Chapter 10: Patient Assessment

Symptom

Subjective findings that the patient feels but that can be identified only by the patient.

Sign

Objective finding that can be seen, heard, felt, smelled, or measured.

Field impression

The conclusion about the cause of the patient’s condition after considering the situation, history, and examination findings.

Scene Size-up

• The evaluation of the conditions you will be operating in

• Continuous situational awareness is necessary

Ensure Scene Safety | Scene Size-up

• Minor difficulties to major dangers; can be dynamic

• Call for additional resources if needed

• Before stepping out, look at the terrain

• Wear high-visibility Class 2 or 3 safety vests on roadways

• Consider environmental conditions

• Any actions you take to protect yourself, do the same for the patient

• Protect bystanders from becoming patients

• Hazards come in different forms, shapes, and sizes

• Be observant in violent situations, retreat if necessary, and contact law enforcement

Determine Mechanism of Injury/Nature of Illness | Scene Size-up

• Medical conditions, traumatic injuries, or both

• MOI

• Certain body parts are more easily injured than others (e.g, the brain, spinal cord, and eyes)

• Blunt trauma (struck at a broad area)

• Penetrating trauma (open wound)

• NOI

• Determine a patient’s illness from a chief complaint

• Talk with the patient and use your senses for your surroundings

Mechanism of injury (MOI)

The forces, or energy transmission, applied to the body that cause injury.

Nature of illness (NOI)

The general type of illness a patient is experiencing.

Chief complaint

The reason a patient called for help; also, the patient’s response to questions such as “What’s wrong?” or “What happened?”

The Importance of the MOI and NOI | Determine Mechanism of Injury/Nature of Illness

• Considering MOI can be useful in preparing for patient care, bringing proper equipment to treat patients

• Can be difficult to identify whether a situation is MOI or NOI

Take Standard Precautions | Scene Size-up

• The type of PPE depends on the situation

• Standard precautions assume that all blood, body fluids, nonintact skin, and mucous membranes may pose a substantial risk of infection

• Take standard precautions before stepping out of the response vehicle

  • Hand washing, gloves, gown, eye protection, and a mask

  • Gloves and eye protection are a minimum

  • Do not touch your skin

• If a condition warrants a higher level of PPE, regroup and upgrade protection

Standard precautions

Protective measures that have traditionally been developed by the Centers for Disease Control and Prevention (CDC) for us in dealing with objects, blood, body fluids, and other potential exposure risks of communicable disease.

Determine Number of Patients | Scene Size-up

• Critical in determining the need for additional resources

• Establish the ICS

• Triage patients

Consider Additional/Specialized Resources | Scene Size-up

• Some situations require more ambulances or specialized resources (e.g, ALS)

• Specialized resources are available through the fire department

• Law enforcement for the scene or traffic control

• Is the scene a threat? How many patients are there? Do we have the proper resources?

Primary Assessment

• Identify and begin treatment of immediate or imminent life threats

• Assess LOC and ABCs instead of vital signs

Form a General Impression | Primary Assessment

• Focus on the rapid identification of life-threatening problems

• Note things like age, sex, race, level of distress, and overall appearance

• Avoid surprising the patient and note their position

• Avoid standing over patients

• Refer to patients by their name

• Ask for chief complaint, which can also give insight into the LOC and ABCs

• Define patient’s condition as stable, potentially unstable, or unstable

Scan for Signs of Uncontrolled External Bleeding | Primary Assessment

Takes priority over other assessments.

Assess Level of Consciousness | Patient Assessment

• Tells you the patient’s neurologic or physiologic status

• Determines if the patient has a life-threatening injury and if they can respond to questions

• Any deviation from AO×4, a person has an altered mental status

• Complete a primary assessment before applying a cervical collar

AVPU scale

A: Awake and alert. The patient is awake, eyes open spontaneously, aware of you, responsive to the environment, follows commands, and tracks people and objects.

V: Responsive to verbal stimuli. Not alert and awake, the eyes do not open spontaneously. The patient is able to respond in a meaningful way when spoken to.

P: Responsive to pain. The patient does not respond to questions but moves or cries out in response to painful stimuli.

• Apply pressure or pinch the sternum

• Pinch the lower jaw

• Pinch the top of the shoulder

U: Unresponsive. Does not respond to verbal or painful stimuli. No cough/gag reflux and lack the ability to protect their airway.

PPTE test

Person. The patient is able to remember his or her name.

Place. The patient is able to identify his or her current location.

Time. The patient is able to tell you the current year, month, and day of the week.

Event. The patient is able to describe what happened (MOI or NOI).

Identify and Treat Life Threats | Assess Level of Consciousness

• Sudden death from airway obstruction, respiratory failure, respiratory arrest, shock, severe bleeding, and cardiac arrest

• Treatment begins with the ABCs or CAB if there is life-threatening bleeding

Assess the Airway | Primary Assessment

Inadequate perfusion from the blockage of air into and out of the lungs.

Responsive Patients | Assess the Airway

• Talking and crying mean that there is an open airway

• If there is an airway problem, stop the assessment and clear the patient’s airway

Unresponsive Patients | Assess the Airway

• Potential for trauma, use the jaw-thrust maneuver

• If there’s no potential for trauma, use the head tilt-chin lift maneuver

• Relaxation of tongue muscles

• Signs include: obvious trauma, noisy breathing, and extremely shallow breathing

Assess Breathing | Primary Assessment

• A person who breathes without assistance has spontaneous respirations

• Breathing adequately but remains hypoxic, administer 94% O₂

• If respirations are > 28 breaths/min or < 8 breaths/min, consider PPV with an airway adjunct

• A patient speaking is a good indicator

• Shallow respirations involve little movement of the chest

• Inadequate breathing signs:

  • Presence of retractions or use of accessory muscles

  • Nasal flaring or seesaw breathing in pediatric patients

  • Two- to three-word dyspnea

  • Tripod position

  • Sniffing position

  • Labored breathing

Assess Circulation | Primary Assessment

• Blood loss, shock, and heart conditions affect circulation

• First identify and control severe external bleeding

Assess Pulse | Assess Circulation

• Palpate pulse

• Palpate the radial pulse for responsive patients older than 1 year

• Palpate the carotid pulse for unresponsive patients older than 1 year

• Palpate the brachial pulse for responsive patients younger than 1 year

• If there’s no carotid pulse, begin CPR and use an AED if necessary

• The patient has a pulse, but no breathing; provide ventilation at 10–12 breaths/min for adults and 12–20 for children

Skin Condition | Assess Circulation

Evaluate skin color, temperature, moisture, and capillary refill.

Skin Color | Skin Condition

• In deeply pigmented skin, check fingernail beds, the mucous membranes in the mouth, the lips, and the underside of the arm and palm, and the conjunctiva of the eyes

• Poor circulation causes the patient’s skin to appear pale, white, ashen, or gray

• Cyanosis

• High blood pressure leads to flushed or red skin

• Yellow skin and sclera from jaundice

Skin temperature | Skin Condition

• Abnormal skin is hot, cool, cold, and clammy (moist)

• Hot from hyperthermia and cool from hypoperfusion

• Adequate to assess the skin temperature by placing the back of your gloved hand on the patient’s forehead

Skin Moisture | Skin Conditions

• Skin is moist in the early stages of shock

• Skin is diaphoretic/wet after exercise

• Report color, temperature, and how moist the skin is

Capillary Refill | Skin Condition

• Can be affected by the patient’s position, age, smoking history, diabetes, medications, and exposure to cold environments (hypothermia, frostbite, vasoconstriction)

• To assess capillary refill in infants, press on the forehead, chin, or sternum

• Report CRT as normal (2 seconds or less)

• Report CRT as delayed or “CRT > 2”

Assess and Control External Bleeding | Assess Pulse

• Direct pressure over a wound (allow coagulation and clotting) and apply a sterile bandage

• Apply tourniquets for arterial hemorrhage of an extremity

Performing a Rapid Exam to Identify Life Threats

1. Assess the head. Have your partner maintain in-line spinal stabilization if indicated.

2. Asses the neck.

3. Assess the chest. Listen to breath sounds on both sides of the chest

4. Assess the abdomen.

5. Assess the pelvis. If there is no pain, gently compress the pelvis downward and look for tenderness and instability.

6. Assess all four extremities. Assess the pulse and motor, and sensory function.

7. Assess the patient’s back and buttocks. If spinal immobilization is indicated, do so with minimal movement to the patient’s spine by log rolling the patient in one motion.

DCAP-BTLS

A mnemonic for assessment in which each area of the body is evaluated for Deformities, Contusions, Abrasions, Punctures/penetrations, Burns, Tenderness, Lacerations, and Swelling.

• Determine Priority of Patient Care and Transport | Primary Assessment

• High-priority patients

  • Unresponsive

  • Difficulty breathing

  • Uncontrolled bleeding

  • Altered LOC

  • Severe chest pain

  • Pale skin or other signs of poor perfusion

  • Complicated childbirth

  • Severe pain in any area of the body

• The Golden Hour is the time from injury to definitive care

• If the patient’s condition is stable, reassess vitals every 15 minutes

• If the patient’s condition is unstable, reassess vitals every 5 minutes

• Decompensated shock

History Taking

• Initiated on the scene with other tasks

• Provides details for the patient’s chief complaint and an account of the patient’s signs and symptoms

  • Date of the incident

  • Patient’s age

  • Patient’s sex

  • Patient’s race

  • Past medical history, including any pertinent information about the patient’s condition, such as medical problems, traumatic injuries, and surgical procedures

  • Patient’s current health status, including diet, medications, drug use, living environment and hazards, physician visits, and family history

Investigate the Chief Complaint (History of Present Illness) | History Taking

• The most serious thing the patient is concerned about

• Make the patient feel comfortable and ask simple and direct questions

• If the patient is unresponsive, information can be gathered from family, witnesses, medical alert jewelry, or medical history documentation

OPRST | Investigate the Chief Complaint (History of Present Illness)

O: Onset. What were you doing when the symptoms began?

P: Provocation/palliation. Does anything make the symptoms better or worse? How are you most comfortable?

Q: Quality. What does the symptom feel like? Is it sharp, dull, crushing, tearing? Does it come in waves? Ask the patient to describe the symptom

R: Region/radiation. Where do you feel the symptom? Does it move anywhere?

S: Severity. On a scale of 0 to 10, with 0 being “nothing at all” and 10 being “the worst you can imagine,” how would you rate your symptom?

T: Timing. How long have you had the symptom? When did it start?

Identify Pertinent Negatives | Investigate the Chief Complaint (History of Present Illness)

• Negative findings that warrant no care or intervention

• Absence of findings should be reported and documented

Obtain SAMPLE History | Investigate the Chief Complaint (History of Present Illness)

S: Signs and symptoms. What signs and symptoms occurred at the onset of the incident?

A: Allergies. Is the patient allergic to any medication, food, or other substance? What reactions did the patient have to any of them? If the patient has no known allergies, you should note this on the run report as “No known allergies.”

M: Medications. What medication is the patient prescribed? What dosage is prescribed? How often does the patient take the medication? What prescription, over-the-counter, and herbal medications has the patient taken in the last 12 hours? Are there medications the patient has been prescribed but is not taking? Does the patient take recreational drugs?

P: Pertinent past medical history. Does the patient have any history of medical, surgical, or trauma occurrences? Is there important family history that should be known?

L: Last oral intake. When and what did the patient last eat or drink? In women of childbearing age, the “L” in SAMPLE also represents last menstrual period.

E: Events leading up to the injury or illness. What are the key events that led up to this incident? What occurred between the onset of the incident and your arrival? What was the patient doing when this illness started?

Critical Thinking in Assessment | Obtain SAMPLE history

• Cookbook medicine does not work well in EMS

• Important for gathering, evaluating, and synthesizing information

Gathering | Critical Thinking in Assessment

• Observing the scene and questioning patients and bystanders

• Can be challenging with patients who are uncooperative, unconscious, or with language barriers present

Evaluating | Critical Thinking in Assessment

Consider what the information gathered means, and what other conditions would produce the same signs and symptoms.

Synthesizing | Critical Thinking in Assessment

Put together all the information gathered to synthesize a plan to manage and care for the patient.

Alcohol and Drugs | Taking History on Sensitive Topics | Critical Thinking in Assessment

• Confusing, hidden, or disguised

• Assure patients who are hiding information that their privacy is protected

• Establish a strong rapport, don’t judge, be honest, and be professional

Physical Abuse or Violence | Taking History on Sensitive Topics

• Must be reported to the authorities

• Immediately involve law enforcement if abuse is suspected

• Determine if the information provided is consistent with the patient and others

• Observe injuries on the patient

• Interview both parties separately

• Documentation is important

Sexual History | Taking History on Sensitive Topics

• Religious beliefs, cultural stereotypes, society’s expectations, and feeling uncomfortable

• Question females about their menstrual period, birth control, pregnancy, and pain in urination

• Question males about urinary symptoms

Special Challenges in Obtaining Patient History

• Silence

• Overly talkative

• Multiple symptoms

  • Prioritize complaints

• Anxiety

  • Underlying medical conditions, psychological shock, and domestic abuse

• Anger and Hostility

• Intoxication

  • Unreliable information; alcohol dulls a patient’s senses

• Crying

• Depression

  • Leading cause of disability

• Confusing Behavior or History

  • More comfortable talking to hospital staff

  • Medical conditions can alter explanation (e.g, hypoxia)

• Limited Cognitive Abilities

  • Ask simple questions; ask parents questions

• Cultural Challenges

• Language Barriers

• Hearing Problems

• Visual Impairments

Secondary Assessment

• Perform a systematic physical examination of the patient

• Inspection. Look for abnormalities

• Palpation. Touch and feel for abnormalities

• Auscultation. Listen to sounds in the body using a stethoscope

• Compare findings on one side of the body with the other side

• Note orders

Systematically Assess the Patient—Secondary Assessment | Secondary Assessment

1. Observe the face.

2. Inspect the area around the eyes and eyelids.

3. Examine the eyes for redness and contact lenses. Check pupil function

4. Look behind the ears for Battle sign.

5. Check the ears for drainage or blood.

6. Observe and palpate the head.

7. Palpate the zygomas.

8. Palpate the maxillae.

9. Check the nose for blood and drainage.

10. Palpate the mandible.

11. Assess the mouth and nose.

12. Check for unusual breath odors.

13. Inspect the neck. Observe for jugular vein distention.

14. Palpate the front and back of the neck.

15. Inspect the chest, and observe breathing motion.

16. Gently palpate over the ribs.

17. Listen to anterior breath sounds (midaxillary midclavicular).

18. Inspect the back. Listen to posterior breath sounds (bases, apices).

19. Observe and then palpate the abdomen and pelvis.

20. Gently compress the pelvis from the sides.

21. Gently press the iliac crests

22. Inspect the extremities; assess distal circulation and motor and sensory function.

23. Log roll the patient, and inspect the back for tenderness or deformities.

Systematically Assess the Patient—Focused Assessment

• Performed on patients who sustained nonsignificant MOIs or on responsive medical patients

• Focus on a specific body part or body system that has been affected

Respiratory System | Systematically Assess the Patient—Focused Assessment

• Expose the patient’s chest and look for trauma or airway obstructions, symmetry, listen for breathing, and measure respiratory rate

• Sounds of stridor or high-pitched wheezing

• Inspiration and expiration (1:3 ratio)

• Obtain respiratory rate, rhythm, quality of breathing, and depth of breathing

Respiratory Rate | Systematically Assess the Patient—Focused Assessment

• Count the peak of chest rise for 30 seconds and multiply by 2

• Check the respirations in a patient without them being aware to get a more accurate reading

  • Check radial pulse and determine respirations

• If a patient coughs, yawns, sighs, or talks, wait a few seconds and start again

Respiratory Rhythm | Respiratory Rate

Regular or irregular patterns.

Quality of Breathing | Respiratory Rate

• Decreased/absent breath sounds or decreased movement on one side are signs of inadequate breathing

• Normal breathing is silent

• Snoring indicates an obstruction

• Bubbling or gurgling; fluid is present

• A patient who coughs up thick, yellow, or green sputum has a respiratory infection

  • Blood from trauma

Depth of Breathing | Respiratory Rate

Depth of the breath determines whether the tidal volume is normal, less than normal, or greater than normal.

Breath Sounds | Respiratory Rate

• Auscultate a patient’s back; if not, check the sides

• Auscultate the apices of the upper lungs, the midlung fields, and the base of the lungs

• Slide the stethoscope under the clothing

• Place the diaphragm of the stethoscope on the skin to hear

• Normal breath sounds. Clear and quiet. You will hear air moving into and out of the lungs.

• Snoring breath sounds. Upper airway obstruction. Does not require a stethoscope.

• Stridor. Obstruction in the neck or upper part of the chest.

• Wheezing breath sounds. The obstruction or narrowing of the lower airways.

  • Wheezing is a lower airway sound

  • Crackling indicated fluid in the lungs

  • Rhonchi is the presence of mucus or fluid in the lungs

Cardiovascular System | Systematically Assess the Patient—Focused Assessment

Check the thoracic region, assess pulse, pay attention to rate, quality, and rhythm, skin condition, compare distal pulses, and consider auscultation.

Pulse Rate | Cardiovascular System

• 60–100 beats/min

• Count the number of pulses in 30 seconds and multiply by two

• Tachycardia when pulse > 100 beats/min

• Bradycardia when pulse < 60 beats/min

Pulse Quality | Cardiovascular System

• Report pulse quality at the carotid or radial arteries in adults or the brachial artery in children

• Report quality as strong, “bounding” for stronger-than-normal pulse, and weak

Pulse Rhythm | Cardiovascular System

• Document pulse as regular for constant rhythms

• If the pulse is irregular—early or late heart beat—call for ALS

Blood Pressure | Cardiovascular System

• The pressure of circulating blood against the walls of the arteries

• Decrease from loss of blood, vasoconstriction, or cardiac pumping problems

  • Compensatory mechanisms are activated → heart beats faster → constriction of arteries → maintains pressure

• Decreased blood pressure indicates late signs of shock

• Systolic and diastolic pressure (in mm Hg)

• Avoid obtaining BP on a patient if the patient has an IV site or any medical device, a mastectomy, or an injury to that arm

• Sphygmomanometer—thigh, adult, and pediatric cuffs

  • Korotkoff sounds

Obtaining Blood Pressure by Auscultation

1. Follow standard precautions. Check for dialysis fistula, central line, previous mastectomy, and injury to the arm. If any are present, use the brachial artery on the other arm. Apply the cuff snugly. The lower border of the cuff should be about 1 inch (2.5 cm) above the antecubital space.

2. Support the exposed arm at the level of the heart. Palpate the brachial artery.

3. Place the stethoscope over the brachial artery, and grasp the ball-pump and turn-valve.

4. Close the valve, and pump to 30 mm Hg above the point at which you stop hearing pulse sounds. Note the systolic and diastolic pressures as you let air escape slowly.

5. Open the valve, and quickly release remaining air.

Obtaining Blood Pressure by Palpation

1. Follow standard precautions. Secure the appropriate-size cuff around the patient’s upper arm.

2. With your nondominant hand, palpate the patient’s radial pulse on the same arm as the cuff. Once you have located it, do not move your fingertips until you have completed taking the blood pressure.

3. While holding the ball-pump in your other hand, close the turn-valve and slowly inflate the cuff until the pulse disappears and then continue to inflate another 30 mm Hg. As the cuff inflates, you will no longer feel the pulse under your fingertips.

4. Open the turn-valve so that air slowly escapes from the cuff, and carefully observe the gauge. When you can again feel the radial pulse under your fingertips, note the reading on the gauge as the patient’s systolic blood pressure.

5. Next, open the turn0valve further, and completely deflate the cuff. Document your findings, including the time, and note that the pressure was taken by palpation.

• Report as “120/P” and verbalize it as “120 palpated'“

Normal Blood Pressure | Cardiovascular System

• Hypotension and hypertension

• General circulation, pulse, skin temperature, and capillary refill should not be asses on an injured limb

  • Compare after obtaining vitals

Neurologic System | Systematically Assess the Patient—Focused Assessment

• Perform an assessment on patients who have altered mental status

• Use AVPU

• Glasgow Coma Score (GCS)

Pupils | Systematically Assess the Patient—Focused Assessment

• Constricted. dilated, or unequal

• Pupils are fixated, dilate with the introduction of light, react sluggishly, and become unequal in size, become unequal when bright light is introduced

• Depressed brain function from:

  • Injury to the brain or the brainstem

  • Trauma or stroke

  • Brain tumor

  • Inadequate oxygenation or perfusion

  • Drugs or toxins (CNS depressants)

PEARRL

• A useful mnemonic for assessing pupils

• P: Pupils

• E: Equal

• A: And

• R: Round

• R: Regular in size

• L: React to Light

Assessing Neurovascular Status | Systematically Assess the Patient—Focused Assessment

1. Palpate the radial pulse in the upper extremity.

2. Palpate the posterior tibial and dorsalis pedis pulses in the lower extremity.

3. Assess capillary refill by blanching a fingernail or toenail.

4. Assess sensation on the flesh near the tip of the index finger and thumb, as well as the little finger.

5. On the foot, first check sensation on the flesh near the tip of the big toe.

6. Also, check sensation on the side of the foot.

7. For an upper extremity injury, evaluate motor function by asking the patient to open the hand. (Perform motor tests only if the hand or foot is not injured. Stop a test if it causes pain.)

8. Also ask the patient to make a fist.

9. For a lower extremity injury, ask the patient to flex the foot and toes (ask the patient to “push down on the gas”)

10. Also have the patient extend the foot and ankle and pull the toes and foot toward the nose.

Head, Neck, and Cervical Spine | Anatomic Regions | Systematically Assess the Patient—Focused Assessment

• Palpate the scalp and skull; symmetry; eyes; zygomas; ears and nose for fluid; maxillae; broken or missing teeth

• Palpate the neck for deformities, bumps, swelling, bruising, bleeding, subcutaneous emphysema

Chest | Anatomic Regions

• Inspect, visualize, and palpate the chest

• Observe chest rising for abnormal breathing signs or paradoxical motion

Abdomen | Anatomic Regions

• Look for trauma and distention; tenderness, rigidity, and patient guarding

• Palpate in the quadrant that is furthest from the patient’s pain

Pelvis | Anatomic Regions

Inspect for symmetry, injury, bleeding, and deformity.

Extremities | Anatomic Regions

• Are extremities properly positioned?

• Inspect for symmetry, cuts, bruises, swelling, obvious injuries, and bleeding

• Pulse. Check distal pulses on the foot. Evaluate skin color, temperature.

• Motor function. Ask the patient to wiggle his or her fingers.

• Sensory function. Ask the patient to close their eyes. Gently pinch a finger or toe and ask the patient what you are doing.

Posterior Body | Anatomic Regions

• Use DCAP-BTLS

Pulse Oximetry | Assess Vital Signs Using the Appropriate Monitoring Device

• Evaluates the effectiveness of oxygenation

• Placed on the finger or earlobe

• Values range between 94–99%

• Functions properly with adequate perfusion and number of blood cells

• Inaccurate with vasoconstriction

Capnography | Assess Vital Signs Using the Appropriate Monitoring Device

• Pulse oximetry cannot measure how much oxygen is used

• Provides information on a patient’s ventilation, circulation, and metabolism

Blood Glucometry | Assess Vital Signs Using the Appropriate Monitoring Device

• Low blood glucose levels can identify why a patient is unresponsive

• High blood glucose for patients with nausea, vomiting, abdominal pain, and a change in mental status

Assessing Blood Glucose Level

1. Take standard precautions. Cleanse the site (finger) with antiseptic.

2. Puncture the site with the lancet.

3. Dispose of the needle in a sharps container.

4. Obtain a drop of blood on the rest strip. Insert the test strip into the glucometer and activate the device per the manufacturer’s instructions.

5. Place a bandage over the puncture site.

Noninvasive Blood Pressure Measurement | Assess Vital Signs Using the Appropriate Monitoring Device

• Manual or electronic sphygmomanometers are noninvasive, but can be prone to inaccurate readings

• Good practice to obtain a manual reading first

Reassessment

• Performed at regular intervals to identify and treat changes in a patient’s condition.

• Repeat the Primary Assessment

  • ABCs

• Reassess Vital Signs

  • Compare with baseline vitals

• Reassess the Chief Complaint

  • Is the current treatment improving the patient’s condition?

  • Has an already identified problem gotten better?

  • Has an already identified problem gotten worse?

  • What is the nature of any newly identified problems?

• Recheck Interventions

  • Revaluate everything

• Identify and Treat Changes in the Patient’s Condition

• Reassess Patient

  • Every 15 minutes for stable patients

  • Every 5 minutes for unstable patients