chapter 10

Patient Assessment Chapter 10

Introduction

  • Quality patient assessment is essential in Emergency Medical Services (EMS).
  • Mastering the patient assessment process is critical as it is used, to some degree, in every patient encounter.
  • Five main parts of patient assessment:
    • Scene size-up
    • Primary survey
    • History taking
    • Secondary survey
    • Reassessment

Sign vs. Symptom

  • It is rare for a single sign or symptom to reveal the patient’s status.
  • Sign: An objective condition that can be observed about the patient, such as vital signs or physical examination results.
  • Symptom: A subjective condition that the patient feels and reports, such as pain or nausea.

Scene Size-up

  • Scene size-up is how EMS personnel prepare for a specific situation involving a patient.
    • Begins with the dispatcher’s basic information and is combined with an inspection of the scene.
    • Maintain continuous situational awareness throughout the assessment.

Steps in Scene Size-up

  1. Take Standard Precautions (BSI)

    • Wear personal protective equipment (PPE):
      • Adjust PPE to the prehospital task at hand, considering risks like blood exposure, body fluids, and communicable diseases.
    • At minimum, gloves must be worn when stepping out of the EMS vehicle. Consider wearing glasses and a mask depending on the situation.

  2. Ensure Scene Safety

    • The prehospital setting is unpredictable, dangerous, and unforgiving.
    • Ensure your own safety first, followed by the patient’s safety.
    • Keep bystanders from becoming patients.
    • Wear a public safety vest and be mindful of possible dangers as you approach the scene.
    • Consider difficulties posed by terrain, traffic safety issues, and environmental conditions.

  3. Forms of Hazards

    • Examples of scene hazards include:
      • Chemical and biological risks
      • Electrical hazards (e.g., downed lines or lightning)
      • Water hazards, fires, explosions, toxic environments
      • Motor vehicle collisions
    • If the scene is unsafe, make it safe or do not enter if that is not possible.
    • Be aware of potential violence scenes, and request law enforcement if needed.

  4. Mechanism of Injury (MOI) / Nature of Illness (NOI)

    • To care for trauma patients, you must understand the mechanism of injury (MOI).
    • Recognize fragile areas that are easily injured:
      • Brain
      • Spinal cord
      • Eyes
    • Use MOI as a guide to predict the potential for serious injury by evaluating three factors:
      • Amount of force applied to the body
      • Length of time the force was applied
      • Areas of the body that are involved.

Types of Trauma

  • Blunt Trauma

    • Force applied over a broad area of the body, typically without broken skin.
    • Tissues and organs below the area of impact may be damaged.

  • Penetrating Trauma

    • Force occurs at a small point of contact, resulting in an open wound with potential for high infection risk.
    • Severity of injury is influenced by:
    • Characteristics of the penetrating object.
    • Amount of force or energy involved.
    • Part of the body that was affected.

Importance of MOI and NOI

  • Recognizing the MOI or NOI early can help in preparing to care for the patient.
    • Do not prematurely categorize the patient as either trauma or medical, as both categories rely on fundamental patient assessment principles.

Determine Number of Patients

  • During the scene size-up, accurately assess the total number of patients.
    • This is critical in determining the need for additional resources.
  • In the event of multiple patients:
    • Utilize the incident command system (ICS).
    • Call for additional units and initiate triage as necessary.

Triage Process

  • Triage involves sorting patients based on the severity of their condition to prioritize care effectively.

Additional Specialized Resources

  • In certain situations, additional or specialized resources may be required:
    • Consider the following questions to determine need:
    • How many patients are there?
    • What is the nature of their conditions?
    • Who contacted EMS?
    • Does the scene pose any threats to you, the patient, or others?
  • Specialized resources can include:
    • Advanced life support
    • Air medical support
    • Fire departments for specialized rescues (e.g., high-angle, hazardous materials, water rescue).

Consider Cervical Spine Injury

  • When assessing patients, have a high index of suspicion for cervical spine injuries, particularly in cases of high-impact trauma.

Primary Survey

  • The primary survey focuses on the patient's presentation and vital signs to identify and initiate treatment for immediate or potential life threats.
  • Begins when you greet the patient.

General Impression

  • Create a general impression to determine priority of care based on immediate assessment.
  • Take note of:
    • Patient's age and gender
    • Level of distress
      ewline - Overall appearance
  • Position yourself at the patient’s level and introduce yourself, using the patient's name.

Assess Chief Complaint

  • Inquire about the chief complaint.
  • Evaluate the patient's skin color and condition.
  • Determine if the patient's condition is:
    • Unstable (sick)
    • Stable (not sick)
    • Stable but potentially unstable (not sick yet)

Assess Level of Consciousness (LOC)

  • LOC is a vital sign indicating the patient’s neurologic and physiological status categorized as:
    • Conscious with unaltered LOC
    • Conscious with altered LOC
    • Unconscious
  • An altered LOC may indicate inadequate perfusion, potentially caused by drugs or medical conditions.

Assessment of Unconscious Patients

  • For unconscious patients, focus on airway, breathing, and circulation (ABC).
  • If sustained unconsciousness occurs, it often signals critical respiratory, circulatory, or central nervous system issues.

AVPU Mnemonic for Responsiveness

  • Use the AVPU mnemonic to assess patient responsiveness:
    • A = Awake
    • V = Responsive to verbal stimuli
    • P = Responsive to physical stimuli or pain
    • U = Unresponsive

Orientation Tests for Mental Status

  • Evaluate the patient’s ability to remember:
    • Long-term memory (place, time)
    • Intermediate-term memory (place, year/month)
    • Short-term memory (approximate day of week/event)

Glasgow Coma Scale (GCS)

  • The GCS provides additional information about mental status changes based on three parameters:
    • Eye opening
    • Best verbal response
    • Best motor response

Pupil Assessment

  • Pupils are circular openings in the iris that should be normally round and equal in size.
  • The reactivity and diameter of the pupils reflect the status of brain perfusion and oxygenation.
  • Changes in pupil diameter can indicate:
    • Constricted pupils in bright light or narcotic usage.
    • Dilated pupils in low light or due to drug influence, hypoxia, or neurological conditions.
    • Unequal pupils can indicate various conditions like head injury or stroke.
  • PEARRL (Pupils Equal And Round, Reactive to Light) is a standard assessment term indicating normal pupil response. If pupils accommodate (PERRLA), it is a further sign of neurologic integrity.

Airway Assessment

  • During primary assessment, always look for signs of airway obstruction:
    • Check if the airway is open (patent), adequate, and clear.
  • Responsive Patients
    • Talking or crying indicates an open airway. Pay attention to speech to identify any airway problems.
  • Unresponsive Patients
    • Assess the airway immediately:
    • Use the modified jaw-thrust technique if necessary.
    • Use the head tilt–chin lift technique if appropriate.
    • Airway obstruction is often due to relaxed tongue muscles.

Signs of Airway Obstruction in Unconscious Patients

  • Look for:
    • Obvious trauma or blockage
    • Noisy breathing (snoring, bubbling, gurgling, crowing)
    • Extremely shallow or absent breathing

Breathing Assessment

  • Confirm that the patient is breathing adequately by:
    • Observing chest rise and fall
    • Feeling for air through the mouth and nose
    • Listening for breath sounds with a stethoscope over each lung.
  • Obtain the respiratory rate (noting if it is fast or slow), rhythm (regular or irregular), quality (character of breathing), and depth (how deep breaths are).

Questions for Breathing Assessment

  • Ask:
    • Does the patient appear to be choking?
    • Is the respiratory rate too fast or too slow?
    • Are the patient’s respirations shallow or deep?
    • Is the patient cyanotic (blue)?
  • Administer supplemental oxygen if necessary based on respiratory conditions (e.g., rates
  • Provide positive-pressure ventilations when respiratory rates fall below 8 or exceed 24 breaths/min.

Normal Respiratory Rates

  • Normal adult range: 12 to 20 breaths/min.
  • Children breathe at faster rates.
  • Respirations should be counted over a 30-second period, multiplied by two to determine the rate.

Quality of Breathing

  • Listen for:
    • Normal breath sounds
    • Wheezing, rales, rhonchi, stridor, absent breath sounds.
  • Depth of breathing relates to the air exchanged based on rates and tidal volume (VT).

Assessment of Circulation

  • Evaluate:
    • Pulse rate, quality, rhythm.
    • Identify external bleeding, tissue color, temperature, and moisture.

Normal Ranges for Pulse Rates

AgeHeart Rate (Beats/Min)
Neonates (to 1 mo)130-160
Infant (1 mo to 1 yr)100-160
Toddler (1-2 yrs)90-150
Preschool (3-5 yrs)80-140
School Age (6-12 yrs)60-100
Adolescent (13-18 yrs)60-100
Adult60-100

Pulse Rhythm Assessment

  • Determine if the pulse is regular or irregular, further categorizing:
    • Regularly irregular
    • Irregularly irregular

Pulse Quality Assessment

  • Bounding Pulse: Stronger than normal.
  • Weak/Thready Pulse: Difficult to feel.

Skin Condition Assessment

  • Evaluate skin color, temperature, moisture, and capillary refill.
  • Assess how well the circulatory system is functioning to perfuse skin with oxygenated blood.
    • Skin Color:
    • Poor circulation leads to pallor.
    • Bluish color indicates inadequate saturation with oxygen.
  • Skin Temperature:
    • Normal skin is warm to touch.
    • Abnormal temperatures suggest pathology.
  • Skin Moisture:
    • Normal skin is dry; wet or excessively dry skin indicates potential issues.

Capillary Refill Assessment

  • Evaluated to assess circulatory system's ability to restore blood to capillaries:
    • Press on skin or fingernail, then release and observe for restoration to normal color.

Assessing and Controlling External Bleeding

  • External bleeding can be controlled with direct pressure.
  • If unsuccessful, a tourniquet may be applied.

Perform Rapid Scan

  • The body must be scanned to identify injuries urgently needing management and protection.
  • This process should take 60 to 90 seconds and is not a detailed physical examination.

Determine Priority and Transport

  • The rapid scan aids in determining transport priority:
    • High priority patients include those with:
    • Difficulty breathing
    • Poor overall impression
    • Unresponsive without gag or cough reflex
    • Severe chest pain or signs of poor perfusion.

Golden Hour Period

  • This refers to the critical time from injury to definitive care, emphasizing that treatment of shock and traumatic injuries should commence as soon as possible.
    • Aim to assess, stabilize, package, and begin transport within 10 minutes (the “Platinum 10”).

Transport Decision Factors

  • Decisions on transport should rely on:
    • The patient's condition
    • Availability of advanced care
    • Distance of transport
    • Local protocols

History Taking

  • History taking captures details about the chief complaint and symptoms, providing insight into the signs and symptoms.
  • Includes demographic information:
    • Date and times of incident and assessments
    • Patient’s age, sex, race, and medical history.

Investigate Chief Complaint

  • Interact with patients to make them comfortable and obtain consent to treat.
  • Use simple, open-ended questions addressed formally (Mr., Ms., or Mrs. with last name).

Collecting Information - SAMPLE

  • Use the SAMPLE mnemonic to garner the following information:
    • Signs and symptoms:
    • Allergies:
    • Medications:
    • Pertinent past medical history:
    • Last oral intake:
    • Events leading up to injury/illness.

Assessing Pain - OPQRST

  • Use the OPQRST mnemonic for pain assessment:
    • Onset
    • Provocation or palliation
    • Quality
    • Region/radiation
    • Severity
    • Timing

Document Pertinent Negatives

  • Document significant negative findings that justify no intervention or care.

Addressing Sensitive Topics in History Taking

  • For sensitive subjects like alcohol and drug use:
    • Recognize the signs can be confusing.
    • Be cautious; history may not always be reliable.

Reporting Physical Abuse

  • Report all physical abuse in children and elderly to law enforcement.
  • For domestic abuse cases:
    • Notify about the family violence center location and provide relevant pamphlets.
    • Document notifications, injuries, and information given without accusatory language.

Inquiring Sexual History

  • Consider females of childbearing age with lower abdominal pain as potentially pregnant.
  • Inquire about urinary symptoms in males and potential STDs in all patients.

Challenges in Gathering Patient History

  • Silence: Be patient; silence can indicate symptoms.
  • Overly Talkative Patients: May be affected by caffeine, nervousness, or drug use.
  • Multiple Symptoms in Geriatric Patients: Prioritize the complaints as in triage, starting with the most serious first.

Addressing Anxiety in Patients

  • Recognize signs of psychological shock including pallor, diaphoresis, shortness of breath, and dizziness.

Managing Anger and Hostility

  • Remain calm and reassuring in the face of anger directed at you or the EMS team. Ensure scene safety.

Dealing with Intoxication

  • Avoid exacerbating a situation with intoxicated patients; ensure they do not feel threatened to prevent violence.

Responding to Emotional Crises (Crying, Depression)

  • Maintain a calm presence, speak softly, and be a good listener.
  • Understand depression symptoms that often reflect broader issues.

Handling Confused Behavior or History

  • Be vigilant for signs of hypoxia, stroke, and other conditions that can affect consciousness. Geriatric patients with dementia may have altered memory.

Limited Cognitive Abilities and Language Barriers

  • Ask simple questions for developmentally impaired patients.
  • Overcome language barriers by using interpreters if possible, and keep communication clear and straightforward.

Addressing Visual and Hearing Impairments

  • Use verbal identification and carefully restore items to their usual locations in the presence of visually impaired patients.
  • For hearing problems, use clear, slow speech, and written communication when needed.

Material on This Presentation

  • The material is evaluated on Test Three, covering the comprehensive aspects of patient assessment in EMS.