Transcript Chapter 13: Patient Assessment

Chapter 13
Patient Assessment
National EMS Education
Standard Competencies
Assessment
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.
National EMS Education
Standard Competencies
Scene Size-up
• Scene safety
• Scene management
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Impact of the environment on patient care
Addressing hazards
Violence
Need for additional or specialized resources
Standard precautions
Multiple patient situations
National EMS Education
Standard Competencies
Primary Assessment
• Primary assessment for all patient situations
− Initial general impression
− Level of consciousness
− ABCs
− Identifying life threats
− Assessment of vital functions
National EMS Education
Standard Competencies
Primary Assessment (cont’d)
• Begin interventions needed to preserve life.
• Integration of treatment/procedures needed
to preserve life
National EMS Education
Standard Competencies
History Taking
• Determining the chief complaint
• Investigation of the chief complaint
• Mechanism of injury/nature of illness
• Past medical history
• Associated signs and symptoms
• Pertinent negatives
National EMS Education
Standard Competencies
History Taking (cont’d)
• Components of the patient history
• Interviewing techniques
• How to integrate therapeutic communication
techniques and adapt the line of inquiry
based on findings and presentation
National EMS Education
Standard Competencies
Secondary Assessment
• Performing a rapid full-body exam
• Focused assessment of pain
• Assessment of vital signs
• Techniques of physical examination
• Respiratory system
− Presence of breath sounds
National EMS Education
Standard Competencies
Secondary Assessment (cont’d)
• Cardiovascular system
• Neurologic system
• Musculoskeletal system
National EMS Education
Standard Competencies
Secondary Assessment (cont’d)
• Techniques of physical examination for all
major
− Body systems
− Anatomic regions
• Assessment of
− Lung sounds
National EMS Education
Standard Competencies
Monitoring Devices
• Obtaining and using information from
patient monitoring devices including (but not
limited to):
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Pulse oximetry
Noninvasive blood pressure
Blood glucose determination
Continuous ECG monitoring
12-lead ECG interpretation
Carbon dioxide monitoring
Basic blood chemistry
National EMS Education
Standard Competencies
Reassessment
• How an when to reassess patients
• How and when to perform a reassessment
for all patient situations
National EMS Education
Standard Competencies
Medicine
Integrates assessment findings with principles
of epidemiology and pathophysiology to
formulate a field impression and implement a
comprehensive treatment/disposition plan for
a patient with a medical complaint.
National EMS Education
Standard Competencies
Medical Overview
• Assessment and management of a
− Medical complaint
• Pathophysiology, assessment, and
management of medical complaints to
include:
− Transport mode
− Destination decisions
Introduction
• One of the most important skills you will
develop is the ability to assess a patient.
− Identify your patient’s problem(s).
− Set your care priorities.
− Develop a patient care plan.
− Execute your plan.
Sick Versus Not Sick
• Determine whether the patient is sick or not
sick.
− If the patient is sick, determine how sick.
• Every time you assess a patient:
− Qualify whether your patient is sick or not sick
− Quantify how sick the patient is
Establishing the Field
Impression
• A determination of
what you think is the
patient’s current
problem
− You must be able to
communicate and ask
the right questions.
• Be a “detective.”
Establishing the Field
Impression
• The process must be organized and
systematic but still flexible.
− Know when to expand your questioning.
− Know when to focus your questioning.
Medical Versus Trauma
• Medical patients
− Identify chief complaint and sift through medical
history.
• Trauma patients
− Medical history may have less impact
− Requires a modified approach
Scene Size-Up
• Involves evaluating the overall safety and
stability of the scene
− Safe and secure access into the scene
− Ready egress out of the scene
− Specialty resources needed
Scene Safety
• Ensure the safety and well-being of your
EMS team and any other responders.
− If the scene is not safe, do what is necessary to
make it safe.
− Requires constant reassessment
Scene Safety
Courtesy of Anthony Caliguire, NREMT-P
− Wear a highvisibility public
safety vest.
− Consider specialty
reflective gloves,
coats, and boots.
© Adam Alberti, NJFirePictures.com
• Crash-and-rescue
scenes often
include multiple
risks.
Scene Safety
• Ensure that your team can safely gain
access to the scene and the patient.
− Consider a snatch and grab.
• Establish a safe perimeter to keep
bystanders out of harm’s way.
Scene Safety
• Be wary of toxic
substances and toxic
environments.
− Proper body and
respiratory protection
is a must.
Courtesy of Tempe Fire Department
Scene Safety
• Potential crime
scenes
− Law enforcement
should enter first.
− Formulate an escape
plan.
− Be aware of violence
from bystanders.
− Patients who abuse
methamphetamines
can be a large threat.
© Paul Chiasson, CP/AP Photos
Scene Safety
• Risks related to the
environment
include:
− Unstable surfaces
− Snow and ice
− Rain
• Consider the
stability of the
structures around
you.
Courtesy of James Tourtellotte/U.S. Customs & Border Control
Scene Safety
• Ensure safety of the patient and bystanders
next.
• When the environment is unfriendly perform
assessment, address threats, and move the
patient as quickly as possible.
Mechanism of Injury or Nature
of Illness
• Mechanism of injury (MOI)
− Forces that act on the body to cause damage
• Nature of illness (NOI)
− General type of illness a patient is experiencing
Mechanism of Injury or Nature
of Illness
• Multiple patients or obese patient may
warrant additional resources.
− Multiple patients must be triaged.
− Be familiar with specialized resources.
− Assess the need for spinal motion restriction.
Standard Precautions
• Your first priority is
your own safety
and the safety of
other EMS team
members.
Standard Precautions
• Treat all patients as potentially infectious.
− Wear properly sized gloves.
− Wear eye protection.
− Wear a HEPA or N95 mask.
− Wear a gown.
− Wash your hands after removing gloves.
Standard Precautions
• Personal protective equipment (PPE)
− Clothing or equipment that provides protection
from substances that pose a health/safety risk
• Steel-toe boots
• Helmets
• Heat-resistant outerwear
• Self-contained breathing apparatus
• Leather gloves
Primary Assessment: Form a
General Impression
• Based on initial presentation and chief
complaint
• Make conscious, objective, and systematic
observations
− Is the patient in stable or unstable condition?
− Is the patient sick or not sick?
Primary Assessment: Form a
General Impression
• Observe level of consciousness.
• Decide whether to implement spinal motion
restriction procedures.
• Determine your priorities of care.
• Identify age and sex of the patient.
Primary Assessment: Form a
General Impression
• Treat life threats as you find them
− What additional care is needed?
− What needs to be done on scene?
− When to initiate transport?
− Which facility is most appropriate?
• Assess mental status by using AVPU
process
Assess the Airway
• Is airway open and patent?
• Listen for noisy breathing.
• Move from simple to complex:
− Position
− Obstruction
Assess the Airway
• For all unresponsive patients:
− Establish responsiveness.
− Assess breathing.
• If ineffective or absent, open the airway.
• Mechanical means requires an airway adjunct
Assess Breathing
• Is the patient breathing?
− If not, you must breathe for him or her.
− If so, is he or she breathing adequately?
• Consider minute volume.
− Respiratory rate multiplied by the tidal volume
inspired with each breath
Assess Breathing
• Assess breathing rate.
− Too fast: greater than 24 breaths/min
− Too slow: 8–20 breaths/min
• Assess for chest rise and fall.
• Assess for breath sounds.
• Assess for air movement.
Assess Circulation
• Palpate the pulse.
− Count the number of beats in 15 seconds and
multiply times four.
• Normal pulse rate for adults is 60–100 beats/min.
• Bradycardia — rate less than 60 beats/min.
• Tachycardia — rate higher than 100 beats/min.
Assess Circulation
• Force: Normal pulse feels “full.”
• Rhythm: Normal rhythm is regular.
• Report your findings:
− Rate
− Force
− Rhythm
• Inspect skin for obvious signs of bleeding.
• Capillary refill
evaluates ability to
restore blood
− To test:
• Place thumb on
patient’s finger
and compress.
• Remove pressure.
• Adequate
perfusion: color
restored within two
seconds.
© Jones and Bartlett Publishers. Courtesy of MIEMSS. © Jones and Bartlett Publishers. Courtesy of MIEMSS.
Assess Circulation
Assess Circulation
• Assess the skin to
evaluate perfusion.
− Color
− Temperature
− Moisture
Assess Circulation
Restoring Circulation
• If a patient has inadequate circulation:
− Restore or improve circulation.
− Control severe bleeding.
− Improve oxygen delivery to the tissues.
Restoring Circulation
• If you cannot feel a pulse, begin CPR until
an AED or manual defibrillator is available.
− Follow standard precautions.
− Evaluate cardiac rhythm of any patient in
cardiac arrest.
− Oxygen delivery is improved through the
administration of 100% supplemental oxygen.
Assess and Control External
Bleeding
• Perform a rapid exam.
− Venous bleeding: steady blood flow
− Arterial bleeding: spurting flow of blood
• Evaluate unresponsive patients by running
your gloved hands from head to toe.
Identify and Treat Life Threats
• Determine if a life threat is present and, if
so, immediately address it.
− A patient who is dying will:
• Become less aware of surroundings
• Stop making attempts to communicate
• Lose consciousness
• Become unresponsive to external stimuli
• Muscles of the jaw will become slack
Identify and Treat Life Threats
• Conditions that cause sudden death:
− Airway obstruction
− Respiratory arrest
− Severe bleeding
Assess the Patient for
Disability
• Perform a neurologic evaluation.
− Have the patient move all extremities.
• Assess for motor strength and weakness.
• Assess grip strength.
• Assess for loss of sensation.
• Be mindful of exposure concerns.
Perform a Rapid Exam
• Observe for asymmetry/obvious defects.
• Palpate the entire surface of the skull, then
down to C7 of the spine.
• Squeeze and roll the shoulder girdles.
• Palate the abdomen and rock the pelvis.
Perform a Rapid Exam
• Grasp each arm at the shoulder girdle and
slide your hands down to the wrist.
• Palpate the legs.
• Ask the patient to wiggle fingers and toes.
• Ask the patient if they are bleeding.
Perform a Rapid Exam
• Guidelines:
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Inspect.
Palpate.
Auscultate.
See Skill Drill 13-1.
• DCAP-BTLS:
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Deformities
Contusions
Abrasions
Punctures/penetration/
paradoxical
movement
Burns
Tenderness
Lacerations
Swelling
Make a Transport Decision
• Identify priority patients.
− Do only what is necessary at the scene and
handle everything else en route.
Priority Patients
• Hypoperfusion or
shock
• Poor general
impression
• Complicated childbirth
• Unresponsive
patients
• Chest pain w/systolic
BP < 100 mm Hg
• Uncontrolled bleeding
• Severe pain
anywhere
• Multiple injuries
• Responsive but does
not or cannot follow
commands
• Difficulty breathing
History Taking
• Gain information about the patient and the
events surrounding the incident.
• Ask open-ended questions.
• Avoid leading questions.
• Ask age-appropriate questions.
• Be patient.
Patient Information
• Name and chief complaint
• Data required by local EMS system
• Who called 911 and why
• Medical ID jewelry
• Information from medical responders
Techniques for History Taking
• Appearance and
demeanor
− Clean, neat, and
professional
− Good attitude
− Identify your
service and
certification level.
− Try to interview in
a private setting.
Techniques for History Taking
• Confidentiality
− Be familiar with relevant laws.
• How to address the patient
− Ask how he or she would like to be addressed.
− Err on the side of formality.
− Be familiar with the cultural groups in area.
Techniques for History Taking
• Note taking
− Let the patient
know that you will
be writing
information down.
© Glen E. Ellman
− Position yourself at
eye level.
− Maintain good eye
contact.
Techniques for History Taking
• Reviewing medical history and information
reliability
− Document the source of all information.
− During routine transfers, look over paperwork.
− Evaluate your sources for reliability.
Responsive Medical Patients
• Chief complaint
− Should be
recorded in
patient’s own
words
− Should include:
• What is wrong
• Why treatment is
being sought
Responsive Medical Patients
• History of illness
− OPQRST
• Onset
• Provocation
• Quality
• Region/radiation/
referral
• Severity
• Time
− SAMPLE
• Signs and
symptoms
• Allergies
• Medications
• Pertinent past
history
• Last oral intake
• Events that led to
injury or illness
Responsive Medical Patients
• “What made you call 9-1-1?”
• Patient may have multiple complaints.
• Flesh out history of chief complaint
• Signs and symptoms: what happened
and when
• Look for medical ID tags or cards.
Responsive Medical Patients
• Past medical history
− Should include:
• Current medications and dosages
• Allergies
• Childhood illnesses
• Adult illnesses
• Past surgeries
• Past hospitalizations and disabilities
Responsive Medical Patients
• Past medical history (cont’d)
− Patient’s emotional affect provides insight into
overall mental health.
− Determine whether the patient has ever
experienced the problem.
• A new problem or condition is best considered
serious until proven otherwise.
Responsive Medical Patients
• Current health status
− Made up of unrelated pieces of information
− Ties together past history with history of current
event
− Decide which items you want to explore and
which you do not
Responsive Medical Patients
• Family history
− Helps establish patterned and risk factors for
potential diseases
− Information should be related to the patient’s
current medical condition.
Responsive Medical Patients
• Social history
− Smoking habits
− Alcohol consumption and drug use
− Sexual habits
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Diet
Occupation
Environment
Travel history
Unresponsive Patients
• Rely on:
− Head-to-toe physical examination
− Normal diagnostic tools
− Family and friends
• Look for clues.
− Pill containers
− Medical jewelry
Trauma Patients
• Life-threatening MOIs
− Ejection from a
vehicle
− Death of another
patient in same
vehicle
− Falls of greater than
15′ to 20′ or three
times patient’s height
− Vehicle rollover
− High-speed vehicle
crash
− Vehicle-pedestrian
collision
− Motorcycle crash
− Penetrating wounds to
head, chest, or
abdomen
Trauma Patients
© Mark C. Ide
© Jack Dagley
Photography/ShutterStock, Inc.
© Corbis
© Larry St. Pierre/ShutterStock, Inc.,
© Jones & Bartlett Learning.
Photographed by Kimberly Potvin
© micheal ledray/ShutterStock, Inc.
© Dan Myers, Figure
Trauma Patients
• High-priority infant
or child MOIs:
− Falls from more than
10′ or two to three
times the child’s
height
− Fall of less than 10′
with loss of
consciousness
− Medium- to highspeed vehicle crash
− Bicycle collision
Trauma Patients
• Two or more serious
MOIs increase the
chance of a serious or
fatal injury.
• In an MVC, determine
whether seat belts and/or
air bags were involved.
− Improperly installed child
seats can be useless.
© Thinkstock/Getty Images
Patients with Minor Injuries or
No Significant MOI
• If a patient shows signs of systemic
involvement, continue with assessment.
Review of Body Systems
• General symptoms
− Ask questions regarding:
• Fever
• Chills
• Malaise
• Fatigue
• Night sweats
• Weight variations
Review of Body Systems
• Skin, hair, and nails
− Rash, itching, hives, or sweating
• Musculoskeletal
− Joint pain, loss of range of motion, swelling,
redness, erythema, and localized heat or
deformity
Review of Body Systems
• Head and neck
− Severe headache or loss of consciousness
− Eyes
• Visual acuity, blurred vision, diplopia, photophobia,
pain, changes in vision, and flashes of light
Review of Body Systems
• Head and neck (cont’d)
− Nose
• Sense of smell, rhinorrhea, obstruction, epistaxis,
postnasal discharge, and sinus pain
− Throat and mouth
• Sore throat, bleeding, pain, dental issues, ulcers,
and changes to taste sensation
Review of Body Systems
• Endocrine
− Enlargement of the thyroid gland
− Temperature intolerance
− Skin changes
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Swelling of hands and feet
Weight changes
Polyuria, polydipsia, polyphagia
Changes in body and facial hair
Review of Body Systems
• Chest and lungs
− Dyspnea and chest pain
− Coughing, wheezing, hemoptysis, and
tuberculosis status
− Previous cardiac events
− Pain or discomfort
− Orthopnea, edema, and past cardiac testing
Review of Body Systems
• Hematology
− History of anemia, bruising, and fatigue
• Lymph nodes
− Tender and enlarged lymph nodes
Review of Body Systems
• Gastrointestinal
− Appetite and general digestion
− Food allergies and intolerances
− Heartburn, nausea and vomiting, diarrhea
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Hematemesis
Bowel regularity, changes in stool, flatulence,
Jaundice
Past GI evaluations and tests
Review of Body Systems
• Genitourinary
− Dysuria
− Increased frequency of urination, urgency
− Nocturia
− Hematuria
− Polyuria
− Pain to the flank and suprapubic region
Review of Body Systems
• Genitourinary (cont’d)
− Men
• Erectile dysfunction, fluid discharge, and testicular
pain
− Females
• Menstrual regularity, last menstrual period,
dysmenorrhea, vaginal discharge, abnormal
bleeding, pregnancies, and contraception use
Review of Body Systems
• Neurologic
− Seizures or syncope, loss of sensation,
weakness in extremities, paralysis, loss of
coordination or memory, and muscle twitches
− Facial asymmetry
− If you suspect stroke or TIA, use Cincinnati
Stroke Scale.
Review of Body Systems
• Psychiatric
− Depression, mood changes
− Difficulty concentrating
− Anxiety, irritability
− Sleep disturbances, fatigue
− Suicidal or homicidal tendencies
Clinical Reasoning
• Combines knowledge of anatomy,
physiology, pathophysiology, and patient’s
complaints
• Pay attention to signs or symptoms that are
inconsistent with working diagnosis.
− Differential diagnosis – a working hypothesis of
the nature of the problem
Communication Techniques
• Encourage
dialogue.
− Use layperson
terminology.
Communication Techniques
Communication Techniques
• Empathetic
response
− Put yourself in the
patient’s shoes.
− Do not hesitate to
communicate your
feelings.
Communication Techniques
• Ask about feelings.
− Tired, depressed, etc.
− Validate the patient’s feelings.
− Be empathetic but effective.
Communication Techniques
• Getting more information
− Question region or location of pain.
− Question quality of abdominal pain.
− Add, delete, and modify questions.
− Avoid close-ended and leading questions.
− Try to be orderly and systematic.
Communication Techniques
• Asking direct questions
− If you need a date, time, etc., ask for it.
• Applying clinical reasoning
− Critical thinking consists of:
• Concept formation
• Data interpretation
• Application of principles
• Reflection in action
• Reflection on action
Communication Techniques
• Applying clinical reasoning (cont’d)
− Think and perform well under pressure.
− Be a patient listener.
− Communicate with patients.
− Look for nonverbal communication.
Getting a History on Sensitive
Topics
• Alcohol and drug
abuse
− Patients may give
an unreliable
history.
− Alcohol can mask
signs and
symptoms.
− Keep a
professional
attitude.
© Jack Dagley Photography/ShutterStock, Inc.
Getting a History on Sensitive
Topics
• Physical abuse,
domestic abuse,
and sexual assault
− Required to report
− Look for clues.
− Always call law
enforcement.
− Maintain evidence
per protocol.
Getting a History on Sensitive
Topics
• Sexual history
− Talk to the patient in private.
− Keep your questions focused.
− Do not interject opinions or biases.
− Treat with compassion and respect.
Cultural Competence
• Common barriers
to communication:
− Race
− Ethnicity
− Age
− Gender
− Language
− Education
− Religion
− Geography
− Economic status
Cultural Competence
• Respect ideas and beliefs.
• Consider dietary practices.
• Obtain consent.
• Provide best possible care for all patients.
• Research prevalent groups in your area.
• Remember the importance of manners.
Special Challenges in History
Taking
• Silence
• Intoxication
• Overly talkative
patients
• Crying
• Patients with
multiple symptoms
• Anxious patients
• Reassurance
• Anger and hostility
• Depression
• Sexually attractive
patients
• Confusing
behaviors or
histories
Special Challenges in History
Taking
• Limited education
or intelligence
• Language barriers
• Hearing problems
• Visual impairment/
blindness
• Family and friends
Age-Related Considerations
• Pediatric patients
− Include child in the history-taking process.
− Be sensitive to the fears of the parents.
− Pay attention to the parent-child relationship.
Age-Related Considerations
• Pediatric patients (cont’d)
− Tailor your questions to the age of the child.
• Neonates/infants: maternal history and birth history
• 3 to 5 years: performance in school
• Adolescent: risk-taking behaviors, self-esteem
issues, rebelliousness, drug and alcohol use, and
sexual activity
− Gather an accurate family history.
Age-Related Considerations
• Geriatric patients
− Accommodate sensory losses.
− Patients tend to have multiple problems.
• May have multiple chief complaints
• May take a multitude of medications
Age-Related Considerations
• Geriatric patients (cont’d)
− Symptoms may be less dramatic.
− Consider including a functional assessment.
• Assessment of mobility
• Upper extremity function
• Activities of daily living
Secondary Assessment
• Process by which quantifiable, objective
information is obtained from a patient about
his or her overall state of health
− Consists of two elements:
• Obtaining vital signs
• Performing a head-to-toe survey
Secondary Assessment
• Not every aspect will be completed in every
patient.
− Factors to consider:
• Location
• Positioning of the patient
• The patient’s point of view
• Maintaining professionalism
Assessment Techniques
Inspection
− Looking at the
patient
− Touching to obtain
information
• Pulses: use finger
• Skull: use palms
• Skin: use back of
hand
© Jones & Bartlett Learning. Courtesy of MIEMSS.
• Palpation
Assessment Techniques
• Percussion
− Striking surface of the body, typically where it
overlies various body cavities
− Detects changes in the densities of the
underlying structures
− See Skill Drill 13-2.
Assessment Techniques
• Auscultation
− Listening with a stethoscope
− Requires:
• Keen attention
• Understanding of what “normal” sounds like
• Lots of practice
Vital Signs
• Pulse
− Assess rate, presence, location, quality,
regularity
− To palpate, gently compress an artery against a
bony prominence.
• Count for 15 minutes and multiply by four.
• Check for central pulse in unresponsive patients.
Vital Signs
Vital Signs
• Respiration
− Assess rate by inspecting the patient’s chest
− Quality
• Pathologic respiratory patterns or rhythms
• Tripod positioning, accessory muscle use,
retractions
− Rate should be measured for 30 seconds and
multiplied by two for pediatric patients.
Vital Signs
• Blood pressure
− Product of cardiac output and peripheral
vascular resistance
• Systolic pressure
• Diastolic pressure
− Measured using a cuff
− Ideally should be auscultated
Vital Signs
• Temperature
− When measuring the tympanic membrane
temperature:
• External auditory canal must be free of cerumen.
• Position the probe so the infrared beam is aimed at
the tympanic membrane.
• Wait 2-3 seconds until temperature appears.
Vital Signs
• Pulse oximetry
− Should never be
used as an
absolute indicator
of the need for
oxygen
− Measures
percentage of
hemoglobin
saturation
Equipment Used in the
Secondary Assessment
• Stethoscope
• Otoscope
• Blood pressure cuff
(sphygmomanometer)
• Scissors
• Capnography
• Glucometry
• Ophthalmoscope
• Reliable light source
• Gloves
• Sheet or blanket
Equipment Used in the
Secondary Assessment
• Stethoscope
− Acoustic: blocks
out ambient
sounds
− Electronic:
converts sound
waves into
electronic signal
and amplifies them
© Denis Pepin/ShutterStock, Inc.
Equipment Used in the
Secondary Assessment
• Blood pressure cuff
− Measurement of
blood pressure
− Consists of
inflatable cuff and
manometer
(pressure meter)
− Use the
appropriate size!
© WizData, Inc./ShutterStock, Inc.
Equipment Used in the
Secondary Assessment
• Ophthalmoscope
− Allows you to look
into patient’s eyes
− Consists of
concave mirror and
battery-powered
light
− Requires dilation of
pupils and
diagnostic
expertise
© Kenneth Chelette/ShutterStock, Inc.
Equipment Used in the
Secondary Assessment
• Otoscope
− Evaluates ears of a patient
− Consists of head and handle
Physical Examination
• Look for signs of
significant distress
• Other aspects:
− Dress
− Hygiene
− Expression
− Overall size
− Posture
− Untoward odors
− Overall state of health
© Jones & Bartlett Learning. Courtesy of MIEMSS.
Physical Examination
• Terms to describe the
degree of distress:
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No apparent distress
Mild
Moderate
Acute
Severe
• Terms to describe the
general state of a
patient’s health:
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Chronically ill
Frail
Feeble
Robust
Vigorous
Full-Body Scan
• A systematic head-to-toe examination
• Patients who should receive:
− Sustained a significant MOI
− Unresponsive
− Critical condition
• See Skill Drill 13-3.
Focused Assessment
• Performed on
patients who have
sustained
nonsignificant
MOIs and are
responsive
• Focus on the
immediate
problem.
Mental Status
• For any patient with a “head” problem,
assess and palpate for signs of trauma.
− Assess the patient in four areas:
• Person
• Place
• Day of week
• The event
Mental Status
• Use the
Glasgow
Coma Scale
− Assigns point
value for eye
opening,
verbal
response, and
motor
response
Mental Status
• Mental status examination
− General appearance
− Speech and language patterns
− Mood
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Thoughts and perceptions
Information relevant to thought content
Insight and judgment
Cognitive function (attention and memory)
Skin
• Serves three major functions
− Regulates the temperature of the body
− Transmits information from the environment to
the brain
− Protects the body from the environment
Skin
• Epidermis (outermost layer)
− Barrier against water, dust, microorganisms,
and mechanical stress
• Dermis
− Composed of collagen and elastic fibers, and a
mucopolysaccharide gel
− Divided into: Papillary dermis and reticular layer
Skin
Skin
• Examine:
− Color
− Moisture
− Temperature
− Texture
− Turgor
− Significant lesions
• Evidence of
diminished
perfusion:
− Pallor
− Cyanosis
− Diaphoresis
− Vasodilation
(flushing)
Skin
• Pallor: poor red blood cell perfusion to the
capillary beds
• Vasoconstriction: indicated by pale skin
• Cyanosis: low arterial oxygen saturation
• Mottling: severe hypoperfusion and shock
Skin
• Ecchymosis: localized bruising or blood
collection within or under the skin
• Turgor: relates to hydration
• Skin lesions: may be only external evidence
of a serious internal injury
Hair
• Examine by inspection and palpation.
− Note:
• Quantity
• Distribution
• Texture
Nails
• Note:
− Color
− Shape
− Texture
− Presence or
absence of
lesions
− Normal nail
should be firm
and smooth.
Head
• Cranium: contains the brain
− Occiput: posterior portion
− Temporal regions: each side of the cranium
− Parietal regions: between temporal regions and
occiput
− Frontal region: forehead
Head
• The scalp covers the cranium.
• Meninges: suspend the brain and spinal
cord (dura matter, arachnoid, pia matter)
• Cerebrospinal fluid: fills between meninges
Head
• Inspect and feel
the entire cranium.
− Deformity
− Asymmetry
−
−
−
−
Warm, wet areas
Tenderness
Shape and contour
Scars or shunts
© E. M. Singletary, M.D. Used with permission.
Head
• Evaluate the face.
− Color
− Moisture
− Expression
−
−
−
−
Symmetry and contour
Swelling or apparent areas of injury
DCAP-BTLS
See Skill Drill 13-4.
Eyes
• Assess functions of CNS.
• Anterior chamber
• Posterior chamber
• Inspect and palpate the upper and lower
orbits.
Eyes
Eyes
• Note periorbital
ecchymosis
(raccoon eyes).
− Snellen (“E”) chart
− Light/dark
discrimination
− Finger counting
© German Ariel Berra/ShutterStock, Inc.
• Assess visual
acuity
Eyes
• Assess pupils.
− Normally round
and equal size
− Pupils should react
instantly to change
in light level.
− Check for size,
shape, and
symmetry, and
reaction to light.
Ears
• Involved with hearing, sound perception,
and balance control
• Includes:
− External ear
− Middle ear
− Inner ear
Ears
Ears
• Assess for changes in hearing perception,
wounds, swelling, and drainage.
− Assess mastoid process of the skull for
discoloration and tenderness.
− Examine by using an otoscope
(see Skill Drill 13-7).
Nose
• Nasal cavity is
divided into two
chambers
− Each chamber
contains three
layers of bone.
− Assess anteriorly
and inferiorly.
Nose
• Look for:
− Asymmetry
− Deformity
− Wounds
−
−
−
−
Foreign bodies
Discharge or bleeding
Tenderness
Evidence of respiratory distress
Throat
• Evaluate mouth, pharynx, and neck
− Prompt assessment is mandatory in patients
with altered mental status.
− Assess for a foreign body or aspiration.
• Be prepared to assist with manual techniques and
suction.
Throat
• Mouth
− Lips
− Symmetry
− Gums
− Look for cyanosis around the lips.
• Inspect airway for obstruction.
Throat
• Tongue
− Size
− Color
− Moisture
• Maxilla and
mandible
− Integrity
− Symmetry
• Oropharynx
− Discoloration
− Pustules
− Unusual odors on
the breath
− Fluids that might
need suctioning
− Edema and
redness
Throat
• Neck
− Symmetry
− Masses
− Venous distention
− Palpate carotid pulses.
− Palpate the suprasternal notch .
− See Skill Drill 13-8.
Cervical Spine
• Consider MOI
− Evaluate for:
• Pain
• Altered mental
status
• Loss of
consciousness at
the time of the
event
Cervical Spine
• Inspect and palpate.
− Stop exam if pain, tenderness, or tingling
results.
− Assess range of motion when there is no
potential for serious injury.
• Passive exam
• Active exam
Chest
• Contains lungs, heart, and great vessels
• Three phases of exam
− Chest wall exam
− Pulmonary evaluation
− Cardiovascular assessment
− See Skill Drill 13-9.
Chest
• Check for:
− Symmetry
− Respiratory effort
− Signs of obstruction
−
−
−
−
General shape of the chest wall
Signs of abnormal breathing
Chest deformities
Tenderness or crepitus
− Normal
− Tracheal
−
−
−
−
Bronchial
Bronchovesicular
Vesicular
Adventitious
• Wheezing, rales,
rhonci, stridor,
pleural friction rubs
© Jones & Bartlett Learning. Courtesy of MIEMSS.
• Auscultate breath
sounds.
© Jones & Bartlett Learning. Courtesy of MIEMSS.
Chest
Chest
• Are sounds:
− Dry or moist?
− Continuous or intermittent?
− Course or fine?
• Are breath sounds diminished or absent?
− In a portion of one lung or entire chest?
− If localized, assess transmitted voice sounds.
Chest
• Assess respiratory rate, depth, and effort.
− Check for accessory muscle use, retractions, or
ventilatory fatigue.
− Check for jugular venous distention (JVD).
Cardiovascular System
• Circulates blood
throughout the
body
− Plasma
− Red blood cells
− White blood cells
− Platelets
Cardiovascular System
• System of tubes:
− Arteries
− Aterioles
− Capillaries
− Venules
− Veins
• Two circuits:
− Systemic
circulation
• Carries oxygenrich blood
− Pulmonary
circulation
• Carries oxygenpoor blood
Cardiovascular System
• Cardiac cycles involves:
− Cardiac relaxation (diastole)
− Filling
− Contraction (systole)
• Heart consists of four chambers
− Two atria
− Two ventricles
Cardiovascular System
Cardiovascular System
• The contraction and relaxation of the heart
generates heart sounds.
Cardiovascular System
Cardiovascular System
• Splitting: events on the right of the heart
usually occur later than those on the left
− Creates two discernible sounds
• Heart sounds can be heard in:
− Parasternal areas
− Region superior to the left nipple
− Refer to Skill Drill 13-10.
Cardiovascular System
• Korotkoff sounds: related to blood pressure
− There are 5 (1st and 5th are significant)
• First: thumping of the systolic
• Fifth: disappears as the diastolic pressure drops
below that created by the blood pressure cuff
Cardiovascular System
• Bruit: abnormal “whoosh”-like sound
− Turbulent blood flow through narrowed artery
• Murmur: abnormal “whoosh”-like sound
− Turbulent blood flow around a cardiac valve
− Graded by range of intensity from 1 to 6
Cardiovascular System
• Arterial pulses are an expression of systolic
blood pressure.
− Palpable where artery crosses bony
prominence
• Venous pressure tends to be low.
− Assess extremities for signs of obstruction or
insufficiency.
Cardiovascular System
• Jugular venous distention (JVD)
− With penetrating left chest trauma, may indicate
cardiac tamponade
− With pedal edema, consider heart failure.
− Note how much distention is present.
Cardiovascular System
• Pay attention to
arterial pulses.
• Obtain blood
pressure and
repeat.
− Note history and
class of
hypertension.
Cardiovascular System
• Palpate and auscultate carotid arteries.
• Listen where cardiac valves are located:
− Aortic valve: right of the sternum
− Pulmonic valve: left of the sternum
− Tricuspid valve: lower left sternal border
− Mitral valve: lateral to the lower left sternal
border
Cardiovascular System
• For a suspected heart problem, assess:
− Pulse
− Skin
− Breath sounds
− Baseline vital signs
− Extremities
Cardiovascular System
• The definition of normal and abnormal
findings is different in a neonate or infant.
− Neonates often have cyanosis following birth.
− “Abnormal” heart sounds may be a normal
variant.
Abdomen
• Divided into
imaginary
quadrants
• Contains:
− Organs of
digestion
− Organs of
urogenital system
− Significant
neurovascular
structures
Abdomen
• Peritoneum: a well-defined layer of fascia
made up of the parietal and visceral
peritoneum
− Intraperitoneal organs
− Extraperitoneal organs
Abdomen
• Organs are organized by viewing the
abdominal wall in a subdivided fashion.
− Quadrants
• Left upper quadrant
• Right upper quadrant
• Left lower quadrant
• Right lower quadrant
Abdomen
• Abdomen can also
be divided by
ninths.
Abdomen
• Three basic mechanisms produce pain:
− Visceral pain
− Inflammation
− Referred pain
• Appropriate and relevant history is critical.
Abdomen
• Inspect and palpate the abdomen.
− Tightness: internal bleeding or inflamed organ
− Upper left pain: ruptured spleen
− Lower left pain: diverticulitis
− Lower right pain: appendicitis
− Generalized pain in women: obstetric or
gynecologic problem
Abdomen
• Orthostatic vital signs (tilt test)
− Blood pressure and pulse are taken in the
supine and sitting or standing positions.
− Determines extent of volume depletion
• If volume-depleted, there is not enough circulating
blood to push into core circulation
Abdomen
• Orthostatic vital signs (tilt test) (cont’d)
− Generally considered positive if:
• Decrease in systolic pressure
• Increase in diastolic pressure of 10 mm Hg
• Increase in pulse rate by 20 beats/min
Abdomen
• Examine the area of complaint last.
− Work slowly.
− Avoid quick movements.
− Proceed in a systematic fashion.
− Refer to Skill Drill 13-11.
Abdomen
• Inspect:
− Skin
− Contour and
appearance
− Symmetry
− Rash or signs of
allergic reaction
− Scars
− Wounds
− Swelling/bruising
− Discoloration in
periumbilical area
or along the flanks
− Localized masses
− Striae
− Dilated veins
− Distention
Abdomen
• Abdomen can be described as:
− Flat
− Rounded
− Protuberant (bulging out)
− Distinguish from obesity
− Scaphoid
− Pulsatile
Abdomen
• Auscultation
− Setting must be quiet.
− Note bowel sounds.
• Hyperactive, hypoactive, increased, decreased,
absent
− Bruits
Abdomen
• Palpation
− Palpate each quadrant gently but firmly.
• Should appear soft without tenderness or masses.
− Guarding: contraction of abdominal muscles
− Rebound tenderness: pain upon release
− Abdominal rigidity: peritoneal irritation and
guarding
Abdomen
• Palpation (cont’d)
− To palpate the liver:
• Place left hand behind patient, parallel to right 11th
and 12th ribs
• Place right hand on right abdomen below rib cage.
• Ask patient to take a deep breath.
• Try to feel the liver edge.
Abdomen
• Palpation (cont’d)
− To palpate the gallbladder:
• Use same technique as for liver
• Response indicating pain may mean possible
inflammation
• When patient takes deep breath, move fingers
under liver edge
Abdomen
• Palpation (cont’d)
− To palpate the spleen:
• With left hand, reach over and around patient
• Press forward lower left rib cage and adjacent soft
tissues.
• With right hand below costal margin, press toward
the spleen.
Abdomen
• Aortic aneurysm
− May be seen pulsating in the upper midline
− Do not palpate an obvious pulsatile mass.
• Hernia
− Place patient in supine position and raise the
head and shoulders.
• Bulge of hernia will usually appear.
Female Genitalia
• Consists of:
− External genitalia
− Ovaries
− Fallopian tubes
− Uterus
− Vagina
Female Genitalia
• Limited and discreet assessment
− Reasons to examine include:
• Life-threatening hemorrhage
• Imminent delivery in childbirth
− Assessment includes:
• Palpating the bilateral inguinal regions
• Palpating the hypogastric region
Female Genitalia
• Reasons for pain on palpation include:
− Ectopic pregnancy
− Complications of third trimester pregnancy
− Nonpregnant ovarian problems
− Pelvic infections
Male Genitalia
• Consists of:
− Reproductive
ducts
− Testes
− Urethra
− Prostate
− Penis
Male Genitalia
• Limited exam with partner present.
− Assess for bleeding, injury, or fracture.
− Note inflammation, discharge, swelling, or
lesions.
− Priapism: prolonged erection
− Look for evidence of urinary incontinence.
Musculoskeletal System
• Joints: areas where bone ends abut each
other and form a kind of hinge
• Skeletal muscles: used to flex and extend
joints
− Joints become more vulnerable to injury, stress,
and trauma as they age.
Musculoskeletal System
• Common injuries:
− Fractures
− Sprains
− Strains
−
−
−
−
Dislocations
Contusions
Hematomas
Open wounds
Musculoskeletal System
• Note:
− Structure and
function
− Limitation or pain
in range of motion
− Bony crepitance
− Inflammation or
injury
− Obvious deformity
− Diminished
strength
− Atrophy
− Asymmetry
− Pain
− Refer to Skill Drill
13-12.
Musculoskeletal System
• Problems with the
shoulders can often
be determined by
noting posture.
− Assess:
• Sternoclavicular joint
• Acromioclavicular joint
• Subacromial area
• Bicipital groove
Musculoskeletal System
• Assess range of motion:
− Ask patient to raise arms above the head.
− Have patient demonstrate external rotation and
abduction.
− Perform internal rotation.
Musculoskeletal System
• Inspect elbows.
− Palpate between the
epicondyles and
olecranon.
− Range of motion:
• Flex and extend
passively and
actively.
• Pronate the forearms
while the elbows are
flexed.
Musculoskeletal System
• Inspect hands and
wrists.
− Palpate the hands.
− Palpate the carpal
bones.
− Range of motion:
• Make fists, then
extend fingers
• Flex/extend wrists
• Move hands laterally
and medially
Musculoskeletal System
• Inspect knees and
hips.
− Range of motion:
• Ask patient to bend
each knee and
raise toward chest.
• Assess for rotation
and abduction of
hips.
− Palpate each hip.
− Palpate pelvis.
Musculoskeletal System
• Observe ankles and
feet.
− Palpate feet and
ankles.
− Assess range of
motion:
• Have patient plantar
flex, dorsiflex, and
invert and evert
ankles and feet.
• Inspect, palpate, and
check forefoot and
toes.
Peripheral Vascular System
• Comprises aspects of
circulatory system
− Lymphatic system:
network of nodes and
ducts dispersed
throughout the body
− Lymph nodes: larger
accumulations of
lymphatic tissues
Peripheral Vascular System
• Perfusion occurs in the peripheral
circulation.
− Diseases of the peripheral vascular system are
often seen in patients with other underlying
medical conditions.
Peripheral Vascular System
• During assessment, pay attention to upper
and lower extremities.
− Signs of acute or chronic vascular problems
− Refer to Skill Drill 13-13.
Peripheral Vascular System
• Assessment
− Inspect upper extremities.
− Five Ps of acute arterial insufficiency:
• Pain
• Pallor
• Parasthesias/Paresis
• Poikilothermia
• Pulselessness
Peripheral Vascular System
• Assessment (cont’d)
− Palpate epitrochlear and axillary lymph nodes.
− Inspect lower extremities.
− Palpate lower extremities.
− Note temperature of feet and legs.
− Attempt to palpate edema.
− Palpate superficial inguinal lymph nodes.
Spine
• Consists of 33
individual
vertebrae
• Anchoring point for
the skull,
shoulders, ribs,
and pelvis
• Protects the spinal
cord
Spine
• Inspect the back.
− Lordosis
− Kyphosis
− Scoliosis
Spine
© Wellcome Trust Library/National Medical Slide
Bank/Custom Medical Stock Photo
© Dr. P. Marazzi/Photo Researchers, Inc.
© Southern Illinois University/Photo Researchers,
Inc.GA5323
Spine
• Palpate the spine.
• Check back for any other findings.
− Tap over costovertebral angles.
− Palpate scapulae, paraspinal areas, and base
of neck.
− Check the buttocks.
Spine
• Range of motion:
− Check passively first, then actively.
• See Skill Drill 13-14.
Nervous System
• Central nervous system: brain and spinal
cord
• Peripheral nervous system: remaining
motor and sensory nerves
Nervous System
• Brain comprises cerebrum, cerebellum, and
medulla
• Except for cranial nerves, nerves are
channeled to the brain via the spinal cord.
− Motor nerves control motion or movement.
− Sensory nerves send external signals to the
brain.
Nervous System
• Cranial nerves go directly to and from the brain.
Nervous System
• Voluntary nervous system
• Involuntary (autonomic) nervous system
− Sympathetic
− Parasympathetic
− Reflexes
− Primitive reflexes
Nervous System
• Neurologic exam
−
−
−
−
Mental status (AVPU)
Cranial nerve function
Distal motor function
Distal sensory
function
− Deep tendon reflexes
• Mental status exam
(COASTMAP)
−
−
−
−
−
−
−
−
Consciousness
Orientation
Activity
Speech
Thought
Memory
Affect (mood)
Perception
Nervous System
• Glasgow Coma Scale may also be used to
assess people with alterations in mental
status.
• See Skill Drill 13-15.
Nervous System
• Cranial nerve
examination
− Determines
presence and
degree of disability
− Can be performed
in less than 3
minutes
Nervous System
• Evaluation of the
motor system
− Posture and body
position
− Involuntary
movements
− Muscle strength
− Coordination
− Proprioception
Nervous System
• Check sensory function.
− Assess primary and cortical sensory functions.
− Evaluate deep tendon reflexes.
• See Skill Drill 13-16.
Nervous System
• Results of the neurologic exam
− Delirium
• Consistent with an acute sudden change in mental
status
− Dementia
• Representative of deterioration of cognitive cortical
functions
Secondary Assessment of
Unresponsive Patients
• After ruling out trauma, position in recovery
position.
− If trauma, position in neutral alignment
• Perform a thorough assessment of the body
and look for signs of illness.
Secondary Assessment of
Unresponsive Patients
• Perform at least two sets of vital signs.
− Should include:
• Auscultated blood pressure
• Accurate pulse and respiratory rates
• Patient’s temperature
• Consider unresponsive patients to be in
unstable condition.
Secondary Assessment of
Trauma Patients
• Two classifications of trauma patients:
− Isolated injury
− Multisystem trauma
• “High visibility factor”
− Do not become distracted by obvious but nonlife-threatening injuries.
Secondary Assessment of
Trauma Patients
• Patient who is unresponsive or has altered
mentation is considered high risk.
• Perform rapid exam.
− When time and condition permit, perform
physical examination.
Secondary Assessment of
Infants and Children
• Attempt to elicit information from the patient
before parents.
• Obtain permission of a parent before
examining if possible.
• Examine from toe to head.
Secondary Assessment of
Infants and Children
• When examining a newborn or neonate, be
aware of normal variants:
− Vernix
− Edema
− Mongolian spots
− Jaundice
− Asymmetry of the head
Secondary Assessment of
Infants and Children
• Provide support of the head and neck.
• Examine eyes for irregularities.
• Inspect the umbilical cord.
• Children are prone to dehydration and
infection.
Secondary Assessment of
Infants and Children
• Ages 1 to 3 years
− Will object to being
touched or
manipulated
− Use toe-to-head
approach.
• Ages 4 to 5 years
− Usually cooperative
and helpful
• School-age
− Be sure to explain
what you are doing.
• Adolescents
− Concerned with bodily
integrity
Secondary Assessment of
Infants and Children
• General principles:
− Remain calm.
− Be patient, gentle, and honest.
− Attempt to keep children with their parents.
− Do not neglect a child’s pain.
Secondary Assessment of
Infants and Children
• Exam techniques can vary slightly:
− Auscultation of a quiet infant’s abdomen is
simple.
− Active tinkling bowel sounds may be heard.
− A more tympanic sound might be heard on
percussion of an infant’s abdomen.
− Palpation techniques will vary with age.
Recording Secondary
Assessment Findings
• Should be orderly and concise
• Document using the forms recommended
by your medical director.
− Note:
• Objective signs
• Pertinent negatives
• Similar relevant information
Limits of the Secondary
Assessment
• Evaluation by a trained physician,
laboratory testing, and radiographic studies
may be needed for a definitive diagnosis.
Monitoring Devices
• Continuous ECG
monitoring
− Purpose is to
establish a
baseline
− Electrodes must be
placed properly.
• The leads are
usually colored
and labeled to help
with placement.
• Continuous ECG
monitoring (cont’d)
− Bipolar leads
consist of two
electrodes.
• Placed on different
limbs
• Einthoven triangle
From Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.
Monitoring Devices
Monitoring Devices
• 12-lead ECG
monitoring
© Jones & Bartlett Learning
− Patient should be
supine.
− Prepare the skin.
− Connect electrodes.
− Connect and apply
the precordial leads.
− Record the ECG.
Monitoring Devices
• Carbon dioxide monitoring
− Capnometry
• Measures carbon dioxide output
− Capnography
• Measures carbon dioxide output and provides a
waveform
Monitoring Devices
Courtesy of Physio-Control, Inc.
Courtesy of Physio-Control, Inc.
Courtesy of Physio-Control, Inc.
Monitoring Devices
• Blood glucometer
− Can obtain reading in two ways in the field:
• From the hub of an IV catheter
• From a finger stick
− Most take only a few seconds.
− Should be calibrated regularly
Monitoring Devices
• Cardiac biomarkers
− Used to assess presence of damage to cardiac
muscle
− May take several hours following a myocardial
infarction for the cardiac biomarkers to become
elevated
Monitoring Devices
• Other blood tests
− Basic and complete metabolic profile (CHEM 7
and CHEM 12)
− Brain natriuretic peptide (BNP) test
− Arterial blood gases
Reassessment
• Stable patients should be reassessed every
15 minutes.
• Unstable patients should be reassessed
every 5 minutes.
Reassessment of Mental
Status and the ABCs
• Compare LOC with baseline assessment.
• Review the airway.
• Reassess breathing, circulation, pulse
Reassessment of Mental
Status and the ABCs
• Response of pediatric and geriatric patients
may differ.
− Children decompensate very quickly.
− Geriatric patients may not show signs of
deterioration.
Reassessment of Patient Care
and Transport Priorities
• Have you addressed all life threats?
• Do priorities need to be revised?
• Is initial transport decision appropriate?
• Obtain another complete set of vital signs
and compare with expected outcomes.
− Priority patients: minimum three sets
Reassessment of Patient Care
and Transport Priorities
• Look for trends.
• Revisit patient complaints.
• Document all of your findings.
Summary
• Patient assessment is the most important
skill a paramedic has.
• Patient assessment has five components:
−
−
−
−
−
Scene size-up
Primary assessment
History taking
Secondary assessment
Reassessment
Summary
• The first step of the patient assessment
process is the scene size-up.
• During the size-up, you also make a
determination of the mechanism of injury or
nature of the patient’s illness.
• Another important step in protecting
yourself is to take standard precautions.
Summary
• The first step in the primary assessment is
to form a general impression of the
patient’s condition.
• During the primary assessment, you should
be able to identify threats to the ABCs;
these life threats should be addressed
immediately.
Summary
• After assessing the patient for disability, you
must make a transport decision and, if the
patient has sustained trauma, perform a
rapid exam.
• Once the primary assessment is complete
and all life threats have been addressed,
you can move into the history-taking phase
of patient assessment.
Summary
• Patient history is a primary means of
diagnosing the chief complaint in the field.
• The first part of a patient’s history also
serves as a good mental status
examination: ask for the patient’s name;
the date, time, and location; the chief
complaint; and the events leading up to the
request for EMS assistance.
Summary
• After clarifying the history of the present
illness, ask the patient about his or her past
medical history, the state of his or her
health, and any pertinent family history.
• For responsive patients, the history may
generally be obtained directly from the
patient; for unresponsive medical patients
and trauma patients, it may be necessary to
obtain the history from family.
Summary
• Use constructive communications skills as
you talk with patients.
• At times you will need to ask patients about
sensitive topics. Be familiar with techniques
for successfully asking patients about these
topics.
• Obtaining a history from a geriatric patient
may involve challenges.
Summary
• Work on strategies within your service and
with your partner for positive
communications with patients.
• Secondary assessment is the process by
which quantifiable, objective information is
obtained from a patient about his or her
overall state of health.
Summary
• There are times when you may not have
time to perform a secondary assessment.
The two types of physical examinations are
the full-body exam and the focused
assessment.
Summary
• The secondary assessment includes
obtaining vital signs and performing a headto-toe survey.
• The techniques of inspection, palpation,
percussion, and auscultation allow you to
use your physical senses to obtain physical
information and to understand the normal
functions of a patient’s body.
Summary
• Vital signs consist of a measurement of
blood pressure; pulse rate, rhythm, and
quality; respiratory rate, rhythm, and quality;
temperature; and pulse oximetry.
• Monitoring devices used by the paramedic
include continuous ECG monitoring, 12-lead
ECG, carbon dioxide monitoring, blood
chemistry analyses, and cardiac
biomarkers, among others.
Summary
• You need to alter your approach to patient
assessment when dealing with infants and
children.
• After the primary assessment, the
reassessment is the single most important
assessment process you will perform.
Summary
• The reassessment is performed on all
patients. It gives you an opportunity to
reevaluate the chief complaint and to
reassess interventions to ensure that they
are still effective.
• A patient in stable condition should be
reassessed every 15 minutes, whereas a
patient in unstable condition should be
reassessed every 5 minutes.
Credits
• Chapter opener: Courtesy of Rhonda Beck
• Backgrounds: Green—Jones & Bartlett Learning;
Purple—Jones & Bartlett Learning. Courtesy of
MIEMSS; Blue—Courtesy of Rhonda Beck; Red—
© Margo Harrison/ShutterStock, Inc.
• Unless otherwise indicated, all photographs and
illustrations are under copyright of Jones & Bartlett
Learning, courtesy of Maryland Institute for
Emergency Medical Services Systems, or have
been provided by the American Academy of
Orthopaedic Surgeons.