Transcript Patient Assessment - faculty at Chemeketa

EMT 052 – Winter 2004
Assessment
Review
Scene Size-Up

Determine the # of Patients
 Call for additional help if necessary

Can my unit handle this scene?







ALS/BLS
Can my agency handle this scene?
Should I initiate MCI Protocols?
Is my crew responding ok to this call?
Are bystanders going to be affected soon?
Temperature?
Water needs of crew members?
Patient Assessment Can be
confusing ……duh
 Lots
of information
 Lots of input from …everyone?
 You NEED to practice!
 Learn the skill sheets!
 As you gain experience, develop
your own assessment process
 Some of you are finding out how
much you don’t know – that’s good
Patient Assessment
 Algorithm-floor
plan
 Emphasis on
critical thinking
 Flexibility is
essential
 Practice, Practice,
Practice!
Let’s Look at the Basics…..
Medical and Trauma

BSI
 Scene Safety
 MOI/NOI
 Number of patients
 Need for additional
help – ALS, other?
 C-spine PRN

General
impression
 LOC - AVPU
 C/C, life threat
 A & B – O2, tidal
 C – blood? Pulse?
Skin? Cap refill?
 ID transport
priority
Trauma or Medical?

Medical – S/S








Respiratory
Cardiac
Altered
mental status
Allergic
reaction
Poisoning/O
D
Environment
al
OB
Behavioral

A - Allergies
 M - Medications
 P - Pertinent hx
 Last oral intake
 Events leading up to illness
(trauma?)
Complications

Factors that can influence your findings






Weather
Scene not safe or not secure
Lack of resources
Your own stress or stress of emergency
workers
Multiple patients
Components you are not prepared for:






Fire
Hazmat
Multiple patients
Disruptive bystanders, family
Kids, death, gross stuff, etc.
Altered LOC – injury, drugs, disease. Etc.
And now……





Focused P.E.
V.S.
Interventions
Transport –
necessary to
reevaluate
original
decision?
Consider
completing
detailed
assessment


On going
assessment –
reevaluating
the finding and
interventions
performed to
this point
Repeat
focused
assessment
with C/C in
mind
On-Going Assessment

Depending on patient
condition……
 Re-assess vital signs every 5
minutes for critical patients
 Primary survey with special
attention to the airway and
breathing as often as
necessary to insure it’s
patent and adequate.
Trauma…..

Focused
Physical
exam and
history/rapid
trauma
assessment
 Obtains
Baseline VS
 SAMPLE Hx

Detailed Physical
Exam








Head
Neck
Chest
Abdomen/Pelvis
Extremities
Posterior
Manage secondary
injuries
Reassess VS and
interventions
Trauma – Significant MOI
 Assess
DECAP-BTLS
 Head
 Neck
 Chest
 Abdomen
 Pelvis
 Extremities
 Posterior
body
Trauma – Significant MOI
 Assess
baseline vital signs
 Obtain SAMPLE history
 Transport
 Perform detailed exam – secondary
survey
 Perform on-going assessment
ABC’s Determine Priorities

Conscious or unconscious?
 Altered LOC?
 Airway open and secure?
 Breathing present and
adequate?
 Pulse? Quality/rate?
Adequate?
 Shock?
 Corrections required?
Priority Transport

Poor general impression
 Unresponsive
 Difficulty breathing
 Shock/Hypoperfusion
 Complicated Childbirth
 Chest pain with BP<100
Systolic
 Uncontrolled bleeding
 Severe Pain Anywhere
 Can you think of others?
Don’t forget
 All
life threats must be
discovered and treated as
they are found
 Everything else, secondary
 Rapid transport and ALS
intervention if required, must
be initiated ASAP
 In the event of a difficult
airway, you may never get
passed the ABCs
Some Things to Consider

Get close to the patient
 Identify yourself – avoid
clichés
 Explain what you are doing
 SAMPLE/OPQRST
 Be suspicious – poor
historians
 What does your patient look
like?
SKIN

Importance of examination of
the skin









Easily accessible
Highly visible
Easily palpable
Will demonstrate many signs of
illness/injury
Expose it
Utilize a good light source
Racial/Ethnic limitations
Alternatives – Where do I look?
Important factor is change
SKIN
 Abnormal
colors
 Dusky/gray/blue

Lips, nail beds, mucous membranes
 Cherry

(milk/yellow)
Anemia or blood loss
 Yellow

red
Carbon monoxide
 Sallow

– cyanosis
(Icteric)
Jaundice - liver

Often noticed first in sclera
SKIN

Pale (whitish)



Vasoconstriction
Sympathetic discharge
Mottling – patchy discoloration


Serious vascular impairment
Wide range of normal exists for temperature
and moisture
– most important factor is
change!
 Repeat
SKIN

Normal vs. Abnormal
 Everything normal? Keep looking!
 Warm/moist: Febrile, heat injury
 Hot/moist: High fever, heat injury
 Warm/dry: febrile, dehydration
 Hot/dry: Heat stroke
 Cool/dry: Hypothermia
 Cool/cold/moist: sympathetic discharge
 Texture: Turgor/Edema/crepitus
 Lesions/Rashes/Wounds/Scars
 Tattoos/Nicotine/Jewelry
Helpless?

Pulse less/ apneic 7 year old boy
 Grandma’s dying and half the family wants
you to help, the other half is blocking the
door to grandma’s room
 You are not feeling well and you can’t get
a really sick patient to go to the hospital.
The phone are not working and the HEAR
system in your unit is malfunctioning
 You arrive on a burning house before the
fire department and bystanders tell you
that the family is unaccounted for. You
have no protective clothing
Elderly Assessment
Considerations

Bucket next to be
 Tripod position
 Hospital bed
 Nebulizer set-up
 Oxygen
 Medications
 Night clothing
during the day

Patient propped up
on pillows
 Heat in rooms
 Cold in rooms
 Condition of home
 Weapons
 Mail unopened
 Other signals?
Elderly Assessment
 Live
alone?
 Incontinent?
 Immobile?
 Recently hospitalized?
 Recently bereaved?
 Altered mental status?
 Hearing and/or vision issues?
Review of Assessments
 Separated
into several subassessments
 Remember priorities
 Differences between medical and
trauma patients
 Re-assess, Re-assess, Reassess
The Medical Patient
 Left
off with:
 ABCD’s
Were OK?
 Transport decision
Stay & Play
 Load & Go

Scene Size-up

Process begins when?
 ASAP – Never too
early
 Starts with?
 BSI – Enroute
 Scene Safety
 All available
resources!!!
Scene Size-Up
 Time
to arrive
 Not time to
touch a
patient yet!
Scene Size-Up
Determine Mechanism of injury /
Nature of Illness
 Mechanism
of Injury
 Blunt Trauma
 Penetrating Trauma
 Nature of Illness
Scene Size-Up

Bunches of
Patients?



Triage
Call for Police, Fire
and EMS resources
Err on the side of
the patient.
Scene Size-Up
 Evaluate
need for C-spine
precautions
Scene Size-Up
 How
Will it
Sound?
 Paint a clear
picture of
what you:
 See
 Doing
 Want
Initial Assessment

General Impression
 Establishes relationship
 At a glance, What do you
see???
 Determine Level of Consciousness/
Responsiveness – AVPU
 Estimate patient’s age
 Patient’s gender
Initial Assessment
 Determine
Chief Complaint (Term)
 Determine Apparent Life Threats
Initial Assessment

Now for the ABC’s (Expanded)
 Airway and Breathing
 Evaluate*
 Find it and Fix it
 Assemble and Deliver Appropriate
Oxygen
 Circulation
 Any Major Bleeding?
 Pulse*
 Skin Condition
Initial Assessment Variation
 Frequently
seen as:
 Airway
 Breathing
 Circulation
 Disability
 Expose
Initial Assessment
 Make
a decision
 Stay & Play?
 Load & Go?
Initial Assessment
 What
not to do:
 Forget
BSI
 Make sure the scene is safe
 Provide High Concentrations of Oxygen
 Evaluate A,B,C’s
 Make the wrong load decision
 Do secondary assessment before
primary assessment
Patient Assessment
Focused History & Physical Exam
Trauma vs Medical
Objectives

Understand the components of:





Focused history
Physical Exam
Detailed Exam
Ongoing Assessment
Understand the appropriate times to complete
a secondary assessment
 Understand the differences in secondary
assessments of medical and trauma patients
The Medical Patient
 Focused
History (Key Terms)
 OPQRST
Onset
 Provokes
 Quality
 Radiation
 Severity
 Time

The Medical Patient
 Focused
History
 Onset

When did this problem start?


What made you call today?
What time did your symptoms begin?
 Provokes

What makes the problem get worse?

Anything make it feel better?
The Medical Patient
 Focused
History
 Quality
What does it feel like?
 Can you describe to me what you are
feeling?


Document their words!!! (C/C)
 Region
or Radiation
Does this problem move anywhere?
 Where else do you feel this?

The Medical Patient
 Focused
History
 Severity

Beware of Perception
How bad does it feel?
 On a scale ….?
 Compare this time to the last time that you had
this problem…Better Or Worse?

The Medical Patient
 Focused
 Time

History
& Treatment
What have you done for this condition so
far? In the past?


Beware of self-medicated patients
Beware of home remedies
What else could we do to make you feel
more comfortable?
 How would you like to sit? Up or down?

The Medical Patient
 SAMPLE
Hx
 Symptoms/Signs
 Allergies
 Medications
 Past
Medical History
 Last Oral Intake
 Events Leading up to current situation
The Medical Patient
 Focused
Physical Exam
 Examine logical areas (Examples)
 Chest
Pain with Trouble Breathing
 Headache (Severe)
 Abdominal Pain
 Dizziness
The Medical Patient
 Baseline
 Might
Vital Signs
be repeat
 Interventions
 What
to do?
 Transport
Decision
 Re-evaluate
 Detailed
 En
Physical Exam
Route PRN
The Medical Patient
 Ongoing Assessment
 Repeat
Initial Assessment
 Repeat Vital Signs
 Repeat Focused Assessment
 Re-check interventions
Assessment of the
Unconscious Medical Patient
 Perform
rapid medical assessment
 Head
 Neck
 Chest
 Abdomen
 Pelvis
 Extremities
 Posterior
Medical Assessment, cont.
 Baseline
vital signs
 Position patient
 Perform sample history
 Transport
 Perform detailed physical exam
Medical Assessment for the
Responsive Patient

Assess chief complaint - C/C, C/O
 OPQRST
 SAMPLE
 Perform focused medical assessment
 Obtain baseline vital signs
 Make transport decision
 Perform components of detailed physical
exam
 Perform on going assessment
Switch Gears
Medical to Trauma
The Trauma Patient - Initial Review
 Scene
Size-up
 MOI
 What
are the significant ones?
 Considered use of c-spine precautions
 Initial Assessment
 ABCD’s
 Make
OK?
a transport decision
The Trauma Patient
 Focused
 Rapid

History & Physical Exam
Trauma Assessment (RTA)
DCAPP-BTLS








Deformities
Contusions
Abrasions
Punctures / Penetrations
Burns
Tenderness
Lacerations
Swelling
The Trauma Patient

Rapid Trauma Assessment

Looking & Feeling for “DCAPP-BTLS”
 Head
 Neck
 C-collar
 Chest
 Abdomen
 Pelvis
 Extremities x 4
 Back
The Trauma Patient
 Rapid
Trauma Assessment
 Baseline
Vital Signs
 SAMPLE History
The Trauma Patient
 The
Detailed Physical
Exam
 The Sequence
 Always completed on a
trauma patient en-route to
the hospital unless there is
a reason for prolonged
scene time
Switch Gears Again
A close up look at the
detailed physical exam
The Detailed Physical Exam
 HEENT
& Face
 Head
 Eyes
- pupils
 Ears
 Nose
 Throat
 Face
& Mouth
The Detailed Physical Exam
 Neck
 DCAPP-BTLS
 Subcutaneous
Emphysema
 Jugular Vein Distention
 Tracheal Shift
 Crepitus
The Detailed Physical Exam
 Shoulders
 DCAPP-BTLS
 Stability
 Chest
 DCAPP-BTLS
 Crepitus
 Paradoxical
Motion
 Breath Sounds
The Detailed Physical Exam
 Abdomen
 DCAPP-BTLS
 Firmness
 Softness
 Tenderness
 Distension
 Evisceration
The Detailed Physical Exam
 Pelvis
 DCAPP-BTLS
 Pain
 Tenderness
 Instability
 Crepitus
 Priapism
The Detailed Physical Exam
 Extremities
 DCAPP-BTLS
 Distal
Circulation
 Sensation
 Movement
 Back
 Use
proper roll
 May have already done
Back to the Trauma Patient
 Manage
any minor injuries
 Ongoing Assessment
 Repeat
initial assessments
 Repeat focused assessment
 Re-assess interventions
 Contact medical control (again)
 Repeat Vital Signs Q5 / Q15
Focused History and Physical
Exam – Trauma Patient
 Reconsider
MOI
 Patient with significant MOI
 Continue
spinal immobilization
 Consider ALS request
 Reconsider transport
 Reassess mental status
 Perform rapid trauma assessment
Patient without significant MOI
 Perform
focused trauma assessment
 Obtain baseline vital signs
 Obtain SAMPLE history
 Perform components of detailed
physical exam
 Transport
 Perform ongoing assessment