Transcript bledsoe_pcpp3_ch02_lecture - McLaren

Paramedic Care: Principles & Practice
Fourth Edition
Volume 3: Patient Assessment
CHAPTER
2
Primary
Assessment
Multimedia Directory
Slide 16
Medical Patient Assessment Video
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Standard
• Assessment
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Competency
• Integrate scene and patient assessment
findings with knowledge of
epidemiology and pathophysiology to
form a field impression.
• This includes developing a list of
differential diagnoses through clinical
reasoning to modify the assessment
and formulate a treatment plan.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Introduction
• Primary assessment:
– Basis of all prehospital emergency
medical care.
– Identify and correct immediately lifethreatening conditions of patient's
airway, breathing, circulation (ABCs).
– If you find these conditions during
assessment, treat at once.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Introduction
• Following primary assessment, decide
priority regarding transport or on-scene
assessment and care.
• Not step-by-step process; series of
decisions based on what you find.
• Proceed systematically through ABCs.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Introduction
• Steps of Primary Assessment
– Form general impression
– Stabilize cervical spine as needed
– Assess baseline mental status
– Assess and manage airway
– Assess and manage breathing
– Assess and manage circulation
– Determine priorities
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Forming a General Impression
• General impression: first, intuitive
evaluation of patient.
• Determine general clinical status and
priority for immediate transport.
– Environment
– Mechanism of injury; nature of illness
– Patient's posture and overall look
– Chief complaint
– Your instincts
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Forming a General Impression
• Patient looks dead: quick evaluation of
responsiveness and breathing.
• Feel for pulse; if absent, begin chest
compressions immediately.
• Patient shows signs of life: conduct
standard primary assessment (ABC).
• Patient's age, gender, race often
influences index of suspicion.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Forming a General Impression
• Determine whether problem results
from trauma or medical problem.
– Sometimes not readily apparent.
• More serious the condition, quieter
patient will be.
• Look, listen, smell environment.
• Gather clues as you enter scene.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Forming a General Impression
• Use Standard Precautions with every
patient.
• If patient alert, identify yourself;
establish rapport.
• Reassure patient; listen to him; do not
trivialize complaints.
• Support your patient psychologically
and physiologically.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Forming a General Impression
• If mechanism of injury significant or
patient unresponsive, manually
stabilize patient's head and neck.
• If patient awake, explain what you are
doing; ask him not to move his neck.
• If patient is small child, place towel or
pad beneath shoulders to maintain
proper alignment of cervical spine.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Manually stabilize the head and neck on first patient contact.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Place a folded towel under your young patient's shoulders to keep the airway aligned. Airway aligned after using
a towel.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Mental Status Assessment
• Baseline mental status crucial.
– Head-injury patients.
– Medical situations that cause altered
levels of response; stroke patients.
• AVPU
– Alert
– Verbal stimuli
– Painful stimuli
– Unresponsive
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Medical Patient Assessment Video
Click here to view a video on the topic of primary assessment steps.
Back to Directory
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Mental Status Assessment
• AVPU Levels—Alert
– Patient awake; open eyes.
– Oriented to person, place, time,
situation.
– Organized, coherent answers to
questions.
– Or may be disoriented and confused.
– Quiet child usually seriously injured or
ill.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Mental Status Assessment
• AVPU Levels—Verbal
– Appears to be sleeping but responds
when you talk to him; he is responsive
to verbal stimuli.
– Responds by speaking, opening eyes,
moaning, or just moving.
– Note level of verbal response.
– Infants: you may have to shout to elicit
response.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Mental Status Assessment
• AVPU Levels—Pain
– If patient does not respond to verbal
stimuli, try to elicit response with
painful stimuli.
– May respond by waking up, speaking,
moaning, opening eyes, moving.
– Decorticate or decerebrate posturing is
nonpurposeful; suggests serious brain
injury.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Mental Status Assessment
• AVPU Levels—Unresponsive
– Comatose; fails to respond to any
noxious stimuli.
– Any alteration or deterioration in mental
status may indicate emergent or serious
problem.
– Take immediate steps to protect
patient's airway.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Airway Assessment
• If patient responsive and can speak
clearly, assume airway patent.
• If patient unconscious, airway may be
obstructed.
• Assume unconscious patient has no gag
reflex; cannot protect his airway.
• Oropharyngeal suctioning will clear
secretions.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Airway Assessment
• If cervical spine injury, open airway
using jaw thrust without head
extension.
• For all other patients, use headtilt/chin-lift maneuver.
• Use head-tilt/chin-lift maneuver if jaw
thrust does not open airway.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Use the jaw-thrust maneuver to open your patient's airway if you suspect a cervical spine injury.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
The head-tilt/chin-lift maneuver in an adult.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Airway Assessment
• To open airways of infants and children,
apply gentle and conservative
extension of head and neck.
• To assess airway, look for chest rise
while you listen and feel for air
movement.
• Noisy airway partially obstructed.
• Gurgling indicates fluid blocking upper
airway.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Airway Assessment
• Stridor caused by life-threatening upper
airway obstruction.
• Foreign body obstruction: abdominal
thrusts to dislodge object.
• Positive pressure ventilation, continuous
positive airway pressure (CPAP), bilevel
positive airway pressure (BiPAP),
intubation, cricothyrotomy: only if
airway becomes totally obstructed.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Airway Assessment
• Respiratory burns: rapid massive
swelling of upper airway; rapid
endotracheal intubation.
• Anaphylaxis: vasoconstrictor
medications to decrease upper airway
swelling.
• Wheezing: constricted bronchioles;
smaller, lower airways; bronchodilator
medication.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Airway Assessment
• If patient is not moving air, he is in
respiratory arrest.
• Immediately provide ventilation with
bag-valve mask and high-flow oxygen.
• If patient unconscious and lacks gag
reflex, insert oropharyngeal airway.
• If gag reflex or significant orofacial
trauma, insert nasopharyngeal airway.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Immediately use a bag-valve mask to ventilate patients who are not moving air.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Use an oropharyngeal airway for unconscious patients without a gag reflex.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
The nasopharyngeal airway rests between the tongue and the posterior pharyngeal wall.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Airway Assessment
• If patient has no gag reflex and cannot
protects airway, use advanced
techniques to maintain airway patency.
– Endotracheal intubation
– Multilumen airways
– Transtracheal techniques
• If patient has airway problem and
shows signs of hypoxia, administer
oxygen by nonrebreather mask.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Breathing Assessment
• Altered mental status, confusion,
apprehension, or agitation
• Shortness of breath while speaking
• Retractions (supraclavicular,
suprasternal, intercostal)
• Asymmetric chest wall movement
• Accessory muscle use (neck,
abdominal)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Breathing Assessment
• Cyanosis
• Audible sounds
• Abnormally rapid, slow, shallow
breathing
• Nasal flaring
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Breathing Assessment
• Assess respiratory rate and quality.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Respiratory Rates
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Breathing Assessment
• Note respiratory pattern.
• Rapid (tachypneic), deep (hyperpneic)
respirations compensatory mechanism.
• Cheyne-Stokes respirations: increasing
and decreasing breaths followed by
period of apnea.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Breathing Assessment
• Biot's respirations: short, gasping,
irregular breaths.
• Some patients with acute pulmonary
edema can benefit from CPAP unit.
• Assess neck and chest before moving
on to circulation.
• Identify and correct life-threatening
conditions before moving on.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
CPAP can provide positive airway pressure, which will maintain lower airway patency.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Breathing Assessment
• Tension pneumothorax: immediately
decompress affected side with large IV
catheter at second intercostal space,
midclavicular line.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Circulation Assessment
Evaluate pulse and skin.
Control hemorrhage.
Go to wrist and feel for radial pulse.
If radial pulse absent, check for carotid
pulse.
• In infant, palpate brachial pulse.
• If pulse absent, begin chest
compressions immediately.
•
•
•
•
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
To assess an adult's circulation, feel for a radial pulse.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
If you cannot feel a radial pulse, palpate for a carotid pulse.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Circulation Assessment
• Assess pulse for rate and quality.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Normal Pulse Rate Ranges
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Circulation Assessment
• Very fast rates (tachycardia).
• Very slow rates (bradycardia).
• Note quality of pulse; normal pulse
should be regular and strong.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Circulation Assessment
• Stop patient's bleeding.
• Major bleeding originates with trauma
or medical emergency.
• New hemostatic agents now used by
civilian EMS responders.
• Internal bleeding not easily controlled
in prehospital setting; transport.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Circulation Assessment
• Assess skin: temperature, moisture,
color.
– Skin: mottled (blotchy), cyanotic
(bluish), pale, or ashen; cool and moist
(clammy).
– Suspect conditions related to or caused
by poor perfusion.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Assess the skin for color, temperature, and moisture.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Priority Determination
• Serious illness or injury: rapid head-totoe assessment; transport immediately.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Priority Determination
• Centers for Disease Control and
Prevention Guidelines
– Step 1: aimed at
consciousness.
– Step 2: aimed at
– Step 3: aimed at
– Step 4: aimed at
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
vital signs and level of
injuries.
mechanism of injury.
miscellaneous findings.
Summary
• Primary assessment: crucial first stage.
• Identify and correct immediate life
threats to patient.
• Secure scene; ensure personal safety.
• It should take less than 1 minute to
perform primary assessment.
• Confirm priority determination and
transport.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Primary assessment includes “gut
check” component; general patient
appearance.
• Assess for cervical spine injuries,
airway or breathing problems,
circulatory issues, mental status, or any
situation that would cause immediate
threat to life.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.