Post on 11-Jan-2016
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