Transcript SECTION 2 - Sam Scheller

Section 3: Patient
Assessment
Chapter 7
Patient
Assessment
Chapter 7: Patient Assessment
Objectives (1 of 15)
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Scene Size-up
Recognize actual and potential hazards.
Describe common hazards found at the scene of a
trauma and a medical patient.
Determine if the scene is safe to enter.
Discuss common mechanisms of injury/nature of
illness.
Discuss the reason for identifying the total number of
patients at the scene.
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Chapter 7: Patient Assessment
Objectives (2 of 15)
Scene Size-up
• Explain the reason for identifying the need for
additional help or assistance.
• Explain how you can determine that the patient
is obviously responsive or possibly has altered
responsiveness.
• Explain the rationale for rescuers to evaluate
scene safety before approaching the scene.
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Chapter 7: Patient Assessment
Objectives (3 of 15)
Initial Assessment
• Summarize the reasons for forming a general
impression of the patient.
• Discuss methods of assessing and managing
the airway in the adult, child, and infant
patient.
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Chapter 7: Patient Assessment
Objectives (4 of 15)
Initial Assessment
• State reasons for management of the cervical spine
once the patient has been determined to be a trauma
patient.
• Describe the methods used for determining whether
a patient is breathing and whether breathing is
adequate.
• Describe the methods used to assess circulation.
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Chapter 7: Patient Assessment
Objectives (5 of 15)
Initial Assessment
• Differentiate between assessing circulation in
an adult, child, and infant patient.
• State what care should be provided to the
adult, child, and infant patient with an
abnormal or absent pulse.
• Discuss the need for assessing the patient for
external bleeding.
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Chapter 7: Patient Assessment
Objectives (6 of 15)
Initial Assessment
• Explain the reasons for prioritizing a
patient for care and transport.
• Explain the importance of forming a
general impression of the patient.
• Explain the value of performing an initial
assessment.
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Chapter 7: Patient Assessment
Objectives (7 of 15)
Initial Assessment
• Demonstrate the techniques for assessing
responsiveness.
• Demonstrate the techniques for assessing
and stabilizing the ABCs.
• Demonstrate the techniques for assessing
the patient’s skin color, temperature,
moisture, and capillary refill.
• Demonstrate the ability to prioritize patients.
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Chapter 7: Patient Assessment
Objectives (8 of 15)
Rapid History and Physical Exam: Unresponsive Patient
• Discuss the method of assessing altered
responsiveness.
• Describe the unique needs for assessing an
individual who is unresponsive.
• Describe the indications for doing a rapid
body survey.
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Chapter 7: Patient Assessment
Objectives (9 of 15)
Rapid History and Physical Exam: Unresponsive Patient
• Discuss the various rapid transport protocols for your
location or organization.
• Explain the indications and value of performing a
rapid body survey on site.
• Demonstrate the performance of a rapid body survey.
• Demonstrate the patient care skills that should be
used to assist an unresponsive patient.
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Chapter 7: Patient Assessment
Objectives (10 of 15)
Focused History and Physical Exam:
Responsive Trauma Patient
• Discuss the significance of the mechanism of injury.
• Differentiate when the assessment may be altered
in order to provide patient care.
• Discuss the reason for performing a focused trauma
history and physical exam.
• Demonstrate the trauma assessment that should be
used to assess a responsive patient based on
mechanism of injury.
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Chapter 7: Patient Assessment
Objectives (11 of 15)
Focused History and Physical Exam:
Responsive Medical Patient
• Describe the unique needs for assessing an
individual with a specific chief complaint with no
known prior history.
• Demonstrate the patient care skills that should be
used to assist a responsive patient with a medical
illness.
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Chapter 7: Patient Assessment
Objectives (12 of 15)
Detailed Physical Exam
• Discuss the components of the detailed
physical exam.
• State the areas of the body that are
evaluated during the detailed physical
exam.
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Chapter 7: Patient Assessment
Objectives (13 of 15)
Detailed Physical Exam
• Explain what additional care should be
provided while performing the detailed
physical exam.
• Demonstrate the skills involved in
performing the detailed physical exam.
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Chapter 7: Patient Assessment
Objectives (14 of 15)
Ongoing Assessment
• Discuss the reason for repeating the
initial assessment as part of the ongoing
assessment.
• Describe the components of the ongoing
assessment.
• Describe monitoring of the assessment
components.
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Chapter 7: Patient Assessment
Objectives (15 of 15)
Ongoing Assessment
• Explain the value of performing an
ongoing assessment.
• Explain the value of trending assessment
components to other health professionals
who assume care of the patient.
• Demonstrate the skills involved in
performing the ongoing assessment.
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Chapter 7: Patient Assessment
Patient Assessment Process
• Scene size-up
• Initial assessment
• Provide spinal
immobilization
• Identify and treat life
threats
• Focused history and
physical exam
• Arrange for
transport if needed
• Detailed physical
exam
• Reassess vital
signs
• Ongoing
assessment
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Chapter 7: Patient Assessment
The Patient Assessment Process
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Chapter 7: Patient Assessment
The Golden Hour
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Chapter 7: Patient Assessment
Components of the Scene
Size-Up
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Protect the safety of all
How many patients?
Is triage needed?
Is extrication needed?
Are more resources needed?
What is the patient’s status?
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Chapter 7: Patient Assessment
Body Substance Isolation
• Assumes all body fluids present a
possible risk for infection.
• Protective equipment
– Latex or vinyl gloves should
always be worn
– Eye protection
– Mask
– Gown
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Chapter 7: Patient Assessment
Scene Safety
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Adverse weather
Avalanche
Rock fall
Steep terrain
Swift water
Traffic (people and
machines)
• Fire or smoke
• Hazardous
materials
• Structural collapses
• Live wires or
lightning
• Dangerous animals
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Chapter 7: Patient Assessment
Mechanism of Injury
• Helps determine the possible extent
of injuries on trauma patients
• Evaluate
– Amount of force applied to body
– Length of time force was applied
– Area of the body involved
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Chapter 7: Patient Assessment
Falls
• Amount of force related
to height of fall
• Note surface that
patient landed on
• Attempt to determine
how patient landed
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Chapter 7: Patient Assessment
Nature of Illness
• Search for clues to determine
the nature of illness.
• Often described by the patient’s
chief complaint
• Gather information from the
patient and people on scene.
• Observe the scene.
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Chapter 7: Patient Assessment
Number of Patients
• Determine the number of patients
and their condition.
• Assess what additional resources
will be needed.
• Triage to identify severity of each
patient’s condition.
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Chapter 7: Patient Assessment
Patient Assessment Process
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Chapter 7: Patient Assessment
Components of the Initial
Assessment
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Develop a general impression.
Assess responsiveness.
Assess airway.
Assess the adequacy of
breathing.
• Assess circulation.
• Identify patient priority.
• Initiate transport decision.
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Chapter 7: Patient Assessment
Develop a General Impression
• Occurs as you approach the scene and
the patient
– Assessment of the environment
– Patient’s chief complaint
– Presenting signs and symptoms of
patient
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Chapter 7: Patient Assessment
Assessing Responsiveness
• Checking responsiveness
– Assess how well the patient responds to
external stimuli.
• Check for orientation
– Check the patient’s memory to person,
place, time, and event. If he or she
recalls all four, then he or she is fully alert
and oriented times four.
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Chapter 7: Patient Assessment
Level of Consciousness
• A
Alert
• V
Responsive to Verbal stimulus
• P
Responsive to Pain
• U
Unresponsive
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Chapter 7: Patient Assessment
Assess and Stabilize the
Airway
• Look for signs of airway compromise:
– Two- to three-word dyspnea
– Use of accessory muscles
– Nasal flaring and use of accessory
muscles in children
– Labored breathing
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Chapter 7: Patient Assessment
Signs of Airway Obstruction in
the Unconscious Patient
• Obvious trauma, blood, or other
obstruction
• Noisy breathing such as bubbling,
gurgling, crowing, or other abnormal
sounds
• Extremely shallow or absent breathing
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Chapter 7: Patient Assessment
Assess and Stabilize
Breathing
• Are the patient’s respirations shallow
or deep?
• Does the patient appear to be
choking?
• Is the patient cyanotic (blue)?
• Is the patient moving air into and out of
the lungs as the chest rises and falls?
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Chapter 7: Patient Assessment
Managing Breathing
• If patient is having difficulty breathing,
reevaluate airway.
• Consider assisting ventilations with a
BVM or applying a nonrebreathing
mask if patient’s respirations are
greater than 24/min or less than 8/min.
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Chapter 7: Patient Assessment
Normal Respiratory Rates
• Adults
12 to 20 breaths/min
• Children
18 to 34 breaths/min
• Infants
30 to 60 breaths/min
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Chapter 7: Patient Assessment
Unresponsive Patients
• Use the look, listen, and feel
technique.
• Consider spinal cord injury.
• Provide high-flow oxygen.
• Assist ventilations if needed.
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Chapter 7: Patient Assessment
Assessing Circulation (1 of 2)
• Assess the pulse.
– Rate, rhythm, and strength
• Assess and control external bleeding.
– Direct pressure
• Evaluate skin color.
– Cyanotic, flushed, pale, or
jaundiced
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Chapter 7: Patient Assessment
Assessing Circulation (2 of 2)
• Evaluate skin temperature.
– Skin is an organ.
• Evaluate skin condition.
– Dry or moist
• Evaluate capillary refill.
– Should be less than 2 seconds
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Chapter 7: Patient Assessment
Restoring Circulation
• Control bleeding and improve
oxygen delivery.
• If unresponsive and pulseless,
begin CPR.
• Apply and operate the AED as
quickly as possible.
• Do not use AED on patients with a
catastrophic traumatic injury.
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Chapter 7: Patient Assessment
Normal Pulse Rates
• Adults
60 to 100 beats/min
• Children
70 to 140 beats/min
• Toddlers
90 to 150 beats/min
• Infants
100 to 160 beats/min
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Chapter 7: Patient Assessment
Identifying Priority Patients
• Poor general
impression
• Complicated
childbirth
• Unresponsive with
no gag or cough
reflexes
• Uncontrolled
bleeding
• Difficulty breathing
• Severe chest pain
• Signs of poor
perfusion
• Inability to move any
part of the body
• Severe pain
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Chapter 7: Patient Assessment
Initiate Transport Decisions
• Contact outside agencies early.
• Preplanning is the key to success.
• Use resources efficiently.
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Chapter 7: Patient Assessment
Patient Assessment Process
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Chapter 7: Patient Assessment
Assessment of Unresponsive
Patients
• Rapid body survey
• Baseline vital signs
• SAMPLE history (from friends,
family of bystanders)
• Rapid transport
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Chapter 7: Patient Assessment
Rapid Body Survey (1 of 4)
• Maintain body
temperature
• Protect the cervical
spine
• Rapid head-to-toe
• Treat injuries
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Chapter 7: Patient Assessment
Rapid Body Survey (2 of 4)
• Maintain spinal immobilization
while checking patient’s ABCs.
• Assess the head.
• Assess the neck.
• Apply a cervical spine
immobilization collar.
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Chapter 7: Patient Assessment
Rapid Body Survey (3 of 4)
• Assess the chest.
• Assess the abdomen.
• Assess the pelvis.
• Assess all four extremities.
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Chapter 7: Patient Assessment
Rapid Body Survey (4 of 4)
• Roll the patient with spinal
precautions.
• Assess baseline vital signs
and SAMPLE history.
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Chapter 7: Patient Assessment
DCAP-BTLS
• D Deformities
• B Burns
• C Contusions
• T Tenderness
• A Abrasions
• L Lacerations
• P Punctures/
Penetrations
• S Swelling
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Chapter 7: Patient Assessment
Vital Signs
• After rapid assessment, obtain baseline
vital signs and a SAMPLE history.
• Vital signs of stable patients should be
reassessed every 15 minutes.
• Vital signs of unstable patients should be
reassessed every 5 minutes.
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Chapter 7: Patient Assessment
Baseline Vital Signs
• Respirations
• Pulse
• Blood pressure (where and
when appropriate)
• Level of responsiveness
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Chapter 7: Patient Assessment
SAMPLE History
• S Signs and symptoms
• A Allergies
• M Medications
• P Past medical history
• L Last oral intake
• E Events leading to the episode
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Chapter 7: Patient Assessment
Patient Assessment Process
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Chapter 7: Patient Assessment
Assessment of Responsive
Trauma Patient
Significant MOI
• Rapid Body Survey
• Baseline Vital Signs
• SAMPLE History
(from friends, family,
and bystanders)
• Rapid Transport
Nonsignificant MOI
• Focused Physical
Exam
• Baseline Vital Signs
• SAMPLE History
• Reevaluate Transport
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Chapter 7: Patient Assessment
The Communication Process
• Do what you can to make
the patient comfortable.
• Listen to the patient.
• Make eye contact.
• Base questions on the
patient's complaint.
• Mentally summarize before
starting treatment.
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Chapter 7: Patient Assessment
Significant MOI
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Reconsider MOI.
Treat immediate or potential life threats.
Maintain spinal immobilization.
Perform rapid body survey and
treatment.
• Obtain baseline vital signs and SAMPLE
history.
• Arrange for rapid transport.
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Chapter 7: Patient Assessment
Nonsignificant MOI
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Identify the patient’s chief complaint.
Consider spinal immobilization.
Assess the specific injury site(s).
Obtain baseline vital signs and
SAMPLE history.
• Provide care and stabilization.
• Reevaluate transport.
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Chapter 7: Patient Assessment
Focused Assessment (1 of 4)
General
• Weakness
• Lightheaded
• Fatigue
• Bleeding
Head Injury
• Headache
• Dizziness
• Loss of
responsiveness
• Double vision
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Chapter 7: Patient Assessment
Focused Assessment (2 of 4)
Neck or Back Injury
• Numbness
• Tingling
• Weakness
• Inability to move
• Difficulty breathing
Chest Injury
• Difficulty breathing
• Cough
• Bloody sputum
• Variable pain
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Chapter 7: Patient Assessment
Focused Assessment (3 of 4)
Abdominal Injury
Pelvic Injury
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• Trouble urinating
• Blood in urine
• Blood from urethra,
vagina, or rectum
• Pregnancy
Nausea, vomiting
Cramps
Blood in urine or feces
Swelling
Last bowel movement
Pregnancy
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Chapter 7: Patient Assessment
Focused Assessment (4 of 4)
Extremity Injuries
• Pain on motion
• Numbness, tingling,
weakness, or loss of
motion in the extremity
• Inability to bear weight
on lower extremity
• DCAP-BTLS
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Chapter 7: Patient Assessment
Patient Assessment Process
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Chapter 7: Patient Assessment
Assessment of Responsive
Medical Patient
• History of illness
• SAMPLE history
• Focused physical
exam
• Baseline vital signs
• Reevaluate transport
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Chapter 7: Patient Assessment
History of Illness
• Important Signs and Symptoms:
– Regional pain
– Fever
– Variation from normal function
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Chapter 7: Patient Assessment
OPQRST (1 of 2)
• O Onset
When did the problem first
start?
• P Provoking factors
What creates or makes the
problem worse?
• Q Quality of pain
Description of the pain
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Chapter 7: Patient Assessment
OPQRST (2 of 2)
• R Radiation of pain or discomfort
Does the pain radiate anywhere?
• S Severity
Intensity of pain on 1-to-10 scale
• T Time
How long has the patient had this
problem?
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Chapter 7: Patient Assessment
SAMPLE History
• Questions to ask:
– Have you ever been told you
have a heart condition?
– Have you ever been told you
have problems with your lungs?
– Have you ever been told you
have seizures?
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Chapter 7: Patient Assessment
Focused Physical Exam
• Investigate problems associated
with chief complaint.
• Examine abnormalities.
• Reassess vital signs.
• Provide emergency care.
• Reevaluate transport.
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Chapter 7: Patient Assessment
Patient Assessment Process
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Chapter 7: Patient Assessment
Detailed Physical Exam (1 of 2)
• More in-depth exam based on focused
physical exam
• Should only be performed if time and
patient’s condition allow
• Usually performed by EMS en route to the
hospital
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Chapter 7: Patient Assessment
Detailed Physical Exam (2 of 2)
• Head-to-toe steps
• DCAP-BTLS
• Vital signs
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Chapter 7: Patient Assessment
Performing the Detailed
Physical Exam (1 of 5)
• Visualize and palpate using DCAP-BTLS.
• Look at the face.
• Inspect the area around the eyes and
eyelids.
• Examine the eyes.
• Pull the patient’s ear forward to assess
for bruising.
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Chapter 7: Patient Assessment
Performing the Detailed
Physical Exam (2 of 5)
• Use the penlight to look for drainage
or blood in the ears.
• Look for bruising and lacerations
about the head.
• Palpate the zygomas.
• Palpate the maxillae.
• Palpate the mandible.
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Chapter 7: Patient Assessment
Performing the Detailed
Physical Exam (3 of 5)
• Assess the mouth for obstructions
and cyanosis.
• Check for unusual odors.
• Look at the neck.
• Palpate the front and the back of
the neck.
• Look for distended jugular veins.
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Chapter 7: Patient Assessment
Performing the Detailed
Physical Exam (4 of 5)
• Look at the chest.
• Gently palpate over the ribs.
• Listen for breath sounds.
• Listen also at the bases and
apices of the lungs.
• Look at the abdomen and
pelvis.
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Chapter 7: Patient Assessment
Performing the Detailed
Physical Exam (5 of 5)
• Gently palpate the abdomen.
• Gently compress the pelvis.
• Gently press the iliac crests.
• Inspect all four extremities.
• Assess the back for tenderness
or deformities.
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Chapter 7: Patient Assessment
Patient Assessment Process
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Chapter 7: Patient Assessment
Ongoing Assessment (1 of 2)
• Repeat the initial assessment.
• Reassess and record vital signs.
• Repeat focused assessment.
• Check interventions.
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Chapter 7: Patient Assessment
Ongoing Assessment (2 of 2)
• Is treatment improving the
patient’s condition?
• Has an already identified problem
gotten better? Worse?
• What is the nature of any newly
identified problems?
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