Transcript When Performing a Physical Examination

LESSON 11
SECONDARY ASSESSMENT
© 2011 National Safety Council
11-1
Introduction
• With no immediate threats to life, obtain the history and
conduct a secondary assessment
• Obtain the patient’s vital signs and perform a physical
examination
• The secondary assessment reveals additional
information and problems
• Continue to reassess the patient to ensure treatment is
effective and that the patient’s condition is not worsening
© 2011 National Safety Council
11-2
Patient History
© 2011 National Safety Council
11-3
Patient History
• Patient’s history is gained from patient or others
• Begin by asking about the patient’s chief complaint
• Although history focuses on specific injury or chief
complaint, it should be complete
• With responsive medical patients, you may take history
before performing physical examination
• With trauma patients and any unresponsive patient,
perform physical examination first
© 2011 National Safety Council
11-4
Taking a History
• Talk to a responsive patient
• With an unresponsive patient, talk to family members or
others at the scene about what they know or saw
• Look for medical alert insignia or other medical
identification
• In the home, look for medication bottles and a Vial of Life
© 2011 National Safety Council
11-5
Taking a History
(continued)
• With trauma patient, assess forces involved
• When taking history of a responsive patient with a
sudden illness, ask fully about the patient’s situation
to learn possible causes
• Look for clues in the environment
© 2011 National Safety Council
11-6
SAMPLE
S = Signs and symptoms
A = Allergies
M = Medications
P = Pertinent past history
L = Last food or drink
E = Events
© 2011 National Safety Council
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Additional Guidelines
for History
• If patient is unresponsive, ask family members or
bystanders
• Check scene for clues of what may have happened
• Consider environment
• Consider patient’s age
• When additional EMS personnel arrive, give them
information you gathered
© 2011 National Safety Council
11-8
Age Variations in History
• When taking the history and performing the secondary assessment,
consider the patient’s life stage
• For pediatric patients:
- Assess an infant’s pulse at brachial artery
- Use capillary refill as an indicator of adequate blood flow in infants and
children younger than 6
- Use distracting measures and other actions to help gain the child’s trust
• For geriatric patients:
- Help the patient obtain eye glasses and hearing aids for improved
communication
- Accept that taking the history may take more time
© 2011 National Safety Council
11-9
Secondary Assessment
• After the history, unless you are now providing critical
patient care, continue patient assessment
• Take the patient’s vital signs
• Perform a physical examination
© 2011 National Safety Council
11-10
Vital Signs
• Some EMR check patient’s
vital signs
• Vitals signs assessed include:
- Breathing rate, rhythm, depth
and ease
- Pulse rate, rhythm and strength
- Skin color, temperature and
condition
- Pupil size, equality and reaction
to light
- Blood pressure
© 2011 National Safety Council
11-11
Importance of Vital Signs
• Vital signs reveal additional information about condition
• Changes in vital signs, from the baseline vital signs, are
important and should be documented
• Changes may show deterioration or improvement with
treatment
• Vital signs vary significantly among different individuals
• Vital signs are affected by stress, activity and other
variables
© 2011 National Safety Council
11-12
Normal Vital Signs
Patient
Normal
Respiratory
Rate at Rest
Normal Pulse Normal Blood
Rate at Rest Pressure
(systolic/diastolic)
Infant
30-40
100-160
70-100 / 56-70
Child
20-30
70-130
70-120 / 50-80
Adult
12-20
60-100
118-140 / 60-90
© 2011 National Safety Council
11-13
Assessing Respiration
• Don’t tell a responsive patient that
you are assessing breathing
• Count respirations while holding
wrist draped across chest as if
taking a pulse
• Observe or feel for the chest rising
and falling (1 cycle = 1 breath)
© 2011 National Safety Council
11-14
Assessing Respiration
• Count number of breaths in
30 seconds and multiply by 2
• Note whether patient is
making an effort to breathe,
is short of breath or is using
accessory muscles of neck
and abdomen in breathing
© 2011 National Safety Council
11-15
(continued)
Characteristics of
Respiratory Distress
• Gasping or wheezing
• Very fast or slow respiratory rate
• Very shallow or very deep breathing
• Shortness of breath, difficulty speaking
© 2011 National Safety Council
11-16
Assessing Pulse
1. Have a responsive patient sit or lie down
2. Take a radial pulse in an adult or child
- If no radial pulse, take carotid pulse in an adult or
brachial pulse in a child
- Always take brachial pulse in an infant
3. Count the beats for 30 seconds and multiply by 2
4. Note strength of pulse (strong or weak)
5. Note rhythm of pulse (regular or irregular)
© 2011 National Safety Council
11-17
Characteristics of Possible
Circulation Problem
• Very fast or very slow pulse
• Very weak or strong, bounding pulse
• Very weak and fast pulse (thready pulse) may
indicate shock
• Irregular rhythm may indicate a cardiac problem
• Unequal pulses at different sites
© 2011 National Safety Council
11-18
Assessing Skin
Temperature and Condition
• Assess skin temperature using back of hand on skin
• Assess skin color
• Assess skin moisture
• In a young child, assess capillary refill
© 2011 National Safety Council
11-19
Skin Characteristics
That May Indicate a Problem
• Skin temperature
• Unusual coloration
• Skin condition
• Capillary refill time >2 seconds may indicate shock or
diminished blood flow
© 2011 National Safety Council
11-20
Assessing Pupils
• Assess size of patient’s pupils
• Assess the pupils for equality
• Assess reactivity to light
© 2011 National Safety Council
11-21
Assessing Pupils
Pupil characteristics that may
indicate a problem:
• Dilated or constricted pupils
• Unequal pupils
• Non-reactive pupils
© 2011 National Safety Council
11-22
(continued)
Blood Pressure
• When heart contracts,
pressure is higher (systolic
pressure)
• Pressure falls lower when
heart relaxes between
beats (diastolic pressure)
• Blood pressure is recorded
as systolic pressure over
diastolic pressure
© 2011 National Safety Council
11-23
Blood Pressure
• Some EMRs are trained
to take blood pressure
• Blood pressure is force of
blood pressing against
arterial wall from heart’s
pumping action
• Blood pressure indicates
level of perfusion
© 2011 National Safety Council
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(continued)
Skill: Measuring Blood Pressure by
Auscultation
© 2011 National Safety Council
11-25
© 2011 National Safety Council
11-26
Repeated Blood Pressure
• It is difficult to interpret blood pressure because of
wide variation among individuals
• Repeated measurements may show a possible trend
in patient’s condition
• A drop in blood pressure in shock usually develops
as a late sign
© 2011 National Safety Council
11-27
Measuring Blood
Pressure by Palpation
• If you don’t have a stethoscope or the scene is noisy,
measure systolic blood pressure by palpation
• While palpating radial pulse, inflate cuff 30 mmHg
beyond the point where you stop feeling pulse
• While watching gauge, open valve to slowly deflate cuff
• Note pressure when you feel radial pulse return
• Record pressure as systolic pressure and include word
‘palpated’ (e.g., “130 palpated” or “130/P”)
© 2011 National Safety Council
11-28
Physical Examination
• Unless you are caring for a life-threatening condition,
perform a physical examination
• Purpose is to find and assess additional signs and
symptoms of illness or injury
• Because patients are often anxious about being
examined, provide emotional support
© 2011 National Safety Council
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Physical Examination
(continued)
• Information gained from examination may help you care
for patient and be of value to arriving EMS personnel
• Complete rapid trauma assessment of unresponsive
patient or a patient with a significant MOI
• Perform focused physical examination of responsive
medical patient or a trauma patient with only a minor
injury
© 2011 National Safety Council
11-30
When Performing a
Physical Examination
• Allow responsive patient to remain in position he/she
finds most comfortable
• Ask responsive patient for consent to do physical
examination
• Don’t start with a painful area
© 2011 National Safety Council
11-31
When Performing a
Physical Examination (continued)
• Watch for facial expression or stiffening of body part
• In responsive patient, begin with area of chief complaint
and examine other body areas only as appropriate
• With unresponsive patient, examine patient from head
to toe in a systematic manner
• If you find life-threatening problem at any time, treat it
immediately
© 2011 National Safety Council
11-32
When Performing a Physical
Examination (continued)
• Sign: an objective
observation or
measurement such as warm
skin or a deformed extremity
• Symptom: a subjective
observation reported by the
patient, such as pain or
nausea
© 2011 National Safety Council
11-33
Use Systematic
Head-To-Toe Approach
• Begin at head because injuries here are more likely to
be serious than injuries elsewhere
• With responsive children, begin at feet and work up
body
• Look and palpate for signs and symptoms throughout
body – compare one side of body to other when
appropriate
© 2011 National Safety Council
11-34
DOTS for Trauma Patients
D = Deformities
O = Open injuries
T = Tenderness (pain)
S = Swelling
© 2011 National Safety Council
11-35
DCAP-BTLS Memory Aid
D = Deformities
C = Contusions
A = Abrasions
P = Punctures/Penetrations
B = Burns
T = Tenderness
L = Lacerations
S = Swelling
© 2011 National Safety Council
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Check Head and Neck
• Skull
• Eyes
• Ears
• Nose
• Breathing
• Mouth
• Neck
© 2011 National Safety Council
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Check Chest
• Deformity?
• Wounds?
• Tenderness?
• Bleeding?
• Use of accessory
muscles?
• Equal chest rise?
© 2011 National Safety Council
11-38
Check Abdomen
• Rigidity?
• Pain?
• Bleeding?
© 2011 National Safety Council
11-39
Back
• Unless head or spinal injury is suspected, roll patient
onto side to examine back
• If head or neck injury is suspected, don’t move patient
but slide your gloved hand under back
• Sweep entire lower back, looking at fingertips of your
gloved hands for any bleeding
• Treat any tenderness, swelling or deformity of lower part
of spine as a sign of spinal injury and don’t move patient
© 2011 National Safety Council
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Check Hips and Pelvis
• Tenderness?
• Instability?
• Incontinence?
• Priapism?
© 2011 National Safety Council
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Check Lower Extremities
• Bleeding? Asymmetry?
Deformity? Pain?
• Normal movement,
sensation, temperature?
• Circulation?
© 2011 National Safety Council
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Check Upper Extremities
• Bleeding? Deformity?
Pain?
• Medial alert identification?
• Normal movement,
sensation, temperature?
• Circulation?
© 2011 National Safety Council
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Reassessment
• Continue to assess while awaiting additional EMS
resources and giving care
• Calm and reassure patient while reassessing
breathing and circulation and repeating vital signs
and physical examination
• Repeat reassessments:
- Every 15 minutes for a stable patient
- Every 5 minutes for an unstable patient
© 2011 National Safety Council
11-44
Performing Reassessment
• The primary assessment of responsiveness, breathing
and circulation
• Vital signs
• The chief complaint
© 2011 National Safety Council
11-45
Importance of Reassessment
• Check that your interventions
are effective
• Perform additional treatments
as needed
© 2011 National Safety Council
11-46
Compare Reassessment
Results to Baseline Status
• Level of responsiveness
• Airway maintenance
• Adequacy of breathing (rate, depth, effort)
• Adequacy of circulation (carotid or radial pulse; skin
color, temperature and moisture)
• Chief complaint (pain remains the same, getting worse
or getting better)
• Presence of new or previously undisclosed symptoms
© 2011 National Safety Council
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Hand-Off Report
• Give EMS hand-off report with detailed information
about the patient’s:
- Age and gender
- Chief complaint
- Responsiveness
- Airway and breathing status
- Circulation status
© 2011 National Safety Council
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Hand-Off Report
(continued)
• Also include:
- Vital signs and physical examination findings
- Results of SAMPLE history
- Interventions provided and the patient’s response to them
• You may also complete a written report containing the
same information
© 2011 National Safety Council
11-49