Patient Assessment

Chapter 7

Topic Overview

Initial Assessment Forming a General Impression Assessing

Mental Status Airway Breathing Circulation

Determining Priority-

Topic Overview

Focused History & Physical Exam Baseline Vitals SAMPLE History

Documentation

Topic Overview

Components of an ongoing assessment Observing and recording findings Ongoing assessment for stable and

unstable patients

Form a General Impression Environment Age Sex Apparent threats to life

Patient Assessment

Initial Assessment Determine General Impression of Patient

How does the patient look, general appearance of patient

Patient's chief complaint or problem Assess the environment

Patient Assessment

Medical or trauma Nature of Illness / Mechanism of Injury

Gender, Age, Race Are Life Threatening Conditions Present

If a life threatening condition is found, treat immediately.

Patient Assessment

Assess the Airway Open and Maintain Airway Medical Patients

Use head-tilt / chin-lift Clear airway and insert oral or nasal airway as

necessary

Patient Assessment Assess Breathing

Yes or No If breathing is adequate and the patient is responsive,

oxygen may be indicated. All responsive patients breathing >24 breaths per

minute or <8 breaths per minute should receive high flow oxygen (defined as a 15 LPM nonrebreather mask).

If the patient is unresponsive and the breathing is adequate, open and maintain the airway and provide high concentration oxygen (15 LPM by nonrebreather mask).

Patient Assessment

If the breathing is inadequate, open and maintain the airway, assist the patient's breathing and utilize ventilatory adjuncts. In all cases oxygen should be used.

If the patient is not breathing, open and maintain the airway and ventilate using ventilatory adjuncts. In all cases oxygen should be used.

Patient Assessment

Assess Circulation Pulse

Unresponsive Adult / Child - Carotid pulse Infant - Brachial pulse

Responsive Adult/Child - Radial, if you cannot palpate radial check

carotid Infant - Brachial pulse

Patient Assessment

Bleeding Skin (Perfusion)

Color Temperature Condition

Patient Assessment

Assess if major bleeding is present. If bleeding is present, control bleeding.

Are Life Threatening Conditions Present If a life threatening condition is found, treat

immediately.

Assess Mental Status

Alert Verbal stimulus Painful Stimulus Unresponsive

Patient Assessment

Assess Mental Status (Level Of Consciousness)

Maintain spinal immobilization if needed Speak to the patient. State your name, level of training first

responder training and ask permission to help.

Patient Assessment Identify Priority Patients

High priority for transport (by EMS) if: Poor general impression Unresponsive patients - no gag or cough Responsive, not following commands Difficulty breathing Shock (hypoperfusion) Complicated childbirth Chest pain with BP <100 systolic Uncontrolled bleeding Severe pain anywhere

Patient Assessment

SAMPLE History S = Signs and Symptoms

O-P-Q-R-S-T Onset Provocation Quality Radiation Severity Time

A = Allergies Medications, Foods, Environment

Patient Assessment

M = Medications Prescriptions, OTCs, Vitamins, Herbs

P = Pertinent past history HIST

L = Last oral intake E = Events leading to illness or injury

Patient Assessment Respirations

Rate Normal, rapid, slow

Character Rhythm, depth, sound and ease of breathing

Pulse Rate Strength Rhythm

Skin Color (pale, cyanotic, flushed, jaundiced) Temperature (hot, cool, cold) Moisture

Pupils

Baseline Vitals - Respirations Observations

Rapid, shallow breathing

Deep, gasping labored breaths

Slowed breathing

Snoring

Possible Problems Shock, heart problems, heat

emergency, diabetic emergency, heart failure, pneumonia

Airway obstruction, heart failure, heart attack, lung disease, chest injury

Head or chest injury, stroke, certain drugs

Stroke, skull fracture, drug or alcohol abuse, partial airway obstruction

Baseline Vitals - Respirations Observations

Crowing

Gurgling

Wheezing

Coughing blood

Possible Problem Airway obstruction, airway injury due

to heat Airway obstruction, lung disease,

lung injury due to heat

Asthma, emphysema, airway obstruction, heart failure

Chest wound, chest infection, rib fracture, punctured lung, internal injuries

Baseline Vitals - Pulse

Observation Rapid, strong pulse

Rapid, weak pulse

Slow, strong pulse No pulse

Possible Problem Internal bleeding (early stages),

fear, heat emergency, overexertion, high blood pressure, fever

Shock, blood loss, heat emergency, diabetic emergency

Stroke, skull fracture, brain injury

Cardiac arrest

Baseline Vitals – Skin Color Observation

Pink

Pale

Cyanotic

Red (Flushed)

Jaundiced Blotchiness

Possible Problem / Cause Normal in light skinned individuals, normal in

inner eyelids, lips & nail beds of dark-skinned patients

Blood loss, shock, decreased BP, emotional distress

Lack of oxygen to cells due to inadequate breathing or heart function

Heat exposure, high BP, emotional excitement, cherry red – CO poisoning

Liver abnormalities Occasionally in patients in shock

Baseline Vitals – Skin Signs Observation

Cool, clammy Cold, moist Cold, dry Hot, dry

Hot, moist Goose bumps with

accompanied shivering, chattering teeth, blue lips & pale skin

Possible Problems Shock, heart attack, anxiety Heat loss Exposure to cold High fever, heat emergency,

spinal injury High fever, heat emergency Shills, communicable

disease, exposure to cold, pain or fear

Baseline Vitals – Pupils

Observations Dilated, nonreactive

Constricted, nonreactive

Unequal

Possible Problems Unresponsiveness, shock,

cardiac arrest, bleeding, certain medications, head injury

Central nervous system damage, certain medications

Stroke, head injury

Patient Assessment

Blood Pressure Pulse Oximetry

Measures oxygen circulating in the blood 95-99% considered normal

Precautions Not accurate in shock or hypothermia False readings in Carbon Monoxide poisoning Movement and nail polish can cause inaccurate readings

NOTE: Do Not withhold oxygen from a patient who may need it

because the oximeter reads “normal”

Patient Assessment

Re-consider Mechanism of Injury Significant mechanism of injury

Ejection from vehicle Death in same passenger compartment Roll-over of vehicle High-speed vehicle collision

Deformities to vehicle’s interior may reveal mechanism

Patient Assessment Falls > 15 feet or 3 times patient’s height Vehicle-pedestrian collision Motorcycle crash Unresponsive or altered mental status Penetrations of the head, chest, or abdomen

Patient Assessment

Hidden injuries Seat belts

If buckled, may have produced injuries. If patient had seat belt on, it does not mean they do

not have injuries. Airbags

May not be effective without seat belt. Patient can hit wheel after deflation. Lift the deployed airbag and look at the steering

wheel for deformation.

Patient Assessment "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.

Infant and child considerations Falls >10 feet Bicycle collision Vehicle in medium speed collision

Patient Assessment If Significant Mechanism of Injury

Reconsider mechanisms of injury Continue spine stabilization Consider requesting Adv. Life Support Reconsider transport decision (activation of EMS) Assess mental status Do detailed physical exam Assess baseline vitals Obtain SAMPLE history

Patient Assessment

Perform a detailed head to toe exam To obtain additional information.

As you perform the exam, inspect and palpate, look for and/or feel for the following examples of injuries or signs or injuries

DOTS Deformity Open Injuries Tenderness Swelling

Patient Assessment

D = Deformities O = Open Injuries T = Tenderness S = Swelling

Patient Assessment

DCAP BTLS Deformities Contusions Abrasions Punctures/Penetrations

PatientAssessment

Burns Tenderness Lacerations Swelling

Patient Assessment Assess the head, inspect and palpate for

injuries or signs of injury. DOTS / DCAP BTLS + Check the eyes

Check DOTS (DCAP BTLS) + Discoloration Unequal pupils Foreign Bodies Blood in anterior chamber

Patient Assessment Check both ears

Look for signs of bleeding from the ears. Can perform halo test Bleeding from the ears without tympanic rupture

indicates possible head injury Look for “Battle’s sign” and/or “Raccoon eyes”

Check the nose Deviation Bleeding

Check the mouth Swollen or lacerated tongue Teeth

Patient Assessment

Assess the neck, inspect and palpate for injuries or signs of injury.

DOTS / DCAP BTLS Jugular vein distension (JVD) Tracheal deviation Apply cervical spinal immobilization collar (CSIC).

Assess the chest, inspect and palpate for injuries or signs of injury.

DOTS / DCAP BTLS

Patient Assessment

Paradoxical motion Unequal movement of chest wall Crepitus Breath sounds in the apices, mid-clavicular line,

bilaterally and at the bases, mid-axillary line, bilaterally

Present Absent Equal

Patient Assessment

Assess the abdomen, inspect and palpate for injuries or signs of injury.

DOTS / DCAP BTLS Palpate all four quadrants

Check for tenderness, rebound tenderness, rigidity, distention

Assess the pelvis, inspect and palpate for injuries or signs of injury.

DOTS / DCAP BTLS Pelvic rock / pelvic squeeze (if appropriate)

Patient Assessment

Assess all four extremities, inspect and palpate for injuries or signs of injury.

DOTS / DCAP BTLS Assess bilaterally

Circulation (distal pulse and/or capillary refill) Sensation Motor function

Assess Back (if and when possible) Roll patient with spinal precautions and assess posterior

body Inspect and palpate using DOTS or DCAP BTLS Examining for injuries or signs of injury.

Patient Assessment

Problems not requiring a full head-to-toe exam include:

Isolated injuries or no significant mechanism of injury

Responsive medical patients Illness-related problems, such as difficulty breathing or

chest pain may not require a full head-to-toe exam

Note: Do Toe-to-Head exam on children

Patient Assessment

Trauma Patient Significant Mechanism

Perform a rapid trauma assessment

Vital signs Gather SAMPLE history

No Significant Mechanism Perform a focused trauma

assessment Vital signs SAMPLE history

Medical Patient Unresponsive

Perform a rapid physical Vital signs SAMPLE history

Responsive SAMPLE history Focused physical Vital signs

Patient Assessment

Ongoing Assessment While waiting for EMS to arrive

Repeat initial assessment Reassess and record vital signs Repeat physical assessment

As dictated based on injury or illness Check on treatment in progress

Patient Assessment

Stable patient Repeat every 15 minutes Trauma Patient

Isolated injury or no significant mechanism of injury

Medical Patient Responsive patient

Patient Assessment

Unstable Patient Reassess every 5 minutes Trauma Patient

Serious injury or serious mechanism of injury

Medical Patient Unresponsive Deteriorating condition

Patient Assessment

Observing Trends Trends change over time Changes noted over time are significant (e.g.

changes in BP or pulse) Repeated assessments are required to observe

trends

Patient Assessment

Check interventions Adequacy of oxygen delivery Adequacy of artificial ventilation External bleeding Other

Splinted extremities

Patient Assessment

Once EMS arrives Provide a report of findings to EMS

Recap patient information Mechanism or Illness Positive findings & pertinent negative findings

Baseline Vitals & changes Results of SAMPLE history

Care provided

Patient Assessment

Review Initial assessment Provide care for immediate life threatening problems Detailed assessment

Head-to-Toe Exam Vital Signs SAMPLE History

Care for problems found during detailed assessment On-going assessment Report of findings