Chapter 17
Patient Assessment
Copyright (c) The McGraw-Hill Companies, Inc. Permission required for reproduction or display.
17-1
Objectives
17-2
Signs and Symptoms (S/S)
• Sign (assessment finding)
– A medical or trauma condition
displayed by the patient
– Can be seen, heard, smelled, measured,
or felt
17-3
Signs and Symptoms (S/S)
• Symptom
– A condition described by the patient
17-4
Vital Signs
•
•
•
•
•
Breathing
Pulse
Temperature
Pupils
Blood pressure
• Vital signs are measured to:
– Detect changes in normal body function
– Recognize life-threatening situations
– Determine a patient’s response to treatment
17-5
Baseline Vital Signs
• An initial set of vital sign
measurements against which later
measurements can be compared
• Allow you to note changes (trends) in
the patient’s condition and response
to treatment
17-6
Vital Signs
Equipment
• Watch with a second hand or digital watch that
shows seconds
– Used to count respirations and pulse
• Penlight or flashlight
– Used to look at your patient’s pupils
• Stethoscope
– Used to hear sounds within the body
– Also used to measure blood pressure
• Blood pressure cuff
• Pen and paper
17-7
Pulse
• Arteries
– Large blood vessels that carry blood away
from the heart to the rest of the body
• Pulse
– Rhythmic contraction and expansion of
the arteries with each beat of the heart
17-8
Circulation
Central Pulses
• A central pulse
is found close to
the body trunk
17-9
Circulation
Peripheral Pulses
• A peripheral pulse is
located farther from
the body trunk than a
central pulse
17-10
Taking a Pulse
• Use the pads of your index
and middle fingers
• Apply gentle pressure to
the artery
• Count the number of beats
for 30 seconds
• Multiply the number by 2 to
determine the number of
beats per minute
– If the pulse is irregular,
count for 1 full minute
17-11
Normal Pulse Rates at Rest
Age
Birth to 1 month
Newborn
1 to 12 months
Infant
1 to 3 years
Toddler
Preschooler 4 to 5 years
School-age 6 to 12 years
child
Adolescent 13 to 18 years
18 years and older
Adult
Beats per Minute
120 to 160
80 to 140
80 to 130
80 to 120
70 to 110
60 to 100
60 to 100
17-12
Possible Causes of a Slow Heart Rate
•
•
•
•
•
•
•
•
Coughing
Vomiting
Straining to have a bowel movement
Heart attack
Head injury
Very low body temperature (hypothermia)
Sleep apnea
Some medications
17-13
Possible Causes of a Rapid Heart Rate
•
•
•
•
•
•
•
Fever
Fear
Pain
Anxiety
Infection
Shock
Exercise
• Heart failure
• Substances such as
caffeine and
nicotine
• Cocaine,
amphetamines,
“Ecstasy,” cannabis
• Some medications
17-14
Pulse Quality
• Refers to the strength of the heartbeat felt
when taking a pulse
• Normal
– Pulse is easily felt
– Pressure is equal for each beat
– “Strong” pulse
• “Weak” = hard to feel
• Weak and fast = “thready”
17-15
Counting Respirations
• Place the patient’s
arm across his
chest or abdomen
• Hold the patient’s
wrist
• Count each rise and
fall of the chest or
abdomen as one
respiration
17-16
Respiratory Rates at Rest
Breaths
Minute
Birth to 1 month
30 to 50
1 to 12 months
20 to 40
1 to 3 years
20 to 30
4 to 5 years
20 to 30
6 to 12 years
16 to 30
Age
Newborn
Infant
Toddler
Preschooler
School-age
child
Adolescent
Adult
13 to 18 years
18 years and
older
per
12 to 20
12 to 20
17-17
Respirations
Shallow Breathing
• Difficult to see movement of the chest or
abdomen during breathing
– Only a small volume of air is exchanged
17-18
Respirations
Labored Breathing
• Increased work (effort)
of breathing
– Gasping for air
– Nasal flaring
– Use of neck,
abdominal, rib
muscles
– Retractions
– Skin color changes
17-19
Abnormal Respiratory Sounds
•
•
•
•
•
Stridor
Snoring
Wheezing
Gurgling
Crowing
17-20
Skin Color, Temperature,
and Moisture
17-21
Perfusion
• Assess perfusion by evaluating:
– Skin color
– Skin temperature
– Skin moisture (moist, dry)
– Capillary refill
• In infants and children younger than
6 years of age
17-22
Skin Color
•
•
•
•
•
Pale
Blue (cyanotic)
Mottled
Flushed (red)
Jaundiced (yellow)
17-23
Skin Temperature and Moisture
• Skin temperature
– Warm (normal)
– Hot
– Cool
– Cold
– Clammy (cool and moist)
• Skin moisture
– Dry (normal)
– Moist
– Excessively dry
17-24
Capillary Refill
• Normal: < 2 sec
• Delayed: 3-5 sec
– Poor perfusion
– Exposure to cool
temperatures
• Markedly delayed: > 5 sec
– Suggests shock
17-25
Pupils
• Examine the patient’s pupils for:
– Size
– Equality
– Reactivity
17-26
Blood Pressure
• Blood pressure
– Force exerted by the blood on the walls of the
arteries
– Blood pressure by auscultation involves the use
of a stethoscope
• Systolic pressure
– The pressure in an artery when the heart is
pumping blood
• Diastolic pressure
– The pressure in an artery when the heart is at rest
17-27
Using a Stethoscope
17-28
Blood Pressure by Auscultation
17-29
Blood Pressure by Auscultation
17-30
Blood Pressure by Auscultation
17-31
Blood Pressure by Auscultation
17-32
Blood Pressure by Auscultation
17-33
Blood Pressure by Auscultation
17-34
Blood Pressure by Palpation
17-35
Blood Pressure by Palpation
17-36
Blood Pressure by Palpation
17-37
Blood Pressure by Palpation
17-38
Normal BP at Rest
Life Stage
Age
Systolic
Pressure
Diastolic
Pressure
Newborn
Birth to 1 month
74 to 100
50 to 68
Infant
1 to 12 months
84 to 106
56 to 70
Toddler
1 to 3 years
98 to 106
50 to 70
Preschooler
4 to 5 years
98 to 112
64 to 70
School-age child 6 to 12 years
104 to 124
64 to 80
Adolescent
13 to 18 years
118 to 132
70 to 82
Adult
18 years and older
100 to 119
60 to 79
17-39
Key Point!
• Unstable patient
– Assess and record vital signs every 5
minutes
• Stable patient
– Assess and record vital signs (at a
minimum) every 15 minutes
• Remember: A stable patient can become
unstable very quickly. Reassess frequently!
17-40
Additional Vital Signs
17-41
Pulse Oximetry
17-42
Exhaled Carbon Dioxide
17-43
Pain Assessment
• Adult
– Use 0 to 10 scale
• Child 3 years or older
– Use the Wong-Baker FACES Pain
Rating Scale
17-44
17-45
Patient Assessment
Overview
• Discover the patient’s signs and symptoms
using your senses
– Sight (look)
– Sound (listen)
– Touch (feel)
– Smell
• Provide emergency medical care based on
those assessment findings and symptoms
17-46
Patient Assessment
Overview
• Look
– Assess parts of the patient’s body and his
behavior.
– Does he look sick or poorly nourished?
– Do you see obvious problems such as:
•
•
•
•
•
•
•
A rash
External bleeding
Vomiting
Seizures
Arm or leg deformity
Pale or flushed skin
Sweating
17-47
Patient Assessment
Overview
• Listen
– Find out why your patient called for
assistance
– Assess the patient’s breathing
– Assess lung sounds
– Assess the patient’s blood pressure
17-48
Patient Assessment
Overview
• Feel
– Skin temperature
– Skin condition
– Presence of swelling, pain
– Position of the trachea
– Air trapping beneath the skin
17-49
Patient Assessment
Overview
• Smell
– Identify odors associated with
specific problems
17-50
Patient Assessment
• Components
– Initial assessment
• Scene size-up
• Primary survey (ABCDE assessment)
• Secondary survey
– Vital signs
– Focused history
– Head-to-toe physical examination
– Reassessment
17-51
Primary Survey
• Rapid assessment to find and treat all
immediate life-threatening conditions
• “Find and fix”
• “Treat as you go”
• Decide if the patient needs immediate
transport or additional on-scene assessment
and treatment
17-52
Secondary Survey
• Purpose
– Discover medical conditions and/or injuries that
were not identified in the primary survey
•
•
•
•
Physical exam
Obtain vital signs
Reassess changes in the patient’s condition
Determine
– Chief complaint
– History of present illness
– Significant past medical history
17-53
Primary Survey
• Must be performed on every patient
• Begins after:
– Scene/situation has been found safe or
made safe
– You have gained access to the patient
• Wear appropriate PPE
17-54
Primary Survey
•
The primary survey has several parts:
– General impression
– Airway/level of responsiveness/cervical spine
protection
– Breathing (ventilation)
– Circulation with bleeding control (perfusion)
– Disability (mini-neurological exam)
– Expose (for examination)
– Identification of priority patients
17-55
General (First) Impression
• “Across-the-room” assessment
• Can be completed in 60 seconds or less
• Purpose
– Decide if the patient looks “sick” or “not
sick”
– If the patient looks sick, you need to act
quickly
17-56
General (First) Impression
17-57
General (First) Impression
• Your general (first) impression is based on
three main areas:
– Appearance
– Breathing
– Circulation
17-58
General (First) Impression
• Appearance
– Patient’s eyes are usually open
– Patient’s eyes should follow you as you
move
– If the patient looks agitated or limp or
appears to be asleep, approach
immediately
– Begin your primary survey
17-59
General (First) Impression
• Breathing
– Both sides of the chest rise and fall equally
– Normal breathing is quiet, painless, and occurs at
a regular rate
– Approach immediately and begin your primary
survey if the patient:
•
•
•
•
Looks as if she is struggling (laboring) to breathe
Has noisy breathing (gurgling, snoring, wheezing)
Is breathing faster or slower than normal
Looks as if her chest is not moving normally
17-60
General (First) Impression
• Circulation
– Skin color should be normal for the
patient’s ethnic group
– Approach the patient immediately and
begin your primary survey if skin color
is abnormal
17-61
Airway, Level of Responsiveness, and
Cervical Spine Protection
• If the patient appears to be awake:
– Tell him your first name
– Let him know you are an EMT
– Explain that you are there to help
– Ask, “Why did you call 9-1-1 today?”
17-62
Airway
• The human body must have a continuous
supply of oxygen to survive
• A life-threatening emergency can result if:
– The flow of air is blocked (obstructed)
– Oxygen-rich blood is not circulated
throughout the body
17-63
Airway
• Alert patient talking clearly or crying without
difficulty
– Patent (open) airway
• Unable to speak, cry, cough, or make any
other sound
– Complete airway obstruction
• Snoring or gurgling
– Partial airway obstruction
17-64
Airway
• If the patient is unresponsive and you do not
suspect trauma, open his airway by using the
head tilt–chin lift maneuver
17-65
Airway
• If the patient is unresponsive and you
suspect trauma, open his airway by using the
jaw thrust maneuver
17-66
Level of Responsiveness
• A = Alert
• V = Responds to Verbal stimuli
• P = Responds to Painful stimuli
• U = Unresponsive
17-67
Level of Responsiveness
• If the patient looks as if he is sleeping:
– Gently rub his shoulder
– Ask, “Are you okay?” or “Can you hear
me?”
– Unresponsiveness may indicate a lifethreatening condition
17-68
Level of Responsiveness
• Assess the patient’s orientation to:
– Person
• The patient can tell you her name
– Place
• The patient can tell you where she is
– Time
• The patient can tell you the day, date, or time
– Event
• The patient can tell you what happened
17-69
Level of Responsiveness
• An alert infant or young
child (younger than 3
years of age)
– Smiles
– Orients to sound
– Follows objects with
his eyes
– Interacts with those
around him
17-70
Level of Responsiveness
• As the infant or young child’s mental status
decreases, the following changes may be
seen:
– The child may cry but can be comforted
– The child may show inappropriate,
persistent crying
– The child may become irritable, agitated,
and restless
– The child may have no response
17-71
Level of Responsiveness
• Note any changes in the patient’s mental
status
• Report any changes to receiving medical
personnel
17-72
Cervical Spine Protection
• Spinal precautions
• In-line stabilization
• Manual stabilization
17-73
Cervical Spine Protection
• If the patient is awake and you suspect
trauma to the head, neck, or back, face the
patient
– Instruct him not to move his head or neck
17-74
Cervical Spine Protection
• Once begun, continue manual stabilization
until patient is secured to a backboard with
head and neck stabilized
17-75
Airway, Level of Responsiveness,
and Cervical Spine Protection
• Emergency care that may be needed to
manage the patient’s airway during the
primary survey:
–
–
–
–
–
–
Spinal stabilization as needed for trauma
Head tilt–chin lift or jaw thrust
Suctioning
Repositioning
Removal of a foreign body
Insertion of an oral or nasal airway
17-76
Breathing
• Responsive patient
– Look and listen
• Unresponsive patient
– Look, listen, and
feel
17-77
Breathing
• If breathing is adequate and patient
responsive
– Allow the patient to assume a comfortable
position
• If unresponsive but breathing is adequate
– Maintain an open airway
– Use airway adjuncts if needed
– Give oxygen by nonrebreather mask
– Recovery position, if no contraindications
17-78
Breathing
• If the patient is unresponsive and breathing
is inadequate or if the patient is not
breathing:
– Begin positive-pressure ventilation
– Watch the patient’s chest while you
breathe slowly into the patient
– If your breaths are going in, the patient’s
chest should rise gently with each breath
17-79
Breathing
• Emergency care that may be needed to
manage the patient’s breathing during the
primary survey:
– Giving oxygen
– Suctioning
– Repositioning
– Removal of a foreign body
– Insertion of an oral or nasal airway
– Positive-pressure ventilation
17-80
Circulation
• Assessment of circulation involves
evaluating:
– Signs of obvious bleeding
– Central and peripheral pulses
– Skin color, temperature, and moisture
– Capillary refill (in children younger than 6
years of age)
17-81
Circulation
Obvious Bleeding
• Look from head to toes for signs of
significant external bleeding
• Control major bleeding, if present
17-82
Circulation
Pulses
17-83
Circulation
• Assess perfusion by evaluating:
– Skin color
– Skin temperature
– Skin moisture
– Capillary refill
• In infants and children younger than 6
years of age
17-84
Circulation
• Emergency care that may be needed to
manage the patient’s circulation during the
primary survey:
– Giving oxygen
– Patient positioning
– Chest compressions
– Bleeding control
17-85
Disability
• Altered mental status
– A change in a patient’s level of awareness
– Also called altered level of consciousness
(ALOC)
17-86
Common Causes of Altered Mental Status
AEIOU-TIPPS
• Alcohol, Abuse
• Epilepsy (seizures)
• Insulin (diabetic
emergency)
• Trauma (head injury),
Temperature (fever,
heat- or cold-related
emergency)
• Infection
• Overdose, (lack of)
Oxygen (hypoxia)
• Psychiatric conditions
• Uremia (kidney failure)
• Poisoning (including
drugs and alcohol)
• Shock, Stroke
17-87
Disability
• Glasgow Coma Scale (GCS)
– Assesses three categories
• Eye opening
• Verbal response
• Motor response
– The Glasgow Coma Score is the sum of
the scores in three categories
17-88
Glasgow Coma Scale
Eye Opening
Best Verbal Response
Best Motor Response
Adult / Child
Score
Infant
Spontaneous, opens with
blinking
4
Spontaneous
Responds to verbal
command, speech, or
shout
3
Responds to verbal
Responds to pain
2
Responds to pain
No response
1
No response
Oriented
5
Coos, babbles
Confused, but able to answer
questions
4
Irritable cry but can be
comforted
Confused; answers with
inappropriate words
3
Inappropriate crying or
screaming
Incomprehensible sounds
2
Grunting or agitated, restless
No response
1
No response
Obeys commands
6
Spontaneous
Purposeful response to pain
5
Purposeful response to touch
Withdraws from pain
4
Withdraws from pain
Abnormal flexion (decorticate)
3
Abnormal flexion (decorticate)
Abnormal extension
(decerebrate)
2
Abnormal extension
(decerebrate)
No response
1
No response
Total = E + V + M 3 to 15
17-89
Disability
• Emergency care that may be needed to
manage the patient’s neurological status
during the primary survey:
– Maintaining an airway
– Giving oxygen
– Ensuring adequate breathing
– Suctioning
– Patient positioning
– Spinal stabilization
17-90
Expose
• Expose pertinent areas of the patient’s body
for examination
• Protect the patient’s modesty
• Consider
– Presence of bystanders
– Environment / weather conditions
17-91
Identifying Priority Patients
• Patients who require immediate transport
(“load and go”):
– Patients who give a poor general impression
– Unresponsive patients
– Responsive patients who cannot follow
commands
– Patients who have difficulty breathing
– Patients who are in shock
– Women who are undergoing a complicated
childbirth
– Patients with chest pain and a systolic blood
pressure <100 mm Hg
– Patients with uncontrolled bleeding
– Patients with severe pain anywhere
17-92
Performing the Secondary Survey
17-93
Secondary Survey
• Typically a head-to-toe examination
• Performed only after you have found and
treated all life-threatening injuries or
illnesses
17-94
Secondary Survey
Should be performed in the following
situations:
• Trauma patients with a significant mechanism of
injury
• Trauma patients with an unknown or unclear
mechanism of injury
• Trauma patients with an injury to more than one area
of the body
• All unresponsive patients
• All patients with an altered mental status
• Some responsive medical patients, as indicated by
history and focused physical examination findings
17-95
Secondary Survey
• Physical examination
• Rapid trauma assessment
• Rapid medical assessment
• Focused physical examination
17-96
Secondary Survey
• Look (inspect)
• Listen (auscultate)
• Feel (palpate)
• Remember to use your sense of smell to
identify unusual odors during the exam
17-97
DCAP-BTLS
• Deformities
• Contusions (bruises)
• Abrasions (scrapes)
• Punctures/penetrations
• Burns
• Tenderness
• Lacerations (cuts)
• Swelling
17-98
Assessment Guidelines
• Explain what you are about to do and why it
must be done
• Properly drape or shield an unclothed patient
from the stares of others
• Conduct the exam professionally and
efficiently
• Talk with the patient throughout the
procedure
• If your patient is a child, ask a parent or
family member to help you
17-99
Vital Signs
•
•
•
•
•
•
Breathing
Pulse
Skin
Pupils
Blood pressure
Pulse oximetry
• Obtain at least two complete sets
17-100
Patient History
• Obtain a SAMPLE history
• History of the Present Illness (HPI)
– Chief complaint
17-101
Key Point
• If the patient appeared
stable at the end of the
primary survey, but
becomes unstable
during the secondary
survey, expedite
patient transport to the
closest appropriate
medical facility.
17-102
Head-to-Toe Physical Examination
17-103
Reassessment of Mental Status
• Purposeful movement
• Nonpurposeful movement
17-104
Head
17-105
Face
17-106
Eyes
17-107
Nose
17-108
Cheeks
I
17-109
Upper and Lower Jaw
17-110
Nose
17-111
Mouth
17-112
Odors
17-113
Eyes
17-114
Ears
17-115
Ears
17-116
Neck
17-117
Check for Medical Identification
17-118
Neck
17-119
Neck
17-120
Chest
17-121
Chest
17-122
Chest
17-123
Lower Back
17-124
Abdomen
17-125
Pelvis
17-126
Extremities
• Assess for DCAP-BTLS.
• Look for open wounds, swelling, and
abnormal positioning, medical ID tag.
• Examine for bone or joint deformities and
tissue swelling.
• Check PMS in each extremity.
– Compare each extremity with the opposite
extremity.
17-127
Lower Extremities
17-128
Upper Extremities
17-129
Back (Posterior Body)
17-130
Emergency Care during the Secondary Survey
Examples:
• Abrasions, burns, and lacerations
– Provide wound care
• Swollen, discolored, deformed extremity
– Provide immobilization
• Minor bleeding
– Control bleeding and provide wound care
17-131
Reassessment
17-132
Reassessment
• Perform on every patient.
• Reassessment allows you to:
– Reevaluate the patient’s condition
– Assess the effectiveness of the emergency
care provided
– Identify any missed injuries or conditions
– Observe subtle changes or trends in the
patient’s condition
– Alter emergency care as needed
17-133
Reassessment
• Repeat the primary survey:
– At least every 15 minutes for a stable patient
– At least every 5 minutes for an unstable patient
• Reassess mental status and maintain an
open airway
• Monitor the patient’s breathing, pulse, skin
color, temperature, and condition
• Repeat the physical exam as needed
• Check the treatments you provide to be sure
that they are effective
• Continue to calm and reassure the patient
17-134
Questions?
17-135