Advanced Patient Assessment

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Advanced Patient Assessment
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General Phases of Assessment

• Review of dispatch information
• Scene Survey/Environmental Safety
• Primary Survey
• Secondary Survey
• Vital Signs
• Patient History

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Review of Dispatch Information

• Location of the incident
• Nature of the incident
• Potential problems at the location
• Information on appropriate equipment
• Mental preparation

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Scene Survey/Environmental Safety

• Note expressions of bystanders
• Identify scene hazards
• Poisonous or caustic substances
• Biological/Germ infested agents
• Water hazards
• Confined spaces
• Extreme heights
• Bloodborne or airborne pathogens
• Traffic Hazards
• Other hazards
• Determine special needs
• Evaluate mechanism of injury

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Primary Assessment

• Completing the ABCDEs
• Goals
• To detect immediate life threats
• To treat life-threatening conditions
• To make decisions regarding immediate transport
  vs.. further on-scene assessment and transport

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Sequence of Assessment Steps

• Airway assessment management
• Breathing assessment management
• Circulation assessment management
• Disability assessment
• Expose examine

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Airway Assessment Mgmt.

• Universal Precautions
• Identify self establish rapport
• Open airway of unconscious patient using simple
  manual maneuver
• Modified-jaw thrust - suspected C-spine injury
• Head-tilt/chin lift non trauma

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Listen For

• Presence of breathing
• Noisy respirations
• Snoring
• Tongue in posterior airway
• Try repositioning the head
• Stridor or crowing
• May indicate laryngeal obstruction
• Difficult to correct in the field
• Wheezing
• Lower airway constriction
• Difficult to correct in the field

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Insert Airway Adjunct if Necessary

• Look for chest rise fall airway obstruction
  in the mouth
• Feel for air movement
• OPA for unconscious patients
• NPA for conscious patients requiring airway
  management
• High concentration of O2 with nonrebreather mask
  for patients with altered mental status or airway
  problems

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Breathing Assessment Mgmt.

• Evaluate respiratory rate tidal volume
• Expose and assess chest for equal symmetrical
  chest rise
• Identify stabilize flail chest/paradoxical
  movement
• Identify stabilize sucking chest wounds
• Identify collapsed lung stabilize
• Chest decompression if necessary within your
  protocols

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Breathing Assessment Mgmt.

• Identify airway correct obstructions
• Auscultate both lungs
• Identify tension pneumothorax
• Provide immediate airway ventilatory management
  with diminished tidal volume or respiratory rate

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Circulation

• Check patient for gross hemorrhage
• Palpate carotid radial pulses at the same time
  (rate, quality, rhythm)
• Bradycardia
• Cardiac problem, head injury, parasympathetic
  nervous system stimulation
• Tachycardia
• Sympathetic nervous system stimulation (pain,
  shock, hypoxia, anxiety)
• Assess skin temp., moisture, color
• Check capillary refill time

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Disability

• Perform a quick check for LOC
• A - Alert
• V - Responds to verbal stimuli
• P - Responds to painful stimuli only
• U - U responsive to voice or pain
• Check pupil quality size response to light
  (PEARL)
• Check ability to move extremities

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Expose

• Expose pertinent areas
• Scan for obvious signs of trauma
• Bleeding, bruising, deformity, edema,
  discoloration (DCAPBTLS)
• Respect privacy of patient
• Use common sense

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Evaluate the Primary Assessment

• Administer patient care according to local
  protocols
• Remember Golden Hour transport suspected trauma
  patients quickly
• Stable trauma patients, consider secondary
  assessment on scene
• Decide whether to involve high-level EMS
  personnel where to meet them

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Secondary Assessment

• Trauma Patient

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Secondary Assessment

• Purpose is to do a complete head to toe exam to
  ensure that you do not miss any subtle signs or
  symptoms of injury.
• Remember that any life-threatening injuries must
  be taken care of in the primary survey

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Methods of Physical Examination

• Inspection - visual exam
• Look for obvious abnormalities
• Note any DCAPBTLS
• Palpation - exam by touch
• Feel for any DCAPBTLS
• Look for guarding
• Auscultation - exam of internal organs by
  listening
• Use a stethoscope
• Listen for diminished breath sounds, rales
  wheezing
• Used to recognize normal findings

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Head

• Check the scalp for lacerations
• Palpate for open wounds, depressions,
  protrusions, lack of symmetry
• Basilar skull fractures allow blood fluid from
  the brain to seep into soft tissue
• Periorbital ecchymosis (raccoon's eyes)
• Battles sign
• Late signs not usually visible on scene

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Ears

• Look for presence of fluid
• Blood or cerebrospinal fluid
• Halo test can confirm presence of CSF
• Never block the flow of fluid from the ears

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Eyes

• Check orbits for instability and asymmetry, signs
  of fracture or dehydration
• Check PEARL
• Look for unequal (anisocoria), dilated or
  pinpoint pupils
• Evaluate eye movement
• Dysconjugate gaze, dolls eyes (not with
  suspected spinal injury
• Cornea for contact lenses or lesions
  

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Face

• Palpate facial bones for stability crepitus
• Look for maxilla/mandible instability or asymmetry

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Nose Mouth

• Examine nares for flaring
• Examine both for fluids or obstructions
• Use suction to remove blood, vomitus, secretions
  or other fluids
• Note unusual orders
• Alcohol, feces, acetone, almonds, etc.

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Neck

• Inspect for tenderness, soft tissue injuries, and
  any (DCAPBTLS)
• Inspect for
• Tracheal deviation
• JVD
• Subcutaneous emphysema
• Crepitus
• Medic Alert Tag

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Chest Back

• Check for DCAPBTLS
• Note chest dimension air exchange
• Palpate anterior posterior thorax
• Note abnormal breathing patterns
• Kussmauls - rapid deep (diabetic coma)
• Cheyne-Stokes - progressive increase in rate
  later gradually subsides , periods of apnea
  (brain stem injury)
• Biots - short, gasping, irregular breaths,
  hyperapnea (severe brain injury)
• Auscultate all lung fields

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Abdomen Lower Back

• Inspect palpate for bruising guarding
• Note signs of intra-abdominal hemorrhage
• Cullens sign - Bruising around the umbilicus
• Grey-Turners sign - bruising over the flanks
• Palpate all four quadrants
• Rebound tenderness
• Guarding or distension
• Abdominal mass, ascites, pulsating mass

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Pelvis

• Apply pressure to illiac crest symphysis pubis
• If pain, crepitation, or instability is elicited,
  suspect fracture

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Male Genitalia

• Examine for external trauma hemorrhage
• Note priapism
• sign of possible spinal cord injury

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Female Genitalia

• Examine for external trauma hemorrhage
• Sexual abuse or rape
• Try to have examiner of same sex
• Conduct exam limited to patient stabilization
• Encourage patient not to douche, bathe, or brush
  teeth
• Provide emotion support reassurance
• Note volume character of blood or discharges in
  OB emergencies

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Lower Extremities

• Examine for DCAPBTLS
• Perform PMS check
• Look for Medic Alert Tag

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Upper Extremities

• Examine for DCAPBTLS
• Perform PMS check
• Look for Medical Alert bracelet

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Neurological Assessment

• Evaluate neurological status compare to primary
  assessment (AVPU)
• Continuum of diminishing responsiveness
• Alert oriented
• Disoriented
• To place
• To time
• To persons
• To self
• A O x 4

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Vital Signs

• Blood Pressure
• Pulse
• Respirations
• Skin Condition

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Blood Pressure

• Must measure in all patients with pulse
• Auscultation
• Palpation
• Systolic
• Diastolic
• Pulse pressure

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Pulse

• Valuable indicator of circulatory function
• Note findings
• Location (carotid, femoral, radial)
• Rate
• Quality (strong, weak)
• Regularity

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Respiration

• Normal rates for adults at rest range from 12-20
  breaths per minute
• Normal tidal volume approximately 500 ml.
• If patient does not appear to be moving enough
  air
• Administer supplemental O2
• Provide at least 800 ml ventilation with BVM
• Intubate as needed

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Skin Color

• Pale (pallor) - decreased blood flow
• Red (flushed) - increased blood flow
• Blue (cyanosis) - severe hypoxia
• Blotchy red - allergic reaction
• Mottled - signifies shock
• Yellow (jaundice) - liver problems

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Skin Temperature

• Cool skin (vasoconstriction)
• Cold skin - rapid loss of body heat
• Hot skin - vasodilation (heat stroke, fever)

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Moisture

• Clammy skin - compensatory shock
• Dry skin - may indicate failure of bodys normal
  sweating mechanism, such as burn injuries, heat
  stroke

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Keys to Assessment

• Vital signs keys to internal body conditions
• Other diagnostic signs include
• pulse oximetry
• blood glucose determination

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Secondary Assessment

• Medical Patient

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Developing a Patient History

• Structures include
• Introductions
• Chief complaint
• History of present illness
• Past medical history
• Family social history

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Introductions

• Done best at eye level
• Attention to non-verbal signs
• Genuine concern and compassion
• Request to use patients name as provided

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Chief Complaint

• Reason patient called for help
• Starting point for interview
• Report and record patients own words

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History of Present Illness

• Elicit subjective symptoms with OPQRST format
• O - Onset
• P - Provocation
• Q - Quality
• R - Radiation
• S- Severity
• T - Time
• Elicit associated symptoms
• Identify pertinent negatives

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Past Medical History

• Use AMPLE format
• A - Allergies
• M - Medications
• P - Past medical history
• L - Last oral intake
• E - Events leading to problem

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Family/Social History

• Pertinent hereditary lifestyle factors
• Record smoking history in packs/years
• Modified physical exam
• Inspect, palpate auscultate only areas
  pertinent to the patients problem

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Communications

• Patient Report
• Requires standardized format terminology
• SOAP format - Subjective -Objective -Assessment -
  Plan
• Sloppy, rambling report indicates the same
  quality of care

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Written Documentation

• Same standardized format as verbal report
• Becomes permanent part of patients medical
  history
• Becomes best legal defense in court