Transcript July 2011 CE - Advocatehealth.com

Patient Assessment
Condell Medical Center EMS System
July 2011 CE
Site Code #107200E-1211
Sharon Hopkins, RN, BSN, EMT-P
1
Objectives
 Upon
successful completion of this
module, the EMS provider will be able to:





1. Define mechanism of injury.
2. Define nature of illness.
3. Define general impression.
4. Discuss purpose of a general impression.
5. Discuss In-field Spine Clearance components.
2
Objectives Cont’d
6. Describe assessment of the patient’s circulation
status during the initial assessment.
 7. Describe normal and abnormal findings of
assessment of skin color, temperature, and
condition.
 8. Describe the physical examination of the patient
with a medical complaint.
 9. Describe components of the on-going physical
examination.

3
Objectives Cont’d





10.Describe purpose of trending of the patient’s
physical assessment.
11.Actively participate in a patient
assessment when given a scenario.
12. Demonstrate placing the HARE traction
splint working in a group.
13. Demonstrate placing the KED device in a
group.
14.Successfully complete the post quiz with a
score of 80% or better.
4
Mechanism of Injury
 What



exactly is this?
Officially “the combined strength, direction,
and nature of forces that injured your patient”
Basically – this is what causes an injury; what
happened to your patient
Determined by information received by
dispatch (how call came in) and confirmed by
your observational and interview skills once
on the scene
5
Nature of Illness Complaint
 This
is the medical complaint your patient
has called EMS for


Not always readily apparent
May even differ from the chief complaint
• The true nature of illness may not be what
the patient initially thought was the problem
Example: Called for difficulty breathing
Patient thought it was allergies
Patient eventually diagnosed with
pneumonia
6
General Impression
 An
impression of what you think is wrong
with the patient
 Formed during the initial impression
 Based
on your observations of
Patient’s appearance
Patient’s environment
Patient’s chief complaint
7
General Impression
 Becomes



a working diagnosis based on:
Your experience
History obtained of present and past
illnesses
Data obtained
Vital signs
Breath sounds
EKG monitor; 12 lead EKG
Glucose level
8
Benefit of Forming General
Impression
 Drives
the choice of protocol followed
 Used to guide your treatment options
 May be changed as the call unfolds


May change as you gather more data
May change based on patient response to
treatment initiated
 May
involve the use of more than one
SOP based on the complaint
9
Scenario for Group Discussion:
What is this general impression?
 You
are called to the scene for difficulty
breathing
 Upon arrival you observe the patient to be
sitting upright in obvious distress
 You hear audible noisy breathing
 The patient is pale, diaphoretic, and
tachycardic
 You auscultate bilateral crackles
 What’s your initial general impression?
10
 Are
you thinking acute pulmonary edema?
 As
you begin to assess the patient, more
information comes forth



The patient has had chest pain 7/10 for the
last 5 hours
The chest pain is non-radiating, feels like a
vise grip on their chest
They have taken multiple doses of their NTG
 Now
what is your general impression?
11
 The
general impression now
includes a possible acute MI
complicated with
acute pulmonary edema
12
Scene Size-up
 First
part of any patient assessment
process
 Begins as you arrive at the scene


Remember to consider information conveyed,
including possible prior knowledge of caller
Can start some formulation of ideas before
actually pulling up to the curb
 Scene
safety is a priority
 Includes determination of mechanism of
injury or nature of illness
 Number of patients; need for equipment
13
Spinal Motion Restriction
 C-spine
control should be considered on
all traumatic and some medical calls

Evaluate the patient
Mechanism of injury
Signs and symptoms
Reliability
 Document
equipment used to restrict
spinal motion if this is care provided
 Document findings if the need for spinal
control/motion restriction is not required
14
In-field Spinal Clearance
 Risky










mechanisms of injury
High velocity MVC > 40mph
Unrestrained occupant in MVC
Passenger compartment intrusion >12″
Ejection from vehicle
Rollover MVC
Motorcycle collision >20 mph
Death in same vehicle
Pedestrian struck by vehicle
Falls > 2 time patient height
Diving injury
15
In-field Spinal Clearance
 Signs




and/or symptoms
Pain in neck or spine
Tenderness/deformity of neck or spine upon
palpation
Paralysis or abnormal motor exam
Abnormal response to painful stimuli
 Any
little complaint of numbness or tingling
to distal extremities or a single digit is
included as an abnormal response

Remember dermatomes from May 2011 CE?
16
In-field Spinal Clearance
 Patient



reliability
Signs of intoxication
Abnormal mental status
Communication difficulty
• Includes non-English speaking patients

Abnormal stress reaction
 Being

added to revised SOP’s
Distracting injuries
• Amazing how the mind can focus on one thing and
ignore other problems
17
 When
in doubt, immobilize
 When
appropriate and supported with
assessment, immobilization not necessary
Either way...
 DOCUMENT
DOCUMENT
DOCUMENT
18
Patient Circulation
 What
is the perfusion status of the patient?
 Is their circulation sufficient to support
perfusion to the brain (mental status) and
generate a blood pressure (can you feel a
radial pulse)?
 Altered mental status first sign of altered
perfusion
 Hypotension a late sign of altered
perfusion
19
Circulation
 Does



the patient have a pulse?
Rate?
• Only 3 options: normal, too slow, or too fast
Quality?
Palpated distally?
• Takes higher blood pressure to generate a
distal pulse (ie: radial)
 Does
the patient have signs of shock?
 Does the patient have life threatening
bleeding?
20
First Patient Contact
 Can


learn a lot from “hello”
Walk up to patient and say hello and introduce
yourself
As you do this, take their hand (feeling their
pulse)
• Do their eyes focus?
• Are their eyes glazed over?
• Do you have a pulse?
• What’s the general information of the
pulse–
 Rate? Regularity? Quality?
21
Circulation Status
 The

eyes are very sensitive to blood flow
Eyes will reflect when circulation is decreased
 Need
adequate perfusion to the brain to
maintain normal mentation
 Need a blood pressure of at least 60
systolic to feel the distal radial pulse
22
Relatively Stable Patient
 If
the patient can talk (make sense)…
 If the patient has a radial pulse…


They are considered relatively stable
even though they may have signs and
symptoms
Hence the phrase “relatively” stable
23
Assessing the Skin
 Reflects



patient circulation
Color
Temperature
Condition
 Skin
not a priority organ and a decrease in
circulation noted with reflexive
vasoconstriction and therefore paleness
during times of poorer circulation
24
Skin Color
 Areas
to assess in the adult
Nail beds
Inside of cheek
Inside of lower lids
 Capillaries are close to the surface of
the skin in these areas so quickly reflect
changes in circulation
• Accurate even in dark complexions
 Normal color is pink
25
Skin Color
 Areas
to assess in pediatrics
Palms of the hands
Soles of the feet
 In darker complexions evaluate lips and
nail beds
 Normal color is pink
26
Skin Color
Skin Color
Significance
Pink
Normal (inner eye, lips,
nail beds)
Vasoconstriction, blood
loss, shock, distress
Hypoxia
Pale
Cyanotic
Flushed/red
Jaundiced
Exposure to heat,
excitement
Abnormality of liver
Mottled/blotchy
Poor circulation
27
Assessing Temperature
 Body
constantly generating and losing
heat
 Body functions in a narrow temperature
range
 EMS most concerned with cases of the
extreme


Hypothermia
Hyperthermia
28
Measuring Temperature

Palpating the skin measures surface
temperature


Core temperature reflects level of heat inside
trunk around organs




Usually evaluated in subjective terms
• Normal/Hot/Warm/Cool/Cold
Normal oral temperature around 98.60F
Normal rectal temperature 1 degree higher
Normal axillary temperature 1 degree lower
Tympanic thermometers very common

Beware: wide margin of error
29
Assessing Skin Condition
 Subjective




evaluation
Normal
Dry
Moist
Diaphoretic
 Can
reflect recent activity level of patient
 Can reflect under/over dressing
30
Skin Condition
Skin Condition
Possible Causes
Cool, clammy
Signs of shock, anxiety
Cold, moist
Body is losing heat
Cold, dry
Exposure to cold
Hot, dry
High fever; heat exposure
Hot, moist
High fever; heat exposure
Goose pimples
with shivering
Chills, communicable disease,
fear, exposure to cold/pain
31
What’s Important???
 Watching
the trends!!!
What is staying the same?
 What is changing?
• What does it mean when there is
a change?

32
Physical Examination
 Used
to evaluate/investigate areas that
are/may be involved in the patient’s
complaint
 Practice and experience dictate your
comfort and capability when performing a
physical exam

Learn to pick up on intuitive information as
well as objective information
33
Steps of Physical Assessment
Inspection – visual process always done first
 Palpation




Auscultation




Palpate painful areas last
Use light touch with finger tips and warmed hands
Most commonly of breath sounds
Warm stethoscope first
Listen directly over skin; not over clothing
Percussion


Rarely done in the field; needs a quiet environment
Requires practice to be a benefit
34
History of Present Illness/Injury
– onset (what were you doing)?
 P – what makes it better/worse?
O

Palliation/provocation
– describe it in your own words
 R – does it radiate/spread anywhere?
 S – what is the discomfort on a scale of
0-10?
 T – what time did this start?
Q
35
On-going Physical Assessment
 The
most important aspect is watching for
changes/trends
 One set of vital signs, one time for
palpation, one time for anything related to
the patient and you have nothing for
comparison


On-going means to repeat what has already
been done
If abnormalities are found, be same person
doing the reassessing
36
Patient Assessment Discussion








Divide the participants up into smaller groups
Assign each group a scenario
The groups should decide on an approach for
assessing their patient
Discuss general impression
Discuss treatment
Discuss what to document
Answer the “Critical Thinking” questions
Smaller group to report their discussion to the
larger group
You may use your SOP’s as reference tool
37
Case Scenario #1

Dispatched for a 67 year-old male with
complaints of difficulty breathing


Sudden onset after smoking a cigarette
Awake, oriented, obeys commands

Tripod position; pursed lip breathing

Radial pulse rapid and regular
 Skin cool, dusky, diaphoretic
 Hx: Emphysema, hypertension, “water in the
lungs”
 On home O2 last 5 years
38
Case Scenario #1 cont’d

Allergies: environmental
 Meds: Lasix, digoxin, Aldactone, theophylline,
Alupent inhaler
 VS: 158/88; P – 120; R – 20; SpO2 85%
 Breath sounds:

Bilateral wheezing

Talking in 1-2 word sentences
 Using accessory muscles
 JVD and pedal edema present and chronic
39
Case Scenario #1

What is the rhythm strip?

Sinus tachycardia with PVC’s
 ST elevation noted so needs 12 lead
• Check if there are 2 or more contiguous leads with
ST elevation present (there is none)
 Note: PVC’s fairly common in the COPD population
40
Case Scenario #1
Small Group Discussion
 What
is your impression?
 What
is your treatment?
 How
do you monitor effectiveness of
treatment?
41
Case Scenario #1

Impression



Treatment




Exacerbation of COPD
Possible left heart failure
Increase oxygen delivery
Administer Albuterol nebulizer treatment for wheezing
Obtain 12 lead EKG
• Note ST segment elevation on Lead II – is there
more? (only present in Lead II)
Reassessment


Respiratory status
EKG monitor (unchanged)
42
Case Scenario #1
Critical Thinking Questions
1. What is the significance of the tripod position,
speaking in 1-2 word sentences, and use of
accessory muscles?
2. What is the relationship with emphysema and
“water in the lungs”?
3. What action can be taken regarding the home
oxygen tank?
4. Based on the patient’s medications, what
electrolyte may be a factor?
5. How do you assess the degree of respiratory
distress?
43
Case Scenario #2
 Dispatched
for a 76 year-old male due to a
fall at home
 Upon arrival your patient is sitting upright
on the couch, watching you approach
 Awake, verbally responsive, oriented x3
 Radial pulse irregular
 Skin normal, dry
 Hx: After a nap patient tried to get up but
fell; Pt states “I can’t get up right”
44
Case Scenario #2
 Hx:
Relatively healthy; total hip
replacement 2 years ago, hypertension
 Allergies: none
 Meds: Hydrodiuril, digoxin, Coumadin
 VS: 146/82; P – 78; R – 16; SpO2 98%
 Does not move left leg on command, left
arm moves weakly and no grasp on left
 Blood glucose 89
 Abrasion to left elbow and knee from fall
 Denies hitting his head
45
Case Scenario #2

What is the rhythm?

Atrial fibrillation
46
Case Scenario #2
Small Group Discussion
 What
is your impression?
 What
is your treatment?
 How
do you monitor effectiveness of
treatment?
47
Case Scenario #2

Impression




Treatment




Acute stroke
Most likely ischemic (a clot) due to risk factor of atrial
fibrillation
Need to also assess for injuries from the fall
IV-O2-monitor
Assess with Cincinnati Stroke Scale
Expedited transport; Activating “Stroke Alert” at
receiving hospital
Reassessment

Monitor B/P, watch for mental status changes
48
Case Scenario #2
Critical Thinking Questions
1.
2.
3.
4.
5.
What is the significance of atrial
fibrillation related to strokes?
What side of the brain has the stroke
affected?
Why isn’t the patient’s speech affected?
How does hypertension predispose to
stroke?
What is the most important questions to
ask?
49
Case Scenario #3
 Dispatched
for a 3 year-old for possible
allergic reaction
 Upon arrival you hear fussy crying
 Patient on mother’s lap squirming, trying to
scratch self
 Watching your approach
 Patient is covered with hives
 Itching started 1 hour ago and 30 minutes
ago broke out in hives
50
Case Scenario #3







Hx: Current ear infection; history of being treated
in the past for multiple ear infections
Allergies: none
Meds: Ampicillin, Flintstone vitamins
VS: P – 188 regular; R – 40 non-labored
Lungs clear
Weight: 30 pounds
Mother had called pediatrician who directed her
to call 911
51
Case Scenario #3
Small Group Discussion
 What
is your impression?
 What
is your treatment?
 How
do you monitor effectiveness of
treatment?
52
Case Scenario #3
 Impression

Simple allergic reaction (no airway
involvement) most likely due to repeat
exposure to the antibiotic
 Treatment

Benadryl 1 mg/kg IVP slowly over 2 minutes
or IM (max 25 mg)
 Reassessment


Monitor breath sounds, vital signs
Monitor subjective complaints
53
Case Scenario #3
Critical Thinking Questions
1.
2.
3.
4.
5.
What causes this patient’s condition?
Is the pulse rate (188) okay for this
patient in this condition?
Why is the patient having a reaction now
if they have taken this antibiotic multiple
times before?
What would wheezing indicate?
What are the differences in treatment for
various levels of allergic reactions?
54
Case Scenario #4
 You
respond to a local business for a
56 year-old female having a “heart attack”
 Patient is awake, oriented, pale
 Radial pulse present, regular, slightly
elevated
 Hx: Was at desk working and developed
pain between shoulder blades, chest
discomfort and slight shortness of breath
for past one hour. Discomfort rated 7/10
55
Case Scenario #4
 Hx:
Hypertension, diet controlled diabetes,
and GERD
 Allergies: morphine
 Meds: Toprol, Hydrochlorothiazide, and
prilosec
 VS: 118/78; P – 92; R-18; SpO2 99%
 Lung sounds are clear
 Blood glucose: 89
56
Case Scenario #4
 What
is the rhythm?
 Sinus
rhythm
57
Case Scenario #4
 Is
there any ST elevation present?
 ST
elevation V2 – V5
58
Case Scenario #4
 What
complication do you monitor for with
ST elevation in this location?



V1 through V6 view the anterior, septal, and
lateral walls of the left ventricle
Supplied by the left anterior descending artery
(LAD)
Occlusion of the LAD (the “widow maker”)
leads to left ventricular damage and therefore
cardiogenic shock and death
• Also watch for heart blocks
59
Case Scenario #4
Small Group Discussion
 What
is your impression?
 What
is your treatment?
 How
do you monitor effectiveness of
treatment?
60
Case Scenario #4
 Impression


Acute MI (ST elevation V2-V5)
Vital signs currently stable
 Treatment


IV-O2-monitor
Aspirin, NTG, morphine if necessary
 Reassessment


Monitor pain level, EKG monitor, vital signs
Watch for drop in B/P after nitroglycerin
61
Case Scenario #4
Critical Thinking Questions
1.
2.
3.
4.
5.
What is the typical presentation of complaints for
men, women, elderly, and diabetics?
Why was there no ST elevation on the Lead II?
If the patient had a transplanted heart, are there
any traditional cardiac drugs not effective?
What does aspirin do for the patient
experiencing an acute MI?
What information needs to be conveyed to the
hospital for them to activate a cardiac alert?
62
Case Scenario #5
 You
have been dispatched for a 68 yearold female with complaints of chest pain
 Upon arrival the patient is sitting on the
floor next to her washing machine
 Awake, oriented, pale and slightly
diaphoretic, very dizzy
 Radial pulse rapid, regular
 Hx: Doing laundry and suddenly couldn’t
catch her breath and felt her heart racing
63
Case Scenario #5
 Hx: Arthritis,
osteoporosis
 Allergies: Iodine, hay fever, pollen, cats
 Meds: Multivitamins, Boniva
 VS: 102/64; P- 196; R – 22; SpO2 95%
 Lungs: clear, breaths shallow
 This feeling has happened once before
years ago and thinks it went away on its
own
64
Case Scenario #5
 What
 SVT
is the rhythm strip?
(narrow QRS complex)
65
Case Scenario #5
Small Group Discussion
 What
is your impression?
 What
is your treatment?
 How
do you monitor effectiveness of
treatment?
66
Case Scenario #5

Impression



Treatment



SVT
Patient relatively stable
• Evaluated mental status and B/P
IV established in antecubital area, preferably right
Administer med as rapidly as possible followed
immediately with saline flush
• Pre-warn the patient that most patients say they
feel “funny” for a few minutes
Reassessment

Vital signs, cardiac monitor
67
Case Scenario #5
 What
is the significance of the rhythms
related to administering Adenosine?
#1 During med administration
#2 Following medication administration
68
Case Scenario #5
Critical Thinking Questions
1.
2.
3.
4.
5.
What is the criteria for SVT?
Describe how to perform the valsalva
maneuver and what response is
expected.
Describe how to administer Adenosine.
What side effects are common with
Adenosine?
When can the 2nd dose of Adenosine be
administered?
69
Return Demonstration

A large volume of calls are of a BLS nature
 Low volume use of equipment means more
practice time required to retain competency of
skills

Work in small groups using one person as the
“patient”
 Apply the HARE traction device
 Apply the KED
70
HARE Traction/Sager Splint
 Used
to splint a suspected fractured femur
 Reduces muscle spasm which reduces
pain
 Prevents bone ends from moving and
damaging close lying tissue
 Takes a minimum of 2 people to apply

Easier if 3 people are available
• 1 to hold traction
• 1-2 to measure/place/secure device
71
HARE Traction
72
Sager Splint
73
HARE Traction/Sager Splint
Pearls
 Never
apply a strap over the knee
 Always assess distal PMS/CMS/SMV
before and after splinting
 Most often need to extend the backboard
off the cart to have a solid surface for the
foot stand to rest on
74
KED Device
 Used
to immobilize a seated patient with
possible spinal injuries onto the standard
back board
 Takes 3 people to place the device on




Is time consuming
Used just to move a seated patient to a
standard back board
Not useful when rapid extrication is required
Manual c-spine control must be constantly
maintained
75
KED Device
76
KED Device Pearls
 Maintain
manual control of the c-spine at
all times until secured to a long back board
 When applying the chin strap, allow for the
possibility of vomiting
 Apply thigh straps last
 Do not lift the patient by the straps

The patient is rotated on their buttocks and
then tilted to the supine position onto the long
board
77
Bibliography




Bledsoe, B., Porter, R., Cherry, R. Paramedic Care
Principles & Practice. Brady. 2009.
Dalton, A., Walker, R. A. Mosby’s Paramedic Refresher
and Review – A Case Studies Approach. 2nd Edition.
Mosby. 1999.
Limmer, D., O’Keefe, M. Emergency Care, 12th Edition.
Brady. 2012
Phalen, T., Aehlert, B. The 12 Lead ECG in Acute
Coronary Syndromes. 2nd Edition. Elsevier Mosby. 2006.
78