Chapter 13: Patient Assessment

Chapter 13

Patient Assessment

National EMS Education

Standard Competencies

Assessment

Integrate scene and patient assessment findings with knowledge of epidemiology and pathophysiology to form a field impression.

This includes developing a list of differential diagnoses through clinical reasoning to modify the assessment and formulate a treatment plan.



Scene Size-up

• Scene safety

• Scene management

− Impact of the environment on patient care

− Addressing hazards

− Violence

− Need for additional or specialized resources

− Standard precautions

− Multiple patient situations



Primary Assessment

• Primary assessment for all patient situations

− Initial general impression

− Level of consciousness

− ABCs

− Identifying life threats

− Assessment of vital functions



Primary Assessment (cont ’ d)

• Begin interventions needed to preserve life.

• Integration of treatment/procedures needed to preserve life



History Taking

• Determining the chief complaint

• Investigation of the chief complaint

• Mechanism of injury/nature of illness

• Past medical history

• Associated signs and symptoms

• Pertinent negatives



History Taking (cont ’ d)

• Components of the patient history

• Interviewing techniques

• How to integrate therapeutic communication techniques and adapt the line of inquiry based on findings and presentation



Secondary Assessment

• Performing a rapid full-body exam

• Focused assessment of pain

• Assessment of vital signs

• Techniques of physical examination

• Respiratory system

− Presence of breath sounds



Secondary Assessment (cont ’ d)

• Cardiovascular system

• Neurologic system

• Musculoskeletal system



Secondary Assessment (cont ’ d)

• Techniques of physical examination for all major

− Body systems

− Anatomic regions

• Assessment of

− Lung sounds



Monitoring Devices

• Obtaining and using information from patient monitoring devices including (but not limited to):

− Pulse oximetry

− Noninvasive blood pressure

− Blood glucose determination

− Continuous ECG monitoring

− 12-lead ECG interpretation

− Carbon dioxide monitoring

− Basic blood chemistry



Reassessment

• How an when to reassess patients

• How and when to perform a reassessment for all patient situations



Medicine

Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression and implement a comprehensive treatment/disposition plan for a patient with a medical complaint.



Medical Overview

• Assessment and management of a

− Medical complaint

• Pathophysiology, assessment, and management of medical complaints to include:

− Transport mode

− Destination decisions

Introduction

• One of the most important skills you will develop is the ability to assess a patient.

− Identify your patient ’ s problem(s).

− Set your care priorities.

− Develop a patient care plan.

− Execute your plan.

Sick Versus Not Sick

• Determine whether the patient is sick or not sick.

− If the patient is sick, determine how sick.

• Every time you assess a patient:

− Qualify whether your patient is sick or not sick

− Quantify how sick the patient is

Establishing the Field

Impression

• A determination of what you think is the patient ’ s current problem

− You must be able to communicate and ask the right questions.

• Be a “ detective.

”

Establishing the Field

Impression

• The process must be organized and systematic but still flexible.

− Know when to expand your questioning.

− Know when to focus your questioning.

Medical Versus Trauma

• Medical patients

− Identify chief complaint and sift through medical history.

• Trauma patients

− Medical history may have less impact

− Requires a modified approach

Scene Size-Up

• Involves evaluating the overall safety and stability of the scene

− Safe and secure access into the scene

− Ready egress out of the scene

− Specialty resources needed

Scene Safety

• Ensure the safety and well-being of your

EMS team and any other responders.

− If the scene is not safe, do what is necessary to make it safe.

− Requires constant reassessment

Scene Safety

• Crash-and-rescue scenes often include multiple risks.

− Wear a highvisibility public safety vest.

− Consider specialty reflective gloves, coats, and boots.

Scene Safety

• Ensure that your team can safely gain access to the scene and the patient.

− Consider a snatch and grab.

• Establish a safe perimeter to keep bystanders out of harm ’ s way.

Courtesy of Tempe Fire Department

Scene Safety

• Be wary of toxic substances and toxic environments.

− Proper body and respiratory protection is a must.

Scene Safety

• Potential crime scenes

− Law enforcement should enter first.

− Formulate an escape plan.

− Be aware of violence from bystanders.

− Patients who abuse methamphetamines can be a large threat.

© Paul Chiasson, CP/AP Photos

Scene Safety

• Risks related to the environment include:

− Unstable surfaces

− Snow and ice

− Rain

• Consider the stability of the structures around you.

Courtesy of James Tourtellotte/U.S. Customs & Border Control

Scene Safety

• Ensure safety of the patient and bystanders next.

• When the environment is unfriendly perform assessment, address threats, and move the patient as quickly as possible.

Mechanism of Injury or Nature of Illness

• Mechanism of injury (MOI)

− Forces that act on the body to cause damage

• Nature of illness (NOI)

− General type of illness a patient is experiencing

Mechanism of Injury or Nature of Illness

• Multiple patients or obese patient may warrant additional resources.

− Multiple patients must be triaged.

− Be familiar with specialized resources.

− Assess the need for spinal motion restriction.

Standard Precautions

• Your first priority is your own safety and the safety of other EMS team members.


• Treat all patients as potentially infectious.

− Wear properly sized gloves.

− Wear eye protection.

− Wear a HEPA or N95 mask.

− Wear a gown.

− Wash your hands after removing gloves.


• Personal protective equipment (PPE)

− Clothing or equipment that provides protection from substances that pose a health/safety risk

• Steel-toe boots

• Helmets

• Heat-resistant outerwear

• Self-contained breathing apparatus

• Leather gloves

Primary Assessment: Form a

General Impression

• Based on initial presentation and chief complaint

• Make conscious, objective, and systematic observations

− Is the patient in stable or unstable condition?

− Is the patient sick or not sick?



• Observe level of consciousness.

• Decide whether to implement spinal motion restriction procedures.

• Determine your priorities of care.

• Identify age and sex of the patient.



• Treat life threats as you find them

− What additional care is needed?

− What needs to be done on scene?

− When to initiate transport?

− Which facility is most appropriate?

• Assess mental status by using AVPU process

Assess the Airway

• Is airway open and patent?

• Listen for noisy breathing.

• Move from simple to complex:

− Position

− Obstruction

Assess the Airway

• For all unresponsive patients:

− Establish responsiveness.

− Assess breathing.

• If ineffective or absent, open the airway.

• Mechanical means requires an airway adjunct

Assess Breathing

• Is the patient breathing?

− If not, you must breathe for him or her.

− If so, is he or she breathing adequately?

• Consider minute volume.

− Respiratory rate multiplied by the tidal volume inspired with each breath

Assess Breathing

• Assess breathing rate.

− Too fast: greater than 24 breaths/min

− Too slow: 8 –20 breaths/min

• Assess for chest rise and fall.

• Assess for breath sounds.

• Assess for air movement.

Assess Circulation

• Palpate the pulse.

− Count the number of beats in 15 seconds and multiply times four.

• Normal pulse rate for adults is 60 –100 beats/min.

• Bradycardia — rate less than 60 beats/min.

• Tachycardia — rate higher than 100 beats/min.


• Force: Normal pulse feels “ full.

”

• Rhythm: Normal rhythm is regular.

• Report your findings:

− Rate

− Force

− Rhythm

• Inspect skin for obvious signs of bleeding.


• Capillary refill evaluates ability to restore blood

− To test:

• Place thumb on patient ’ s finger and compress.

• Remove pressure.

• Adequate perfusion: color restored within two seconds.


• Assess the skin to evaluate perfusion.

− Color

− Temperature

− Moisture


Restoring Circulation

• If a patient has inadequate circulation:

− Restore or improve circulation.

− Control severe bleeding.

− Improve oxygen delivery to the tissues.

Restoring Circulation

• If you cannot feel a pulse, begin CPR until an AED or manual defibrillator is available.

− Follow standard precautions.

− Evaluate cardiac rhythm of any patient in cardiac arrest.

− Oxygen delivery is improved through the administration of 100% supplemental oxygen.

Assess and Control External

Bleeding

• Perform a rapid exam.

− Venous bleeding: steady blood flow

− Arterial bleeding: spurting flow of blood

• Evaluate unresponsive patients by running your gloved hands from head to toe.

Identify and Treat Life Threats

• Determine if a life threat is present and, if so, immediately address it.

− A patient who is dying will:

• Become less aware of surroundings

• Stop making attempts to communicate

• Lose consciousness

• Become unresponsive to external stimuli

• Muscles of the jaw will become slack

Identify and Treat Life Threats

• Conditions that cause sudden death:

− Airway obstruction

− Respiratory arrest

− Severe bleeding

Assess the Patient for

Disability

• Perform a neurologic evaluation.

− Have the patient move all extremities.

• Assess for motor strength and weakness.

• Assess grip strength.

• Assess for loss of sensation.

• Be mindful of exposure concerns.

Perform a Rapid Exam

• Observe for asymmetry/obvious defects.

• Palpate the entire surface of the skull, then down to C7 of the spine.

• Squeeze and roll the shoulder girdles.

• Palate the abdomen and rock the pelvis.


• Grasp each arm at the shoulder girdle and slide your hands down to the wrist.

• Palpate the legs.

• Ask the patient to wiggle fingers and toes.

• Ask the patient if they are bleeding.


• Guidelines:

− Inspect.

− Palpate.

− Auscultate.

− See Skill Drill 13-1 .

• DCAP-BTLS:

− Deformities

− Contusions

− Abrasions

− Punctures/penetration/ paradoxical movement

− Burns

− Tenderness

− Lacerations

− Swelling

Make a Transport Decision

• Identify priority patients.

− Do only what is necessary at the scene and handle everything else en route.

Priority Patients

• Hypoperfusion or shock

• Complicated childbirth

• Chest pain w/systolic

BP < 100 mm Hg

• Uncontrolled bleeding

• Severe pain anywhere

• Multiple injuries

• Poor general impression

• Unresponsive patients

• Responsive but does not or cannot follow commands

• Difficulty breathing

History Taking

• Gain information about the patient and the events surrounding the incident.

• Ask open-ended questions.

• Avoid leading questions.

• Ask age-appropriate questions.

• Be patient.

Patient Information

• Name and chief complaint

• Data required by local EMS system

• Who called 911 and why

• Medical ID jewelry

• Information from medical responders

Techniques for History Taking

• Appearance and demeanor

− Clean, neat, and professional

− Good attitude

− Identify your service and certification level.

− Try to interview in a private setting.


• Confidentiality

− Be familiar with relevant laws.

• How to address the patient

− Ask how he or she would like to be addressed.

− Err on the side of formality.

− Be familiar with the cultural groups in area.


© Glen E. Ellman

• Note taking

− Let the patient know that you will be writing information down.

− Position yourself at eye level.

− Maintain good eye contact.


• Reviewing medical history and information reliability

− Document the source of all information.

− During routine transfers, look over paperwork.

− Evaluate your sources for reliability.

Responsive Medical Patients

• Chief complaint

− Should be recorded in patient ’ s own words

− Should include:

• What is wrong

• Why treatment is being sought


• History of illness

− OPQRST

• Onset

• Provocation

• Quality

• Region/radiation/ referral

• Severity

• Time

− SAMPLE

• Signs and symptoms

• Allergies

• Medications

• Pertinent past history

• Last oral intake

• Events that led to injury or illness


• “ What made you call 9-1-1?

”

• Patient may have multiple complaints.

• Flesh out history of chief complaint

• Signs and symptoms: what happened and when

• Look for medical ID tags or cards.


• Past medical history

− Should include:

• Current medications and dosages

• Allergies

• Childhood illnesses

• Adult illnesses

• Past surgeries

• Past hospitalizations and disabilities


• Past medical history (cont ’ d)

− Patient ’ s emotional affect provides insight into overall mental health.

− Determine whether the patient has ever experienced the problem.

• A new problem or condition is best considered serious until proven otherwise.


• Current health status

− Made up of unrelated pieces of information

− Ties together past history with history of current event

− Decide which items you want to explore and which you do not


• Family history

− Helps establish patterned and risk factors for potential diseases

− Information should be related to the patient ’ s current medical condition.


• Social history

− Smoking habits

− Alcohol consumption and drug use

− Sexual habits

− Diet

− Occupation

− Environment

− Travel history

Unresponsive Patients

• Rely on:

− Head-to-toe physical examination

− Normal diagnostic tools

− Family and friends

• Look for clues.

− Pill containers

− Medical jewelry

Trauma Patients

• Life-threatening MOIs

− Ejection from a vehicle

− Death of another patient in same vehicle

− Falls of greater than

15 ′ to 20′ or three times patient ’ s height

− Vehicle rollover

− High-speed vehicle crash

− Vehicle-pedestrian collision

− Motorcycle crash

− Penetrating wounds to head, chest, or abdomen

© Mark C. Ide

Trauma Patients

© Jones & Bartlett Learning.

Photographed by Kimberly Potvin

© Corbis © Dan Myers, Figure

© Jack Dagley

Photography/ShutterStock, Inc.

© Larry St. Pierre/ShutterStock, Inc., © micheal ledray/ShutterStock, Inc.

Trauma Patients

• High-priority infant or child MOIs:

− Falls from more than

10 ′ or two to three times the child ’ s height

− Fall of less than 10 ′ with loss of consciousness

− Medium- to highspeed vehicle crash

− Bicycle collision

Trauma Patients

• Two or more serious

MOIs increase the chance of a serious or fatal injury.

• In an MVC, determine whether seat belts and/or air bags were involved.

− Improperly installed child seats can be useless.

© Thinkstock/Getty Images

Patients with Minor Injuries or

No Significant MOI

• If a patient shows signs of systemic involvement, continue with assessment.

Review of Body Systems

• General symptoms

− Ask questions regarding:

• Fever

• Chills

• Malaise

• Fatigue

• Night sweats

• Weight variations


• Skin, hair, and nails

− Rash, itching, hives, or sweating

• Musculoskeletal

− Joint pain, loss of range of motion, swelling, redness, erythema, and localized heat or deformity


• Head and neck

− Severe headache or loss of consciousness

− Eyes

• Visual acuity, blurred vision, diplopia, photophobia, pain, changes in vision, and flashes of light


• Head and neck (cont ’ d)

− Nose

• Sense of smell, rhinorrhea, obstruction, epistaxis, postnasal discharge, and sinus pain

− Throat and mouth

• Sore throat, bleeding, pain, dental issues, ulcers, and changes to taste sensation


• Endocrine

− Enlargement of the thyroid gland

− Temperature intolerance

− Skin changes

− Swelling of hands and feet

− Weight changes

− Polyuria, polydipsia, polyphagia

− Changes in body and facial hair


• Chest and lungs

− Dyspnea and chest pain

− Coughing, wheezing, hemoptysis, and tuberculosis status

− Previous cardiac events

− Pain or discomfort

− Orthopnea, edema, and past cardiac testing


• Hematology

− History of anemia, bruising, and fatigue

• Lymph nodes

− Tender and enlarged lymph nodes


• Gastrointestinal

− Appetite and general digestion

− Food allergies and intolerances

− Heartburn, nausea and vomiting, diarrhea

− Hematemesis

− Bowel regularity, changes in stool, flatulence,

− Jaundice

− Past GI evaluations and tests


• Genitourinary

− Dysuria

− Increased frequency of urination, urgency

− Nocturia

− Hematuria

− Polyuria

− Pain to the flank and suprapubic region


• Genitourinary (cont ’ d)

− Men

• Erectile dysfunction, fluid discharge, and testicular pain

− Females

• Menstrual regularity, last menstrual period, dysmenorrhea, vaginal discharge, abnormal bleeding, pregnancies, and contraception use


• Neurologic

− Seizures or syncope, loss of sensation, weakness in extremities, paralysis, loss of coordination or memory, and muscle twitches

− Facial asymmetry

− If you suspect stroke or TIA, use Cincinnati

Stroke Scale.


• Psychiatric

− Depression, mood changes

− Difficulty concentrating

− Anxiety, irritability

− Sleep disturbances, fatigue

− Suicidal or homicidal tendencies

Clinical Reasoning

• Combines knowledge of anatomy, physiology, pathophysiology, and patient ’ s complaints

• Pay attention to signs or symptoms that are inconsistent with working diagnosis.

− Differential diagnosis – a working hypothesis of the nature of the problem

Communication Techniques

• Encourage dialogue.

− Use layperson terminology.



• Empathetic response

− Put yourself in the patient ’ s shoes.

− Do not hesitate to communicate your feelings.


• Ask about feelings.

− Tired, depressed, etc.

− Validate the patient ’ s feelings.

− Be empathetic but effective.


• Getting more information

− Question region or location of pain.

− Question quality of abdominal pain.

− Add, delete, and modify questions.

− Avoid close-ended and leading questions.

− Try to be orderly and systematic.


• Asking direct questions

− If you need a date, time, etc., ask for it.

• Applying clinical reasoning

− Critical thinking consists of:

• Concept formation

• Data interpretation

• Application of principles

• Reflection in action

• Reflection on action


• Applying clinical reasoning (cont ’ d)

− Think and perform well under pressure.

− Be a patient listener.

− Communicate with patients.

− Look for nonverbal communication.

Getting a History on Sensitive

Topics

• Alcohol and drug abuse

− Patients may give an unreliable history.

− Alcohol can mask signs and symptoms.

− Keep a professional attitude.

© Jack Dagley Photography/ShutterStock, Inc.


Topics

• Physical abuse, domestic abuse, and sexual assault

− Required to report

− Look for clues.

− Always call law enforcement.

− Maintain evidence per protocol.


Topics

• Sexual history

− Talk to the patient in private.

− Keep your questions focused.

− Do not interject opinions or biases.

− Treat with compassion and respect.

Cultural Competence

• Common barriers to communication:

− Race

− Ethnicity

− Age

− Gender

− Language

− Education

− Religion

− Geography

− Economic status

Cultural Competence

• Respect ideas and beliefs.

• Consider dietary practices.

• Obtain consent.

• Provide best possible care for all patients.

• Research prevalent groups in your area.

• Remember the importance of manners.

Special Challenges in History

Taking

• Silence

• Overly talkative patients

• Patients with multiple symptoms

• Anxious patients

• Reassurance

• Anger and hostility

• Intoxication

• Crying

• Depression

• Sexually attractive patients

• Confusing behaviors or histories

Special Challenges in History

Taking

• Limited education or intelligence

• Language barriers

• Hearing problems

• Visual impairment/ blindness

• Family and friends

Age-Related Considerations

• Pediatric patients

− Include child in the history-taking process.

− Be sensitive to the fears of the parents.

− Pay attention to the parent-child relationship.


• Pediatric patients (cont ’ d)

− Tailor your questions to the age of the child.

• Neonates/infants: maternal history and birth history

• 3 to 5 years: performance in school

• Adolescent: risk-taking behaviors, self-esteem issues, rebelliousness, drug and alcohol use, and sexual activity

− Gather an accurate family history.


• Geriatric patients

− Accommodate sensory losses.

− Patients tend to have multiple problems.

• May have multiple chief complaints

• May take a multitude of medications


• Geriatric patients (cont ’ d)

− Symptoms may be less dramatic.

− Consider including a functional assessment.

• Assessment of mobility

• Upper extremity function

• Activities of daily living


• Process by which quantifiable, objective information is obtained from a patient about his or her overall state of health

− Consists of two elements:

• Obtaining vital signs

• Performing a head-to-toe survey


• Not every aspect will be completed in every patient.

− Factors to consider:

• Location

• Positioning of the patient

• The patient ’ s point of view

• Maintaining professionalism

Assessment Techniques

Inspection

− Looking at the patient

• Palpation

− Touching to obtain information

• Pulses: use finger

• Skull: use palms

• Skin: use back of hand


• Percussion

− Striking surface of the body, typically where it overlies various body cavities

− Detects changes in the densities of the underlying structures



• Auscultation

− Listening with a stethoscope

− Requires:

• Keen attention

• Understanding of what “ normal ” sounds like

• Lots of practice

Vital Signs

• Pulse

− Assess rate, presence, location, quality, regularity

− To palpate, gently compress an artery against a bony prominence.

• Count for 15 minutes and multiply by four.

• Check for central pulse in unresponsive patients.

Vital Signs

Vital Signs

• Respiration

− Assess rate by inspecting the patient ’ s chest

− Quality

• Pathologic respiratory patterns or rhythms

• Tripod positioning, accessory muscle use, retractions

− Rate should be measured for 30 seconds and multiplied by two for pediatric patients.

Vital Signs

• Blood pressure

− Product of cardiac output and peripheral vascular resistance

• Systolic pressure

• Diastolic pressure

− Measured using a cuff

− Ideally should be auscultated

Vital Signs

• Temperature

− When measuring the tympanic membrane temperature:

• External auditory canal must be free of cerumen.

• Position the probe so the infrared beam is aimed at the tympanic membrane.

• Wait 2-3 seconds until temperature appears.

Vital Signs

• Pulse oximetry

− Should never be used as an absolute indicator of the need for oxygen

− Measures percentage of hemoglobin saturation

Equipment Used in the


• Stethoscope

• Blood pressure cuff

(sphygmomanometer)

• Capnography

• Glucometry

• Ophthalmoscope

• Otoscope

• Scissors

• Reliable light source

• Gloves

• Sheet or blanket



• Stethoscope

− Acoustic: blocks out ambient sounds

− Electronic: converts sound waves into electronic signal and amplifies them

© Denis Pepin/ShutterStock, Inc.



• Blood pressure cuff

− Measurement of blood pressure

− Consists of inflatable cuff and manometer

(pressure meter)

− Use the appropriate size!

© WizData, Inc./ShutterStock, Inc.



• Ophthalmoscope

− Allows you to look into patient ’ s eyes

− Consists of concave mirror and battery-powered light

− Requires dilation of pupils and diagnostic expertise

© Kenneth Chelette/ShutterStock, Inc.



• Otoscope

− Evaluates ears of a patient

− Consists of head and handle

Physical Examination

• Look for signs of significant distress

• Other aspects:

− Dress

− Hygiene

− Expression

− Overall size

− Posture

− Untoward odors

− Overall state of health

© Jones & Bartlett Learning. Courtesy of MIEMSS.

Physical Examination

• Terms to describe the degree of distress:

− No apparent distress

− Mild

− Moderate

− Acute

− Severe

• Terms to describe the general state of a patient ’ s health:

− Chronically ill

− Frail

− Feeble

− Robust

− Vigorous

Full-Body Scan

• A systematic head-to-toe examination

• Patients who should receive:

− Sustained a significant MOI

− Unresponsive

− Critical condition

• See Skill Drill 13-3 .

Focused Assessment

• Performed on patients who have sustained nonsignificant

MOIs and are responsive

• Focus on the immediate problem.

Mental Status

• For any patient with a “ head ” problem, assess and palpate for signs of trauma.

− Assess the patient in four areas:

• Person

• Place

• Day of week

• The event

Mental Status

• Use the

Glasgow

Coma Scale

− Assigns point value for eye opening, verbal response, and motor response

Mental Status

• Mental status examination

− General appearance

− Speech and language patterns

− Mood

− Thoughts and perceptions

− Information relevant to thought content

− Insight and judgment

− Cognitive function (attention and memory)

Skin

• Serves three major functions

− Regulates the temperature of the body

− Transmits information from the environment to the brain

− Protects the body from the environment

Skin

• Epidermis (outermost layer)

− Barrier against water, dust, microorganisms, and mechanical stress

• Dermis

− Composed of collagen and elastic fibers, and a mucopolysaccharide gel

− Divided into: Papillary dermis and reticular layer

Skin

Skin

• Examine:

− Color

− Moisture

− Temperature

− Texture

− Turgor

− Significant lesions

• Evidence of diminished perfusion:

− Pallor

− Cyanosis

− Diaphoresis

− Vasodilation

(flushing)

Skin

• Pallor: poor red blood cell perfusion to the capillary beds

• Vasoconstriction: indicated by pale skin

• Cyanosis: low arterial oxygen saturation

• Mottling: severe hypoperfusion and shock

Skin

• Ecchymosis: localized bruising or blood collection within or under the skin

• Turgor: relates to hydration

• Skin lesions: may be only external evidence of a serious internal injury

Hair

• Examine by inspection and palpation.

− Note:

• Quantity

• Distribution

• Texture

• Note:

− Color

− Shape

− Texture

− Presence or absence of lesions

− Normal nail should be firm and smooth.

Nails

Head

• Cranium: contains the brain

− Occiput: posterior portion

− Temporal regions: each side of the cranium

− Parietal regions: between temporal regions and occiput

− Frontal region: forehead

Head

• The scalp covers the cranium.

• Meninges: suspend the brain and spinal cord (dura matter, arachnoid, pia matter)

• Cerebrospinal fluid: fills between meninges

Head

• Inspect and feel the entire cranium.

− Deformity

− Asymmetry

− Warm, wet areas

− Tenderness

− Shape and contour

− Scars or shunts

© E. M. Singletary, M.D. Used with permission.

Head

• Evaluate the face.

− Color

− Moisture

− Expression

− Symmetry and contour

− Swelling or apparent areas of injury

− DCAP-BTLS


Eyes

• Assess functions of CNS.

• Anterior chamber

• Posterior chamber

• Inspect and palpate the upper and lower orbits.

Eyes

Eyes

• Note periorbital ecchymosis

(raccoon eyes).

• Assess visual acuity

− Snellen ( “ E ” ) chart

− Light/dark discrimination

− Finger counting

Eyes

• Assess pupils.

− Normally round and equal size

− Pupils should react instantly to change in light level.

− Check for size, shape, and symmetry, and reaction to light.

Ears

• Involved with hearing, sound perception, and balance control

• Includes:

− External ear

− Middle ear

− Inner ear

Ears

Ears

• Assess for changes in hearing perception, wounds, swelling, and drainage.

− Assess mastoid process of the skull for discoloration and tenderness.

− Examine by using an otoscope

(see Skill Drill 13-7 ).

• Nasal cavity is divided into two chambers

− Each chamber contains three layers of bone.

− Assess anteriorly and inferiorly.

Nose

Nose

• Look for:

− Asymmetry

− Deformity

− Wounds

− Foreign bodies

− Discharge or bleeding

− Tenderness

− Evidence of respiratory distress

Throat

• Evaluate mouth, pharynx, and neck

− Prompt assessment is mandatory in patients with altered mental status.

− Assess for a foreign body or aspiration.

• Be prepared to assist with manual techniques and suction.

Throat

• Mouth

− Lips

− Symmetry

− Gums

− Look for cyanosis around the lips.

• Inspect airway for obstruction.

• Tongue

− Size

− Color

− Moisture

• Maxilla and mandible

− Integrity

− Symmetry

Throat

• Oropharynx

− Discoloration

− Pustules

− Unusual odors on the breath

− Fluids that might need suctioning

− Edema and redness

Throat

• Neck

− Symmetry

− Masses

− Venous distention

− Palpate carotid pulses.

− Palpate the suprasternal notch .


Cervical Spine

• Consider MOI

− Evaluate for:

• Pain

• Altered mental status

• Loss of consciousness at the time of the event

Cervical Spine

• Inspect and palpate.

− Stop exam if pain, tenderness, or tingling results.

− Assess range of motion when there is no potential for serious injury.

• Passive exam

• Active exam

Chest

• Contains lungs, heart, and great vessels

• Three phases of exam

− Chest wall exam

− Pulmonary evaluation

− Cardiovascular assessment


Chest

• Check for:

− Symmetry

− Respiratory effort

− Signs of obstruction

− General shape of the chest wall

− Signs of abnormal breathing

− Chest deformities

− Tenderness or crepitus

Chest

• Auscultate breath sounds.

− Normal

− Tracheal

− Bronchial

− Bronchovesicular

− Vesicular

− Adventitious

• Wheezing, rales, rhonci, stridor, pleural friction rubs

Chest

• Are sounds:

− Dry or moist?

− Continuous or intermittent?

− Course or fine?

• Are breath sounds diminished or absent?

− In a portion of one lung or entire chest?

− If localized, assess transmitted voice sounds.

Chest

• Assess respiratory rate, depth, and effort.

− Check for accessory muscle use, retractions, or ventilatory fatigue.

− Check for jugular venous distention (JVD).

Cardiovascular System

• Circulates blood throughout the body

− Plasma

− Red blood cells

− White blood cells

− Platelets


• System of tubes:

− Arteries

− Aterioles

− Capillaries

− Venules

− Veins

• Two circuits:

− Systemic circulation

• Carries oxygenrich blood

− Pulmonary circulation

• Carries oxygenpoor blood


• Cardiac cycles involves:

− Cardiac relaxation (diastole)

− Filling

− Contraction (systole)

• Heart consists of four chambers

− Two atria

− Two ventricles



• The contraction and relaxation of the heart generates heart sounds.



• Splitting: events on the right of the heart usually occur later than those on the left

− Creates two discernible sounds

• Heart sounds can be heard in:

− Parasternal areas

− Region superior to the left nipple

− Refer to Skill Drill 13-10 .


• Korotkoff sounds: related to blood pressure

− There are 5 (1st and 5th are significant)

• First: thumping of the systolic

• Fifth: disappears as the diastolic pressure drops below that created by the blood pressure cuff


• Bruit: abnormal “ whoosh ” -like sound

− Turbulent blood flow through narrowed artery

• Murmur: abnormal “ whoosh ” -like sound

− Turbulent blood flow around a cardiac valve

− Graded by range of intensity from 1 to 6


• Arterial pulses are an expression of systolic blood pressure.

− Palpable where artery crosses bony prominence

• Venous pressure tends to be low.

− Assess extremities for signs of obstruction or insufficiency.


• Jugular venous distention (JVD)

− With penetrating left chest trauma, may indicate cardiac tamponade

− With pedal edema, consider heart failure.

− Note how much distention is present.


• Pay attention to arterial pulses.

• Obtain blood pressure and repeat.

− Note history and class of hypertension.


• Palpate and auscultate carotid arteries.

• Listen where cardiac valves are located:

− Aortic valve: right of the sternum

− Pulmonic valve: left of the sternum

− Tricuspid valve: lower left sternal border

− Mitral valve: lateral to the lower left sternal border


• For a suspected heart problem, assess:

− Pulse

− Skin

− Breath sounds

− Baseline vital signs

− Extremities


• The definition of normal and abnormal findings is different in a neonate or infant.

− Neonates often have cyanosis following birth.

− “ Abnormal ” heart sounds may be a normal variant.

Abdomen

• Divided into imaginary quadrants

• Contains:

− Organs of digestion

− Organs of urogenital system

− Significant neurovascular structures

Abdomen

• Peritoneum: a well-defined layer of fascia made up of the parietal and visceral peritoneum

− Intraperitoneal organs

− Extraperitoneal organs

Abdomen

• Organs are organized by viewing the abdominal wall in a subdivided fashion.

− Quadrants

• Left upper quadrant

• Right upper quadrant

• Left lower quadrant

• Right lower quadrant

Abdomen

• Abdomen can also be divided by ninths.

Abdomen

• Three basic mechanisms produce pain:

− Visceral pain

− Inflammation

− Referred pain

• Appropriate and relevant history is critical.

Abdomen

• Inspect and palpate the abdomen.

− Tightness: internal bleeding or inflamed organ

− Upper left pain: ruptured spleen

− Lower left pain: diverticulitis

− Lower right pain: appendicitis

− Generalized pain in women: obstetric or gynecologic problem

Abdomen

• Orthostatic vital signs (tilt test)

− Blood pressure and pulse are taken in the supine and sitting or standing positions.

− Determines extent of volume depletion

• If volume-depleted, there is not enough circulating blood to push into core circulation

Abdomen

• Orthostatic vital signs (tilt test) (cont ’ d)

− Generally considered positive if:

• Decrease in systolic pressure

• Increase in diastolic pressure of 10 mm Hg

• Increase in pulse rate by 20 beats/min

Abdomen

• Examine the area of complaint last.

− Work slowly.

− Avoid quick movements.

− Proceed in a systematic fashion.


Abdomen

• Inspect:

− Skin

− Contour and appearance

− Symmetry

− Swelling/bruising

− Discoloration in periumbilical area or along the flanks

− Rash or signs of allergic reaction

− Scars

− Wounds

− Striae

− Dilated veins

− Distention

− Localized masses

Abdomen

• Abdomen can be described as:

− Flat

− Rounded

− Protuberant (bulging out)

− Distinguish from obesity

− Scaphoid

− Pulsatile

Abdomen

• Auscultation

− Setting must be quiet.

− Note bowel sounds.

• Hyperactive, hypoactive, increased, decreased, absent

− Bruits

Abdomen

• Palpation

− Palpate each quadrant gently but firmly.

• Should appear soft without tenderness or masses.

− Guarding: contraction of abdominal muscles

− Rebound tenderness: pain upon release

− Abdominal rigidity: peritoneal irritation and guarding

Abdomen

• Palpation (cont ’ d)

− To palpate the liver:

• Place left hand behind patient, parallel to right 11th and 12th ribs

• Place right hand on right abdomen below rib cage.

• Ask patient to take a deep breath.

• Try to feel the liver edge.

Abdomen


− To palpate the gallbladder:

• Use same technique as for liver

• Response indicating pain may mean possible inflammation

• When patient takes deep breath, move fingers under liver edge

Abdomen


− To palpate the spleen:

• With left hand, reach over and around patient

• Press forward lower left rib cage and adjacent soft tissues.

• With right hand below costal margin, press toward the spleen.

Abdomen

• Aortic aneurysm

− May be seen pulsating in the upper midline

− Do not palpate an obvious pulsatile mass.

• Hernia

− Place patient in supine position and raise the head and shoulders.

• Bulge of hernia will usually appear.

Female Genitalia

• Consists of:

− External genitalia

− Ovaries

− Fallopian tubes

− Uterus

− Vagina


• Limited and discreet assessment

− Reasons to examine include:

• Life-threatening hemorrhage

• Imminent delivery in childbirth

− Assessment includes:

• Palpating the bilateral inguinal regions

• Palpating the hypogastric region


• Reasons for pain on palpation include:

− Ectopic pregnancy

− Complications of third trimester pregnancy

− Nonpregnant ovarian problems

− Pelvic infections

Male Genitalia

• Consists of:

− Reproductive ducts

− Testes

− Urethra

− Prostate

− Penis

Male Genitalia

• Limited exam with partner present.

− Assess for bleeding, injury, or fracture.

− Note inflammation, discharge, swelling, or lesions.

− Priapism: prolonged erection

− Look for evidence of urinary incontinence.

Musculoskeletal System

• Joints: areas where bone ends abut each other and form a kind of hinge

• Skeletal muscles: used to flex and extend joints

− Joints become more vulnerable to injury, stress, and trauma as they age.


• Common injuries:

− Fractures

− Sprains

− Strains

− Dislocations

− Contusions

− Hematomas

− Open wounds


• Note:

− Structure and function

− Limitation or pain in range of motion

− Bony crepitance

− Inflammation or injury

− Obvious deformity

− Diminished strength

− Atrophy

− Asymmetry

− Pain

− Refer to Skill Drill

13-12 .


• Problems with the shoulders can often be determined by noting posture.

− Assess:

• Sternoclavicular joint

• Acromioclavicular joint

• Subacromial area

• Bicipital groove


• Assess range of motion:

− Ask patient to raise arms above the head.

− Have patient demonstrate external rotation and abduction.

− Perform internal rotation.


• Inspect elbows.

− Palpate between the epicondyles and olecranon.

− Range of motion:

• Flex and extend passively and actively.

• Pronate the forearms while the elbows are flexed.


• Inspect hands and wrists.

− Palpate the hands.

− Palpate the carpal bones.


• Make fists, then extend fingers

• Flex/extend wrists

• Move hands laterally and medially


• Inspect knees and hips.


• Ask patient to bend each knee and raise toward chest.

• Assess for rotation and abduction of hips.

− Palpate each hip.

− Palpate pelvis.


• Observe ankles and feet.

− Palpate feet and ankles.

− Assess range of motion:

• Have patient plantar flex, dorsiflex, and invert and evert ankles and feet.

• Inspect, palpate, and check forefoot and toes.

Peripheral Vascular System

• Comprises aspects of circulatory system

− Lymphatic system: network of nodes and ducts dispersed throughout the body

− Lymph nodes: larger accumulations of lymphatic tissues


• Perfusion occurs in the peripheral circulation.

− Diseases of the peripheral vascular system are often seen in patients with other underlying medical conditions.


• During assessment, pay attention to upper and lower extremities.

− Signs of acute or chronic vascular problems



• Assessment

− Inspect upper extremities.

− Five P s of acute arterial insufficiency:

• Pain

• Pallor

• Parasthesias/Paresis

• Poikilothermia

• Pulselessness


• Assessment (cont ’ d)

− Palpate epitrochlear and axillary lymph nodes.

− Inspect lower extremities.

− Palpate lower extremities.

− Note temperature of feet and legs.

− Attempt to palpate edema.

− Palpate superficial inguinal lymph nodes.

Spine

• Consists of 33 individual vertebrae

• Anchoring point for the skull, shoulders, ribs, and pelvis

• Protects the spinal cord

• Inspect the back.

− Lordosis

− Kyphosis

− Scoliosis

Spine

Spine

© Wellcome Trust Library/National Medical Slide

Bank/Custom Medical Stock Photo

© Dr. P. Marazzi/Photo Researchers, Inc.

© Southern Illinois University/Photo Researchers,

Inc.GA5323

Spine

• Palpate the spine.

• Check back for any other findings.

− Tap over costovertebral angles.

− Palpate scapulae, paraspinal areas, and base of neck.

− Check the buttocks.

Spine

• Range of motion:

− Check passively first, then actively.


Nervous System

• Central nervous system: brain and spinal cord

• Peripheral nervous system: remaining motor and sensory nerves

Nervous System

• Brain comprises cerebrum, cerebellum, and medulla

• Except for cranial nerves, nerves are channeled to the brain via the spinal cord.

− Motor nerves control motion or movement.

− Sensory nerves send external signals to the brain.

Nervous System

• Cranial nerves go directly to and from the brain.

Nervous System

• Voluntary nervous system

• Involuntary (autonomic) nervous system

− Sympathetic

− Parasympathetic

− Reflexes

− Primitive reflexes

Nervous System

• Neurologic exam

− Mental status (AVPU)

− Cranial nerve function

− Distal motor function

− Distal sensory function

− Deep tendon reflexes

• Mental status exam

(COASTMAP)

− Consciousness

− Orientation

− Activity

− Speech

− Thought

− Memory

− Affect (mood)

− Perception

Nervous System

• Glasgow Coma Scale may also be used to assess people with alterations in mental status.


Nervous System

• Cranial nerve examination

− Determines presence and degree of disability

− Can be performed in less than 3 minutes

Nervous System

• Evaluation of the motor system

− Posture and body position

− Involuntary movements

− Muscle strength

− Coordination

− Proprioception

Nervous System

• Check sensory function.

− Assess primary and cortical sensory functions.

− Evaluate deep tendon reflexes.


Nervous System

• Results of the neurologic exam

− Delirium

• Consistent with an acute sudden change in mental status

− Dementia

• Representative of deterioration of cognitive cortical functions

Secondary Assessment of


• After ruling out trauma, position in recovery position.

− If trauma, position in neutral alignment

• Perform a thorough assessment of the body and look for signs of illness.



• Perform at least two sets of vital signs.

− Should include:

• Auscultated blood pressure

• Accurate pulse and respiratory rates

• Patient ’ s temperature

• Consider unresponsive patients to be in unstable condition.


Trauma Patients

• Two classifications of trauma patients:

− Isolated injury

− Multisystem trauma

• “ High visibility factor ”

− Do not become distracted by obvious but nonlife-threatening injuries.


Trauma Patients

• Patient who is unresponsive or has altered mentation is considered high risk.

• Perform rapid exam.

− When time and condition permit, perform physical examination.


Infants and Children

• Attempt to elicit information from the patient before parents.

• Obtain permission of a parent before examining if possible.

• Examine from toe to head.



• When examining a newborn or neonate, be aware of normal variants:

− Vernix

− Edema

− Mongolian spots

− Jaundice

− Asymmetry of the head



• Provide support of the head and neck.

• Examine eyes for irregularities.

• Inspect the umbilical cord.

• Children are prone to dehydration and infection.



• Ages 1 to 3 years

− Will object to being touched or manipulated

− Use toe-to-head approach.

• Ages 4 to 5 years

− Usually cooperative and helpful

• School-age

− Be sure to explain what you are doing.

• Adolescents

− Concerned with bodily integrity



• General principles:

− Remain calm.

− Be patient, gentle, and honest.

− Attempt to keep children with their parents.

− Do not neglect a child ’ s pain.



• Exam techniques can vary slightly:

− Auscultation of a quiet infant ’ s abdomen is simple.

− Active tinkling bowel sounds may be heard.

− A more tympanic sound might be heard on percussion of an infant ’ s abdomen.

− Palpation techniques will vary with age.

Recording Secondary

Assessment Findings

• Should be orderly and concise

• Document using the forms recommended by your medical director.

− Note:

• Objective signs

• Pertinent negatives

• Similar relevant information

Limits of the Secondary

Assessment

• Evaluation by a trained physician, laboratory testing, and radiographic studies may be needed for a definitive diagnosis.


• Continuous ECG monitoring

− Purpose is to establish a baseline

− Electrodes must be placed properly.

• The leads are usually colored and labeled to help with placement.


• Continuous ECG monitoring (cont ’ d)

− Bipolar leads consist of two electrodes.

• Placed on different limbs

• Einthoven triangle


• 12-lead ECG monitoring

− Patient should be supine.

− Prepare the skin.

− Connect electrodes.

− Connect and apply the precordial leads.

− Record the ECG.


• Carbon dioxide monitoring

− Capnometry

• Measures carbon dioxide output

− Capnography

• Measures carbon dioxide output and provides a waveform


Courtesy of Physio-Control, Inc.

Courtesy of Physio-Control, Inc.


• Blood glucometer

− Can obtain reading in two ways in the field:

• From the hub of an IV catheter

• From a finger stick

− Most take only a few seconds.

− Should be calibrated regularly


• Cardiac biomarkers

− Used to assess presence of damage to cardiac muscle

− May take several hours following a myocardial infarction for the cardiac biomarkers to become elevated


• Other blood tests

− Basic and complete metabolic profile (CHEM 7 and CHEM 12)

− Brain natriuretic peptide (BNP) test

− Arterial blood gases

Reassessment

• Stable patients should be reassessed every

15 minutes.

• Unstable patients should be reassessed every 5 minutes.

Reassessment of Mental

Status and the ABCs

• Compare LOC with baseline assessment.

• Review the airway.

• Reassess breathing, circulation, pulse

Reassessment of Mental

Status and the ABCs

• Response of pediatric and geriatric patients may differ.

− Children decompensate very quickly.

− Geriatric patients may not show signs of deterioration.

Reassessment of Patient Care and Transport Priorities

• Have you addressed all life threats?

• Do priorities need to be revised?

• Is initial transport decision appropriate?

• Obtain another complete set of vital signs and compare with expected outcomes.

− Priority patients: minimum three sets

Reassessment of Patient Care and Transport Priorities

• Look for trends.

• Revisit patient complaints.

• Document all of your findings.

Summary

• Patient assessment is the most important skill a paramedic has.

• Patient assessment has five components:

− Scene size-up

− Primary assessment

− History taking

− Secondary assessment

− Reassessment

Summary

• The first step of the patient assessment process is the scene size-up.

• During the size-up, you also make a determination of the mechanism of injury or nature of the patient ’ s illness.

• Another important step in protecting yourself is to take standard precautions.

Summary

• The first step in the primary assessment is to form a general impression of the patient ’ s condition.

• During the primary assessment, you should be able to identify threats to the ABCs; these life threats should be addressed immediately.

Summary

• After assessing the patient for disability, you must make a transport decision and, if the patient has sustained trauma, perform a rapid exam.

• Once the primary assessment is complete and all life threats have been addressed, you can move into the history-taking phase of patient assessment.

Summary

• Patient history is a primary means of diagnosing the chief complaint in the field.

• The first part of a patient ’ s history also serves as a good mental status examination: ask for the patient ’ s name; the date, time, and location; the chief complaint; and the events leading up to the request for EMS assistance.

Summary

• After clarifying the history of the present illness, ask the patient about his or her past medical history, the state of his or her health, and any pertinent family history.

• For responsive patients, the history may generally be obtained directly from the patient; for unresponsive medical patients and trauma patients, it may be necessary to obtain the history from family.

Summary

• Use constructive communications skills as you talk with patients.

• At times you will need to ask patients about sensitive topics. Be familiar with techniques for successfully asking patients about these topics.

• Obtaining a history from a geriatric patient may involve challenges.

Summary

• Work on strategies within your service and with your partner for positive communications with patients.

• Secondary assessment is the process by which quantifiable, objective information is obtained from a patient about his or her overall state of health.

Summary

• There are times when you may not have time to perform a secondary assessment.

The two types of physical examinations are the full-body exam and the focused assessment.

Summary

• The secondary assessment includes obtaining vital signs and performing a headto-toe survey.

• The techniques of inspection, palpation, percussion, and auscultation allow you to use your physical senses to obtain physical information and to understand the normal functions of a patient ’ s body.

Summary

• Vital signs consist of a measurement of blood pressure; pulse rate, rhythm, and quality; respiratory rate, rhythm, and quality; temperature; and pulse oximetry.

• Monitoring devices used by the paramedic include continuous ECG monitoring, 12-lead

ECG, carbon dioxide monitoring, blood chemistry analyses, and cardiac biomarkers, among others.

Summary

• You need to alter your approach to patient assessment when dealing with infants and children.

• After the primary assessment, the reassessment is the single most important assessment process you will perform.

Summary

• The reassessment is performed on all patients. It gives you an opportunity to reevaluate the chief complaint and to reassess interventions to ensure that they are still effective.

• A patient in stable condition should be reassessed every 15 minutes, whereas a patient in unstable condition should be reassessed every 5 minutes.

Credits

• Chapter opener : Courtesy of Rhonda Beck

• Backgrounds : Green —Jones & Bartlett Learning;

Purple —Jones & Bartlett Learning. Courtesy of

MIEMSS; Blue —Courtesy of Rhonda Beck; Red—

© Margo Harrison/ShutterStock, Inc.

• Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett

Learning, courtesy of Maryland Institute for

Emergency Medical Services Systems, or have been provided by the American Academy of

Orthopaedic Surgeons.

Chapter 13: Patient Assessment

Chapter 13

Patient Assessment

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Chapter 13

Patient Assessment

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