Transcript Assessment of the Patient

Assessment of the
Patient
Concepts of Emergency Medicine
Pam Knepp, RN BSN
Assessment of the Patient
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Scene Size-up
Initial Assessment
Focused History and Physical Exam
Vital Signs
Hand-off to EMTs
Patient Assessment
Bergeron, J. David & Chris Le Bandour. (2009). First Responder. 8th
Edition. Pearson Prentice Hall. Upper Saddle River:NJ.
Patient Assessment
Bergeron et al. (2009). First Responder. 8th Edition. Pearson Prentice Hall. Upper
Saddle River:NJ.
Scene Size-up
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Every patient assessment begins with scene size-up,
which includes:
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Taking BSI precautions (body substance isolation)
Determining if the scene is safe
Identifying the MOI (mechanism of injury) or nature of
illness
Determining the number of patients
Identifying any additional resources needed
Scene Size-up
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BSI precautions
Rescuer wears protective
eye wear.
Scene Size-up
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BSI precautions
Rescuer dons gloves.
Scene Size-up
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BSI precautions
Rescuer wears both a gown
and a simple surgical
mask.
Scene Size-up
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BSI precautions
Rescuer wears a HEPA
mask. (filters the air so
less allergens or
pollutants are being
inhaled)
Scene Size-up
*Scene Safety:
An assessment of the
scene and
surroundings will
provide valuable
information to the
First Responder and
will ensure the wellbeing of the First
Responder.
Scene Size-up
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Scene Safety:
1)
Personal protection
Protection of the patient
Protection of bystanders
2)
3)
**If the scene is not safe, make it safe. Otherwise,
DO NOT ENTER.
Scene Size-up
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Unstable situation
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HazMAT situation
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Violent situation
Scene Size-up
*Identify Mechanism of Injury:
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In trauma situations
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An evaluation of the forces that caused an injury
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May be beneficial in determining the presence of internal
injuries
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Determined from the patient, family, or bystanders, and
inspection of the scene
Scene Size-up
*Identify Mechanism of
injury
Trauma patient
Scene Size-up
*Identify mechanism of injury
Impact #1
“A car collides head on with a tree.”
Scene Size-up
*Identify Mechanism of
injury
Impact #2
“The car collision causes the
drivers chest to hit steering
wheel.”
“The steering wheel causes
damage to the chest area and
broken ribs.”
Scene Size-up
*Identify mechanism of
injury
“The impact of the steering wheel to the
drives chest area cause additional damage to
inner organs.”
Impact #3
Scene Size-up
*Identify nature of illness:
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In medical situations
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Determined from the patient, family, or bystanders
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Why was EMS called?
Scene Size-up
*Identify nature of illness
Scene Size-up
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Determine the number of patients and additional resources
needed:
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It is important to account for all patients involved.
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Request additional resources if needed:
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Fire department
Police
ALS crews (Advanced Life Support)
Rescue
Utilities
Call for resources early.
Initial Assessment
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Form a general impression of the patient.
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Assess the patient’s mental status.
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Assess the patient’s airway.
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Assess the patient’s breathing.
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Assess the patient’s circulation.
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Make a decision on the priority the patient (notify dispatch)
Initial Assessment
The initial assessment is completed to assist the First
Responder in identifying Immediate Threats to
Life.
Initial Assessment
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Form a General Impression of the Patient
Based on the First Responder’s immediate
assessment of the environment and the
patient’s chief complaint.
Initial Assessment
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Form a general impression of the
patient
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Assess the Patient’s Mental Status:
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Classify the patient’s mental status
into one of the following
categories:
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Alert
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Verbal
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Painful
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Unresponsive
Initial Assessment
*Assess the patient’s
mental status.
Assessing the apparently
unresponsive patient
Initial Assessment
*Assess the patient’s mental
status
Assessing the apparently responsive
patient
Initial Assessment
*Assess the patient’s
airway
Head-Tilt; Chin-Lift
Initial Assessment
*Assess the patient’s airway
Jaw-thrust maneuver (with suspected neck injury)
Initial Assessment
*Assess the patient’s airway
Suction of needed
Initial Assessment
*Assess the patient’s airway
Insert an airway adjunct as needed
Initial Assessment
*Assess the patient’s breathing
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Look at the effort of breathing.
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Look, listen, and feel for presence of ventilations.
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Ventilate as needed.
Initial Assessment
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Assess the patient’s circulation
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Check for a pulse (carotid artery in adults and
brachial artery in infants).
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Check for serious bleeding (control bleeding).
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Check skin color.
Initial Assessment
Make a decision on the priority of the patient
and alert dispatch.
High priority:
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Poor general impression
 Unresponsiveness
 Breathing difficulties
 Severe bleeding or shock
 Complicated childbirth
 Chest pain
 Severe pain
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Focused History and Physical Exam
Trauma Patient
Medical Patient
Significant Mechanism of Injury
Unresponsive Medical Patient
• Perform a rapid trauma assessment
• Take vital signs
• Gather SAMPLE history
• Perform a rapid physical assessment
• Take vital signs
• Gather SAMPLE history
No Significant Mechanism of Injury
Responsive Medical Patient
• Perform a focused trauma assessment
• Take vital signs
• Gather SAMBLE history
• Gather SAMPLE history
• Perform focused physical exam
• Take vital signs
Focused History and Physical Exam
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Trauma Patient—Significant MOI:
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Significant mechanisms of injury include:
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Ejection from a vehicle
Death of another passengers in a MVC
Falls greater than 15 feet
Rollover vehicle collision
High-speed vehicle collision
Vehicle-pedestrian collision
Motorcycle crash
Unresponsiveness or altered mental status
Penetrations of the head, chest, or abdomen
Focused History and Physical Exam
* Trauma Patient—Significant MOI:
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Significant mechanisms of injury in a child include:
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Falls greater than 10 feet
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Bicycle collision
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Medium-speed vehicle collision
Focused History and Physical Exam
* Physical Exams or Assessments:
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Deformities
Contusions
Abrasions
Punctures and Penetrations
Burns
Tenderness
Lacerations
Swelling
Focused History and Physical Exam
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Trauma patient – Rapid
trauma assessment
Stabilize the head and neck, and
check the head (scalp and
face).
Focused History and Physical Exam
* Trauma assessment –
rapid trauma assessment
Check the neck and apply a cervical
collar (if trained to do so). Note
any swelling or tenderness.
Focused history and physical exam
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Trauma patient – rapid
trauma assessment
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Check the chest
Check each quadrant of the
abdomen (note any
abnormalities, tenderness, or
foreign bodies)
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Focused History and Physical exam
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Trauma Patient—
Rapid Trauma
Assessment
Check the pelvis, pressing gently down
and inward.
Focused History and Physical Exam
* Trauma Patient—
Rapid Trauma
Assessment
Check the extremities, legs, and then
arms (look for any deformity,
swelling, or discoloration).
Focused History and Physical Exam
* Trauma Patient—
Rapid Trauma
Assessment
Check for distal pulse, motor function,
and sensation in each extremity.
Focused History and Physical Exam
* Trauma Patient—Rapid Trauma
Assessment
Check the back and buttocks while
maintaining c-spine
immobilization:
1) keep arms close to center of body
and patient is moved keeping the
entire body aligned while rolling
patient on his side.
2) the patient is rolled on the count
of the person holding c-spine.
Focused History and Physical Exam
* Trauma Patient—No Significant MOI:
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Steps of assessment include:
 Perform a focused trauma assessment.
 Take vital signs.
 Gather SAMPLE history.
S-signs/symptoms
A-allergies
M-medication
P-past history
L-last oral intake
E-events prior
Focused History and Physical Exam
* Trauma Patient—Focused Trauma
Assessment
1)
2)
3)
Examine the area that is injured.
Take vital signs.
Provide appropriate care (i.e. stabilize any
injuries, control bleeding, dress wounds)
Focused History and Physical Exam
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Trauma Patient:
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SAMPLE History:
Signs and symptoms
 Allergies
 Medications
 Pertinent past medical history
 Last oral intake
 Events leading to the illness or injury
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Focused History and Physical Exam
* Medical Patient—Unresponsive:
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Steps of assessment include:
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Perform a rapid physical exam (head-to-toe).
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Take vital signs (pulse, respirations, blood pressure – if
equipment available, mental status).
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Gather SAMPLE history.
Focused History and Physical Exam
* Medical Patient—Responsive:
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Steps of assessment include:
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Gather SAMPLE history.
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Take vital signs (pulse, respirations, blood pressure-if
equipment available, mental status)
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Perform a focused physical exam.
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Area of chief complaint
**Note any medical identification devices (i.e. allergy bracelets)
Vital Signs
* Pulse:
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Assess for three characteristics:
Rate (number of beats per minute)
 Strength (weak, bounding, thready, absent)
 Rhythm (regular or irregular)
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Carotid pulse in the neck (most distinct pulse felt)
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Radial pulse in the lateral portion of the forearm, on the
thumb side of the wrist (most easily accessible)
Vital Signs
* Pulse:
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To measure a radial pulse rate (number of beats/minute)
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Use your 1st and 2nd fingertips to feel for an artery.
Do not use your thumb.
Find the artery (usually radial or carotid)
Apply moderate pressure.
Count the beats for 30 seconds.
Multiply your 30-second count by 2.
Vital Signs
*PULSE
Observation
Possible Problem
Rapid, strong pulse
Internal bleeding (early stages), fear, heat
emergency, overexertion, high blood
pressure, fever
Rapid, weak pulse
Shock, blood loss, heat emergency, diabetic
emergency, failing circulatory system
Slow, strong pulse
Stroke, skull fracture, brain injury
No pulse
Cardiac arrest
Bergeron et al. (2009) First Responder. 8th Edition. Pearson Prentice Hall. Upper Saddle River:NJ.
Vital Signs
* Pulse:
The normal pulse rate for adults is 60–100 bpm.
 Rate > 100 = Tachycardia
 Rate < 60 = Bradycardia
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Newborn infants = 120 to 160 bpm
 Up to 5 years old = 80 to 140 bpm
 5 to 12 years of age = 70 to 110 bpm
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Vital Signs
* Respirations:
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Assess for 2 characteristics:
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Rate:
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Slow
Normal
Rapid
Character:
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Rhythm—(Regular or Irregular)
Depth—(Normal, Shallow, or Deep)
Sound—(Abnormal Sounds)
Ease—(Labored, Difficult, or Painful)
Vital Signs
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Respirations:
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To measure & assess respirations:
After pulse count, leave your hand on the wrist.
 Observe the rise and fall of the chest.
 Listen for sounds.
 Count the number of breaths in 30 seconds.
 Multiply your 30-second count by 2.
 Note rhythm, depth, sound, and ease of breathing.
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Vital Signs
Observation
Possible Problem
Rapid, shallow breaths
Shock, heart problems, heat emergency, diabetic
emergency, heart failure, pneumonia
Deep, gasping labored breaths
Airway obstruction, heart failure, heart attack, lung
disease, chest injury, diabetic emergency
Slow breathing
Head injury, stroke, chest injury, certain drugs
Snoring
Stroke, fractured skull, drug or alcohol abuse,
partial airway obstruction
Crowing
Airway obstruction, airway injury due to heat
Gurgling
Airway obstruction, lung disease, lung injury due to
heat
Wheezing
Asthma, emphysema, airway obstruction, heart
failure
Coughing blood
Chest wound, chest infection, fractured ribs,
punctured lung, internal injury
Bergeron et al. (2009). First Responder. 8th Edition. Pearson Prentice Hall. Upper Saddle River:NJ.
Vital Signs
* Respirations:
The normal respiratory rate for adults is 12–20
breaths per minute.
 > 28 or < 8 are considered serious.
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Newborn infants = 25–50 breaths per min.
 Up to 5 years old = 20–30 breaths per min.
 5 to 12 years of age = 15–30 breaths per min.
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Vital Signs
*Skin color, temperature, moisture
Observation
Significant / Possible Problem
Pink
Normal in light-skinned patients; normal in inner
eyelids, lips, and nail beds of dark-skinned patients
Pale
Constricted blood vessels possibly resulting from
blood loss, shock, decreased blood pressure,
emotional distress
Blue (cyanotic)
Lack of oxygen in blood cells and tissue resulting
from inadequate breathing or heart function
Red (flushed)
Heat exposure, high blood pressure, emotional
excitement; cherry red indicates late stages of
carbon monoxide poisoning
Yellow (jaundiced)
Liver abnormalities
Blotchiness (mottling)
Occasionally in patients that are in shock
Bergeron et al. (2009). First Responder. 8th Edition. Pearson Prentice Hall. Upper Saddle Hall:NJ.
Vital Signs
*Skin signs
Skin Signs
Significant / Possible Problem
Cool, clammy
Shock, anxiety, heart attack
Cold, moist
Body is losing heat
Cold, dry
Exposure to cold
Hot, dry
High fever, heat emergency, spinal injury
Hot, moist
High fever, heat emergency
Goose bumps accompanied by shivering, chattering
teeth, blue lips, and pale skin
Chills, communicable disease, exposure to cold,
pain, or fear
Bergeron et al. (2009). First Responder. 8th Edition. Pearson Prentice Hall. Upper Saddle River:NJ.
Vital Signs
* Pupils
Observation
Possible Problem
Dilated, nonreactive pupils
Unresponsiveness, shock, cardiac arrest, bleeding,
certain medications, head injury
Constricted, nonreactive pupils
Central nervous system damage, certain
medications
Unequal pupils
Stroke, head injury
Bergeron et al. (2009). First Responder. 8th Edition. Pearson Prentice Hall. Upper Saddle River:NJ.
Ongoing Assessment
While awaiting the
additional EMS
resources, the First
Responder should
continue to assess the
patient.
Ongoing Assessment
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Repeat initial assessment:
Repeat every 15 minutes for a stable patient.
Repeat every 5 minutes for an unstable patient.
Repeat exams as needed.
Repeat vital signs.
Check interventions.
Calm and reassure.
Provide comfort measures.
Hand-off Report to EMS
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Verbal Report:
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Patient’s mental status
Age and sex
Chief complaint
Airway, breathing, and circulatory status
Physical findings
SAMPLE history
Interventions applied
Patient’s response to interventions
Accurate Documentation if Required
Summary
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Scene Size-up
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Initial Assessment
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Focused History and Physical
Exam
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Vital Signs
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Hand-off to EMTs
References
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Bergeron, J. David & Chris Le Bandour.
(2009). First Responder. 8th Edition.
Pearson Prentice Hall. Upper Saddle River:
NJ.
Knepp, Pamela RN BSN. Personal
experience.
Smith, Travis NREMT-P, CCEMT-P.
Personal experience.