Transcript Patient Assessment

“It’s amazing what you can
see when you look”
Yogi Berra
Patient
Assessment
not a basic skill
do not diagnose
the question is ...
Do I have a critical
patient?
Patient Assessment
Scene size-up
 Initial assessment
 Focused history and physical exam
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– Vital signs
– History
Detailed physical exam
 Ongoing assessment
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Scene Size Up
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Body Substance Isolation/Standard Precautions
Safety, Safety, Safety, Safety, ...
Mechanism of injury
or
Nature of illness
# of patients
Need for additional resources
Need for extrication / spinal precautions
Body Substance Isolation
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Assumes all body fluids present a
possible risk for infection
 Protective equipment
– Latex or vinyl gloves should always be
worn
– Eye protection
– Mask
– Gown
– Turnout gear
Scene Safety
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Look for danger
Park in a safe area
Speak with law enforcement first if
present.
The safety of you and your partner
comes first!
Next is safety of patient(s) and
bystanders.
Request additional resources.
Mechanism of Injury

Force body was exposed to
– Chief complaint
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Evaluate:
– Amount of force applied
– Length of time it was applied
– Area involved
Nature of Illness
Search for clues
 This is chief complaint
 Gather information from the
patient/bystanders
 Observe the scene.
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Chief Complaint
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Most serious problem voiced by
the patient
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May not be the most significant
problem present
Number of Patients
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# of patients and condition.
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Additional resources needed?
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Triage to identify severity of each
patient’s condition.
Additional Resources
Medical resources
– Additional units
– Advanced life support
 Nonmedical resources
– Fire suppression
– Rescue
– Law enforcement
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Spinal Immobilization
Consider early during assessment.
 Do not move without immobilization.
 Err on the side of caution.
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Initial Assessment
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Develop a general
impression
Assess mental status
Assess airway
Assess the adequacy of
breathing
Assess circulation
Establish patient rapport
Identify patient priority
Develop a General Impression
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As you approach the scene
– Assessment of the environment
– Patient’s chief complaint
– Presenting signs and symptoms of patient
• No vitals yet, only skin signs/cap refill
Assessing Mental Status
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Checking responsiveness
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Check for orientation
Checking Responsiveness
A - Alert
 V - Verbal
 P - Pain
 U - Unresponsive
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Checking Orientation
Person
 Place
 Time
 Event
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Glasgow Coma Scale
More advanced LOC indicator
 Eye
 Verbal
 Motor
 point
scale 15 - 3
GCS
Eye Opening
spontaneous
to voice
to pain
none
=4
=3
=2
=1
GCS
VERBAL
Oriented
Confused
Inappropriate words
Incomprehensible sounds
None
=5
=4
=3
=2
=1
GCS
MOTOR
obeys command
localizes pain
withdraws (pain)
flexion (pain)
extension (pain)
none
=6
=5
=4
=3
=2
=1
Assessing ABC’s
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We know how to assess the unresponsive
 More evaluation needed in responsive pt.
 Is patient speaking to you?
– A and B
– Full sentences
– 2 or 3 word
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What are skin signs like? Cap refill?
–C
– Indicates perfusion
Establish Patient Rapport
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People Skills
 Do what you can to make the patient comfortable
 Listen to the patient
 Make eye contact
 Base questions on the patient's complaint
– More to follow
 Mentally summarize before starting treatment
 Obtain consent
Decision point
 Regardless
 Is
if trauma or medical
patient critical?
 Do
they need rapid transport?
Identifying Priority Patients
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Poor general
impression
Unresponsive with
no gag or cough
reflexes
Responsive but
unable to follow
commands
Difficulty breathing
Signs of poor
perfusion
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Complicated
childbirth
Uncontrolled
bleeding
Severe pain
Severe chest pain
Inability to move any
part of the body
The Golden Hour
Medical vs. Trauma
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Determination should come
after initial assessment is
finished.
Patients may have traumatic
injuries caused by a medical
reason.
Initially assume all patients
have both medical and
traumatic aspects to their
condition.
Trauma Patients
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With significant MOI
Unresponsive or disoriented
Extremely intoxicated
Patients whose complaint cannot be
identified or understood
• Proceed with rapid trauma assessment
• Rapid transport
• Consider ALS backup
Significant Mechanism of Injury
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Ejection from vehicle
Death in passenger compartment
Fall greater than 15´-20´
Vehicle rollover
High-speed collision
Unresponsiveness or altered mental status
Penetrating trauma to head, chest, or
abdomen
Auto vs auto
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SAFETY
observe/ask questions about mechanism
Speed
position of patient before accident
(driver, backseat, etc..)
KO?
restrained? airbag?
Passenger space
intrusion?
Auto vs pedestrian or
bicycle/motorcycle
SAFTEY
 observe/ask questions about
mechanism
 helmet?
 KO?
 Injuries more likely to be severe
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Rapid Physical Exam
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60-90 seconds
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head-to-toe exam
– Significant trauma
patients
– Unresponsive
medical patients
DCAP-BTLS
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D Deformities
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B Burns
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C Contusions
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T Tenderness
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A Abrasions
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L Lacerations
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P Punctures/
Penetrations
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S Swelling
Rapid Physical Exam
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(1 of 3)
Maintain spinal immobilization
while checking patient’s ABCs.
 Use DCAP BTLS
 Assess the head.
 Assess the neck.
 Apply a cervical spine
immobilization collar.
Rapid Physical Exam
(2 of 3)
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Assess the chest.
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Assess the abdomen.
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Assess the pelvis.
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Assess all four extremities.
Rapid Physical Exam
(3 of 3)
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Roll the patient with spinal
precautions.
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Assess baseline vital signs
and SAMPLE history.
Detailed Physical Exam
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more in-depth
only performed if time allows
performed en route to the hospital
have system - head to toe
practice same way every time
always check area before covering
for our lab, rapid trauma assessment
and detailed physical exam are same
(Head to Toe)
Focused History and Physical
Exam (medical)
Medical history
 Baseline vital signs
 Physical exam
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Focused History and Physical
Exam (Trauma-no significant mechanism)
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Assess the chief complaint.
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Chest pain
Shortness of breath
Abdominal pain
Any pain associated with bones or
joints
– Dizziness
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Obtain baseline vital signs and
SAMPLE history
SAMPLE History
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S Signs and symptoms
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A Allergies
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M Medications
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P Past medical history
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L Last oral intake
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E Events leading to the episode
Alternate
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HAM
– History
– Allergies
– Medications
Vital Signs
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After rapid assessment, obtain baseline
vital signs and a SAMPLE history.
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Vital signs of stable patients should be
reassessed every 15 minutes.
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Vital signs of unstable patients should
be reassessed every 5 minutes.
Focused Physical Exam
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Investigate problems associated
with chief complaint.
 Examine abnormalities.
 Assess vital signs.
– Skins
– Chest Auscultation
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Make transportation decision.
 Document findings.
Assessing the Responsive
Medical Patient
Ask general questions
 May not be obvious
 Use patient’s own words
 Multiple complaints?
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Questions to ask: Chest pain
 OPQRST
 Shortness
of breath also?
 Medication?
OPQRST
O
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Onset
Provoking factors
Quality of pain
Radiation / Region
Severity
Time / Treatment
Questions to ask:
Shortness of breath
How long?
 Sudden or slow onset?
 Chest pain also?
 Chest auscultation
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Questions to ask:
Abdominal pain
OPQRST
 N/V
 Normal bowel movement & urination?
 GI bleed?
 FEMALES
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– pregnant?
– LMP, normal?
Assessing the
Unresponsive Patient (Medical)
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Perform a rapid medical assessment.
Obtain baseline vital signs.
Obtain SAMPLE history from family if
available.
Provide emergency care and transport.
Document findings.
Questions to ask:
Altered level of consciousness
 DERM
 AEIOU
TIPS
 Sudden or Slow?
 Ask bystanders
DERM
D
- depth of consciousness
 E - eyes
 R - respirations (abnormal patterns)
 M - motor function
AEIOU TIPS
A - alcohol, apnea, arrhythmia,
anaphylaxis
 E - epilepsy/environment
 I - insulin
 O - overdose
 U - uremia/underdose
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AEIOU TIPS
T
- trauma
 I - infection
 P - psychogenic
 S - stroke
Questions to ask:
Overdose - Poisonings
 what
 how
long ago
 route
 any other?
Questions to ask: Diabetes
 Taken
your medicine?
 Eaten normally?
 Slow or fast onset?
 its
a balance!
Questions to ask: Seizures
 How
long did it last?
 Fall?
 More
than 1?
 How did it start
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What is status epilepticus?
Questions to ask: Syncope
 out
how long?
 fall?
 chest pain?
 irregular heart beat?
Questions to ask:
Shootings - a.k.a.
GSW
 SAFETY
#
shots heard
 type of gun (caliber)
 distance
 other associated trauma?
Questions to ask: Stabbings - a.k.a.
“cutting”
 SAFETY
 type
of knife? (size)
 associated trauma?
Questions to ask: Assaults
 SAFETY
 hit
with what?
 where?
 # of times?
 KO?
Questions to ask: Falls
 trip
& fall? or dizzy & fall?
 how far?
 how did they land?
 What did they land on?
 KO?
Ongoing Assessment
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Is treatment improving the
patient’s condition?
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Has a problem gotten better?
Worse?
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Any newly identified
problems?
Steps of the Ongoing Assessment
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Repeat the initial assessment.
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Reassess vital signs.
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Repeat focused assessment.
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Check interventions.
Documentation
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Skin color, temperature, and moisture
Initial assessment findings
Baseline and subsequent vital signs
and SAMPLE history
Circulation, sensation and movement in
all extremities
Breath sounds
That’s all folks!!
questions?