Transcript Paramedic Care: Principles & Practice Volume 2

Paramedic Care:
Principles & Practice
Volume 2
Patient Assessment
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Chapter 2
Physical Exam Techniques
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Topics
Physical Examination Approach and
Overview
Overview of a Comprehensive Examination
Anatomical Regions
Physical Examination of Infants and
Children
Recording Examination Findings
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Introduction
The physical examination begins when you
first set eyes on your patient.
The purpose of the physical exam is to
investigate areas that you suspect are
involved in your patient’s primary problem.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Physical Examination
Approach and Overview
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Physical Examination
Approach and Overview
Topics
– Examination techniques
– Equipment
– The general approach to the patient
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Examination Techniques
Inspection
Palpation
Percussion
Auscultation
These 4 techniques are the foundation
of the physical exam.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Inspection
Informed
observation that
allows the
paramedic to judge
clinical status
immediately
Consciously
evaluate each body
area.
– Focus on areas of
expected signs and
symptoms.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Palpation
Using your sense
of touch to gather
information
Palpation may be
either deep or light.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Percussion
The production of
sound waves by
striking one object
against another
Resonance
– The denser the
medium, the quieter the
tone
– Compare with what you
know to be normal
May be impractical in
the field setting
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Auscultation
Listening for
sounds produced
by the body
You should perform
auscultation in a
quiet environment.
Listen for the
presence of sound.
– Intensity, pitch,
duration, and
quality
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Equipment
Stethoscope
Sphygmomanometer (BP cuff)
Ophthalmoscope
Otoscope
Scale
Other
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Use a stethoscope to
auscultate most sounds.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Sphygmomanometer
Measures blood
pressure
Auscultate
movement of blood
through an artery
Calibrated in
millimeters of
mercury (mmHg)
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Visualize the interior of the eye
with an ophthalmoscope.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
An otoscope is used to
inspect the ear.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
A Platform Scale
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Additional Equipment
Sterile tongue
blades
Penlight
Visual acuity chart
Reflex hammer
Thermometer
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
General Approach
How the patient is approached sets the
stage for efficient and effective assessment.
Systematically assess your patient’s
complaints.
Maintain a calm, professional, and confident
demeanor.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Overview of a Comprehensive
Examination
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Overview of a
Comprehensive Examination
The General Survey
– Appearance
– Measurement of Vital Signs
– Additional Assessments
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Appearance
Level of consciousness
Signs of distress
Apparent state of health
Vital statistics
Sexual development
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Appearance
Skin color and obvious lesions
Posture, gait, and motor activity
Dress, grooming, and personal hygiene
Odors of breath or body
Facial expression
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Vital Signs
Pulse, respiration, blood pressure, and body
temperature
Primary indicators of your patient’s health
Measure early and repeat
– Observe trends
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Pulse
A valuable indicator
of circulatory
function
Measure rate,
rhythm, and quality.
Normal pulse rate
for an adult is 60 to
100 beats per
minute.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Know each pulse position
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Respirations
Observe your
patient’s respiratory
rate, effort, and
quality.
Observe for subtle
signs of distress.
Recognize the
need for rapid
intervention.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Breathing Patterns Associated
with Specific Diseases
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Blood Pressure
Measures the force
of blood against the
arteries’ walls as
the heart contracts
and relaxes
– Systolic
– Diastolic
– Korotkoff’s sounds
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Blood Pressure
Average blood pressure in the adult patient
is 120/80.
– Hypertension
– Hypotension
Pulse pressure is the difference between
systolic and diastolic.
Orthostatic vital signs
– May indicate hypovolemia
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Body Temperature
Normal body temperature is 98.6°F(37°C).
– Hyperthermia
– Hypothermia
May be obtained orally, axillary, or rectally.
– Axillary is the least accurate
Thermometers
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Use a battery-operated oral
thermometer to take the
patient’s temperature.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
A Tympanic Thermometer
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Additional Assessment
Techniques
Pulse Oximetry
– Measures the
oxygen saturation
of your patient’s
blood.
– Normal oxygen
saturation at sea
level should be
between 96 and
100 percent.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Additional Assessment
Techniques
Several factors affect the accuracy of a
pulse oximetry reading:
– Reduced blood flow to tissue
Hypovolemia, hypothermia
– Carbon monoxide (CO) poisoning
Causes saturation of hemoglobin with CO instead of
oxygen
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Additional Assessment
Techniques
Capnography
– Real-time measurement of exhaled carbon
dioxide concentrations.
– End-tidal CO2 detector
The low CO2 content of inspired air makes the device
purple, whereas the higher CO2 content of expired air
makes it yellow.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Capnography
Colormetric
Electronic Monitor
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Additional Assessment
Techniques
Cardiac Monitoring
– Monitors the electrical
activity of the heart in
three “leads” or
positions
Adequately
identifies lifethreatening cardiac
rhythms
– 12-lead monitors are
essential in gathering
data to confirm a
myocardial infarction.
ECG reading does not necessarily correlate
with the mechanical function of the heart!
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Additional Assessment
Techniques
Blood Glucose
Determination
– Procedure takes
less than one
minute to perform
– Read the
manufacturer’s
instructions
carefully
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomical Regions
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomical Regions
Following the general survey, specific
systems may be examined in detail.
The specific situation, your experience, and
common sense will determine whether you
conduct a thorough examination.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomical Regions
Click here to view an interactive exercise on anatomical landmarks.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Skin
The largest organ in the human body
Protects against pathogens, minor trauma,
excretion, and maintenance of body
temperature
Consists of 2 layers that lie atop the
subcutaneous fat
– Dermis
– Epidermis
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Skin
Characteristics to
assess:
–
–
–
–
–
–
Color
Moisture
Temperature
Texture
Mobility and turgor
Lesions
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hair
Hair is a tactile
sensory organ.
Note color, quality,
distribution,
quantity, and
texture.
May indicate a
pituitary or
hormonal problem
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Nail
Inspect and palpate
the fingernails and
toenails.
Observe the color
beneath the
transparent nail.
Look for lesions,
ridging, grooves,
depressions, and
pitting.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Head
The scalp consists of 5 layers of tissue:
–
–
–
–
–
Skin
Connective tissue
Aponeurosis
Loose tissue
Periosteum
Extremely vascular
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Skull
Consists of the
cranium and the
face
Bones of the skull
fuse at their
sutures.
Bones of the face
have sinuses.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Skull
The Cranium
– Palpate from front
to back.
– Examine the skull
when you inspect
and palpate the
scalp and hair.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Skull
Facial Bones
– Inspect the face.
– Observe the bony
orbits of the eye.
– Palpate the facial
bones for stability.
– Evaluate the TMJ.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Eyes
The eye consists of
internal and
external structures.
The internal eye
consists of the
sclera, cornea, iris,
lens, and retina.
– The opening in the
center of the iris is
the pupil.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Eyes
The external eye
consists of the
eyelid, conjunctiva,
lacrimal gland,
ocular muscles,
and the bony skull
orbit.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Eyes
Examining the Eye
–
–
–
–
–
Test for visual acuity.
Test the visual fields.
Examine the external eyes.
Inspect each cornea for opacities.
Inspect the size, shape, and symmetry of the
pupils.
Assess reactivity
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Eyes
Ophthalmoscopic
Exam
– Requires a
significant amount
of practice to
master this physical
exam skill
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Eyes
Ophthalmoscopic
Exam
– Red reflex
– Optic disk should
appear as a
yellowish orange to
pink round
structure.
© James P. Gillman/Phototake
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Ears
Three Components:
– The outer ear
– The middle ear
– The inner ear
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Ears
Examine the
External Ear.
– Inspect:
Size
Shape
Position
Lesions
– Palpate:
Mastoid process
Tragus
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Ears
Visualize the
interior ear with an
otoscope.
– Auditory canal
– Tympanic
membrane
Color
Integrity
Landmarks
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Examining the Ear
Click here to view a video on ear examination.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
View Through the Otoscope
© ISM/Phototake
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ