Han 477 Quiz 1

Patient assessment steps

\-identify pt's problem

\-set care priorities

\-develop differential diagnosis & patient care plan

\-execute plan

Textbook/cookbook medicine

by the book

\-treating every patient the same

**-we DO NOT do this in real life**

Sick vs Not Sick

\-quantify how sick the patient is

\-can determine sickness based on patient presentation and vital signs

Life threats

conditions that can cause sudden death

\-eg. airway obstruction, respiratory arrest, severe bleeding

The goal of the primary assessment is to identify and treat life threats

\-must be treated **before** proceeding

\

Scene Size-Up

* evaluate overall safety and stability (protect yourself)


* look at the scene and see if any speciality resources are needed


* determine is PPE is required
* take standard precautions
* determine MOI and NOI

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

What is their chief complaint (must know prior to obtaining PMH, allergies, etc...)

Standard Precautions

treat all patients as potentially infectious

* gloves, eye protection, gown, mask
* -PPE --> clothing and equipment (eg. steel toe boots, helmets, etc.)

Primary Assessment: form a general impression

based on initial presentation and CC

make conscious, objective and systematic observations

determine pt's stability and sick/not sick

observe level of consciousness

determine priorities of care

ABC

airway, breathing, circulation

does not need to be done in this exact order

AMS

altered mental status

can be checked by asking questions (name, facts), testing motor skills, asking those who know pt's normal state

Assessment of airway

\-evaluate if the airway is open and patent

listen for noisy breathing

supine = laying down on back (can close airways)

complex= sitting up and forwards (open airways)

Assessment of airway - unresponsive patients

establish responsiveness and assess breathing

if ineffective or absent --> open the airway

mechanical means require an airway adjunct

Assess breathing

\-If not breathing (must breathe for pt)

if breathing, determine if pt is breathing adequately

look for breathing rate, by seeing chest rise and fall

assess breath sounds and air movements

Minute Volume

The amount of air breathed in during each respiration multiplied by the number of breaths per minute.

\-respiratory rate X tidal volume

Normal breathing rate

12-20 breaths per minute

fast breathing (more than 40) can lead to respiratory arrest due to increased carbon dioxide

Assess circulation

palpate the pulse: count # of beats in 15 seconds and multiply times 4

common areas to measure: radial, carotid, inguinal

force: feels "full"

rhythm: normal is regular

inspect skin for signs of bleeding

Normal pulse

60-100 bpm

bradycardia: less than 60

tachycardia: more than 100

Capillary refill

evaluates ability to restore blood

testing: test on thumb, blood/color should return within 2 secs

\-inadequate perfusion could indicate lack of hydration or (severe) hemorrhagic shock

Assess and Control External Bleeding

* In trauma patients, identify and immediately control major external bleeding
* This step should occur before addressing airway or breathing concerns
* evaluate unresponsive patients by running your gloved hands from head to toe

Vessel Bleeding

\-venous bleeding: steady blood flow (dark red)

arterial bleeding: spurting, pulsating flow of blood (bright red) -worse than venous because can bleed out

capillaries bleeding: slow flow of blood

A patient who is dying will:

* Become less aware of surroundings
* Stop making attempts to communicate
* Lose consciousness
* Have inadequate resp. pattern
* Become unresponsive to external stimuli
* jaw becomes slack

Performing a rapid exam

\-guidelines: inspect, palpate, auscultate

history taking: gain info about patient and events surrounding incident, ask open ended and age appropriate questions, avoid leading, be patient

History taking techniques

* clean, neat, professional appearance and demeanor
* good attitude
* ID service/certification
* Interview in private setting
* eye contact

Chief Complaint (CC)

\-recorded in patient's own words

includes: what is wrong, treatment being sought, duration of CC

for responsive (awake and alert) patients

OPQRST

* onset
* provocation
* Quality
* Region/radiation/referral
* Severity
* Time

SAMPLER

* signs and symptoms
* Allergies
* Meds
* Pertinent past history
* Last oral intake
* Event that led to injury/illness
* Risk factors

Past medical history should include

* Adult illnesses
* Past surgeries
* Allergies
* Current medications and dosages
* Past hospitalizations/disabilties
* prior history of particular condition
* Family + travel history
* A new problem or condition is best considered serious until proven otherwise
* Patient's emotional affect provides insight into overall mental health.

Medical history for unresponsive patients

must rely on head-to-toe physical exam

obtain history of family and friends

clues in external setting

pill containers, medical jewelry, medical ID

Communication Techniques

\-pay attention to signs and symptoms not consistent with working diagnosis

\-encourage dialogue: use layperson terminology

-differential diagnosis: working hypothesis of nature of problem

\: working hypothesis of nature of problem

Facilitation (Communication)

Encouraging patient to feel open to give information needed

pay attention, eye contact, repeat key information, nod head

phrases to use: that's helpful, please go on

Reflection (Communication)

Pausing to consider something significant that you've just been told

phrase: "hold on let me think for a moment"

Clarification (Communication)

Asking patients for more information when aspect of the history is vague or unclear

Confrontation (Communication)

Make patient aware of something not consistent with their behavior, actual scene, or information the patient is giving

Interpretation (Communication)

Inferring the cause of the patient's distress, then asking the patient if you are right

Getting a History on Sensitive Topics

concerning alcohol and drug abuse

patient may give unreliable history

alcohol can mask signs and symptoms

keep professional, positive, and careful attitude

Challenges in History Taking

\-limited education or intelligence

language barriers

hearing problems

visual problems

using fam/friends

Secondary Assessment

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


1. Obtaining vital signs
2. Performing a head-to-toe survey

Inspection

looking at the body's appearance

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 normal sound, lots of practice

Pulse

assess rate, presence, location, quality, regularity,

palpate by gently compress an artery against a bony prominence

count for 15 seconds and multiply by four

check for central pulse in unresponsive patients

normal pulse rate between 60-100 for adults

Respiration

assess rate by inspecting the pt's chest

quality: pathologic respiratory patterns or rhythms

tripod positioning (sitting in a chair hands on knees), accessory muscle use (ribcages and neck), retractions

rate should be measured for 30 seconds

multiplied by two for pediatric patients

Blood Pressure

product of cardiac output and peripheral vascular resistance

systolic and diastolic pressure

measured using a cuff

deally should be auscultated

Normal Blood Pressure

120/80 mmHg

\-above 140 = hypertension

\-below 99 = hypotension

Pulse oximetry

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

measures percentage of hemoglobin saturation

Normal pulse ox

95-100%

Physical Examination

Look for signs of significant distress by observing overall appearance

dress

hygiene

expression

overall size

posture

untoward odors

Overall state of health

Mental Status

for any patient with a "head" problem, assess and palpate for signs of trauma

assess the patient: person, place, day of week, the event

AVPU

Level of consciousness check: alert, verbal stimuli, painful stimuli, unresponsive

Glasglow Coma Scale (GCS)

a neurologic scale used to assess level of consciousness

eye opening, verbal response, motor response

highest =15

lowest = 3

8 is the indicator of diminished mental status

Pallor

poor red blood cell perfusion to capillary beds

Vasoconstriction

indicated by pale skin

Cyanosis

low arterial oxygen saturation

Mottling

severe hypo perfusion and shock

Ecchymosis

localized bruising or blood collection within or under the skin

Turgor

relates to hydration

pinching skin and returning to normal state

also affected by age

Skin lesions

may be only external evidence of a serious internal injury

Cranium

contains the brain

scalp covers it

Occiput

posterior portion

Temporal regions

each side of the cranium

Parietal regions

between temporal regions and occiput

Frontal region

forehead

Meninges

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

Cerebrospinal fluid

fills between meninges

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

\-small pupils = brain damage, drug use (opioid abuse)

\-dilated pupils = brain dead (unresponsive)

Evaluate 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

evaluate mouth/lips

symmetry, gums, look for cyanosis around the lips

inspect airway for obstruction

Auscultate breath sounds

normal, tracheal, bronchial, bronchovesicular, vesicular, adventitious (wheezing, rales, rhonci, stridor, pleural friction rubs)

Chest sounds

Are sounds: dry or moist, continuous or intermittent, course or fine

Are breath sounds: diminished or absent, whole lungs or portion, assess transmitted voice sounds

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

Common injuries musculoskeletal system

fractures, sprains, strains, dislocations, contusions, hematomas, open wounds

Assessment of musculoskeletal system

\-structure and function

\-limitation or pain in range of motion

\-bony "crepitus"

\-inflammation or injury

\-obvious deformity

\-diminished strength

\-atrophy

\-asymmetry

\-pain

Spine

consists of 33 individual vertebrae

\-anchoring point for the skull, shoulders, ribs, and pelvis

\-protects spinal cord

Central Nervous System (CNS)

brain and spinal cord

Brain

cerebrum, cerebellum, and medulla

Nerves

expect for cranial nerves, nerves are channeled to the spinal cord

\-motor nerves control motion or movement

\-sensory nerves send external signals to the brain

Peripheral Nervous System (PNS)

remaining motor and sensory nerves

Cranial Nerves

12 pairs of nerves arising from the brain

Delirium

consistent with an acute sudden change in mental status

Dementia

representative of deterioration of cognitive cortical function

\-chronic changes over time

Carbon dioxide monitoring devices

capnometry and capnography

Capnometry

measures carbon dioxide

Capnography

measures carbon dioxide output and provides a waveform

Normal carbon dioxide levels

35-45 mmHg

Blood glucometer

can obtain reading in two ways

from a the hub of an IV catheter or finger stick

Reassessment of Mental Status & ABCs

compare LOC with baseline assessment \n -review the airway \n -reassess breathing, circulation, pulse \n -response of pediatric (children decompensate very quickly) and geriatric (may not show signs of deterioration) patients may differs

Patient assessment components

Scene Size-Up \n Primary Survey \n History Taking \n Secondary Assessment \n Reassessment

First step of primary assessment

general impression of the pt's condition \n -identify life threats (treated immediately) to the ABCS \n -move on to history-taking phase of patient assessment

Patient history is a

primary means of diagnosing the chief complaint

\-serves as a good mental status examination

Secondary assessment includes

vital signs and performing a head-to-toe survey

Vital signs consist of a measurement of

blood pressure; pulse rate, rhythm, and quality; respiratory tare, rhythm, and quality; temperature; and pulse ox

When dealing with infants and children

alter your approach to patient assessment

Reassessment

a procedure for detecting changes in a patient's condition. It involves four steps: repeating the primary assessment, repeating and recording vital signs, repeating the physical exam, and checking interventions

\
performed on all patients

confirms if interventions are effective

A patient in stable condition should be reassessed

every 15 minutes

A patient is unstable condition should be reassessed

every 5 minutes

Respiratory system functions to

delivers oxygen to tissue and removes carbon dioxide from tissue