpor
GOLDEN HOUR – first 60 mins, time from injury to definitive care
Traumatic injuries: assess, stabilize, package, & begin transport w/n 10 minutes
C. FOCUSED HISTORY AND PHYSICAL EXAM
- based on the patient’s chief complaint
Decompensatory shock – body eventually loses its ability to compensate
1. RAPID TRAUMA ASSESSMENT
- quick head-to- toe exam to identify DCAP-BTLS performed in 60-90 seconds
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
TRAUMA ASSESSMENT
D Deformities
C Contusions
A Abrasions
P Punctures/ Penetrations
B Burns
T Tenderness
L Lacerations
S Swelling
ASSESS FOR DCAP-BTLS:
* Maintain spinal immobilization while checking patient’s ABCs.
1. HEAD (Assess the head)
2. NECK (Assess for jugular vein distention, tracheal deviation)
* Apply a cervical spine immobilization collar.
Jugular vein distention (sitting at 45 angle) - suggests a problem with blood returning to the heart
3. CHEST (Assess for paradoxical motion, listen to breath sounds)
Retractions - when the skin pulls in around the ribs duirng inspiration
* Indicates impaired flow of air
Paradoxical motion - when only one section of the chest rises on inspiration while another area falls
* Indicates fracture of several ribs (flail)
4. ABDOMEN (feel for rigidity and distention: firm, soft, tender or distended)
5. PELVIS (compress downward and inward)
* Pain or tenderness suggest that severe injury may be present
6. EXTREMITIES (assess for PMR)
a. Pulse: distal pulses (dorsalis pedis or posterior tibial or radial)
b. Motor Function: ask to wiggle fingers and toes
* Inability to move a single extremity result to bone, muscle or nerve injury
* Inability to move several extremities is a sign of brain or spinal cord injury
c. Sensory Function: gently squeeze or pinch and ask patient to identify what you are doing
* Inability to feel sensation in the extremity may indicate local nerve injury
* Inability to feel in several extremity may be sign of spinal cord injury 7. BACK and Buttocks
* Roll the patient with spinal precautions.
VITAL SIGNS * Vital signs of stable patients should be reassessed every 15 minutes. * Vital signs of unstable patients should be reassessed every 5 minutes.
SAMPLE HISTORY * S Signs and symptoms * A Allergies * M Medications * P Past medical history * L Last oral intake * E Events leading to the episode
MAKE TRANSPORTATION DECISION
2. FOCUSED PHYSICAL EXAM
- focuses in the location of the body system related to the chief complaint
ASSESS THE CHIEF COMPLAINT
1. Chest pain – listen for breath sounds, V/S
2. Shortness of breath – look for signs of airway obstruction and trauma to the neck and chest. Listen to breath sounds
3. Abdominal pain - palpate for tenderness, rigidity and guarding
4. Any pain associated with bones or joints - expose site and evaluate PMS below affected area
- assess range of motion (ask to move extremity or joint)
5. Dizziness - evaluate LOC and orientation. Inspect head for trauma
PHYSICAL EXAM TECHNIQUES
1. Inspection - simply looking for abnormalities
2. Palpation - touching for abnormalities
3. Auscultation - listening to sounds using stethoscope
Obtain baseline vital signs and SAMPLE history
Make transportation decision.
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.
OPQRST
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
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?
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.
D. DETAILED PHYSICAL EXAM * More in-depth exam based on focused physical exam * Usually performed en route to the hospital
PERFORMING THE DETAILED PHYSICAL EXAM
Visualize and palpate using DCAP-BTLS.
1. Look at the FACE.
2. EYES
Inspect the area around the eyes and eyelids.
Raccoon eyes - bruising or discoloration around the eyes (head trauma)
3. EARS
Battle’s sign - bruising or discoloration behind the ears (head trauma)
Use the penlight to look for drainage or blood in the ears.
4. Palpate the zygomas.
5. Palpate the maxillae.
6. Palpate the mandible.
7. MOUTH
Assess the mouth for obstructions (Ex. Loose or broken teeth)
Check for unusual odors (alcohol odor or fruity breath odor)
8. NECK
Look for distended jugular veins
Subcutaneous emphysema - sensation of crackling or popping indicating that air is leaking into space under the skin
* Patient has pneumothorax or damaged larynx or trachea
9. CHEST
Palpate over the ribs.
Paradoxical motion - means that patient has flail chest and needs supplemental oxygen or assisted ventilation
Listen for breath sounds
a. Normal - clear and quiet
b. Wheezing - high-pitched squel on expiration (obstruction on lower airway)
c. Rales or crackles - moist crackling indicating cardiac failure
d. Rhonchi - low-pitched noisy sound on expiration due to mucus in lungs
e. Stridor - heard w/o a stethoscope, airway obstruction in upper airway
10. ABDOMEN & PELVIS * Gently palpate the abdomen. * Gently compress the pelvis. * Gently press the iliac crests.
11. EXTREMITIES Evaluation of the circulation, sensation and movement below the injury to be sure it has not compromised neurovascular status E. ONGOING ASSESSMENT
Steps of the Ongoing Assessment * Repeat the initial assessment. * Reassess and record vital signs. * Repeat focused assessment. * Check interventions.
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.
