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Assessment of the Patient

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Assessment of the Patient Concepts of Emergency Medicine Pam Knepp, RN BSN References Bergeron, J. David & Chris Le Bandour. (2009). First Responder. 8th Edition. – PowerPoint PPT presentation

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Title: Assessment of the Patient


1
Assessment of the Patient
  • Concepts of Emergency Medicine
  • Pam Knepp, RN BSN

2
Assessment of the Patient
  • Scene Size-up
  • Initial Assessment
  • Focused History and Physical Exam
  • Vital Signs
  • Hand-off to EMTs

3
Patient Assessment
Bergeron, J. David Chris Le Bandour. (2009).
First Responder. 8th Edition. Pearson Prentice
Hall. Upper Saddle RiverNJ.
4
Patient Assessment
Bergeron et al. (2009). First Responder. 8th
Edition. Pearson Prentice Hall. Upper Saddle
RiverNJ.
5
Scene Size-up
  • Every patient assessment begins with scene
    size-up, which includes
  • 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

6
Scene Size-up
  • BSI precautions
  • Rescuer wears protective eye wear.

7
Scene Size-up
  • BSI precautions
  • Rescuer dons gloves.

8
Scene Size-up
  • BSI precautions
  • Rescuer wears both a gown and a simple surgical
    mask.

9
Scene Size-up
  • BSI precautions
  • Rescuer wears a HEPA mask. (filters the air so
    less allergens or pollutants are being inhaled)

10
Scene Size-up
  • Scene Safety
  • An assessment of the scene and surroundings will
    provide valuable information to the First
    Responder and will ensure the well-being of the
    First Responder.

11
Scene Size-up
  • Scene Safety
  • Personal protection
  • Protection of the patient
  • Protection of bystanders
  • If the scene is not safe, make it safe.
    Otherwise, DO NOT ENTER.

12
Scene Size-up
  • Unstable situation
  • HazMAT situation
  • Violent situation

13
Scene Size-up
  • Identify Mechanism of Injury
  • In trauma situations
  • An evaluation of the forces that caused an injury
  • May be beneficial in determining the presence of
    internal injuries
  • Determined from the patient, family, or
    bystanders, and inspection of the scene

14
Scene Size-up
  • Identify Mechanism of injury
  • Trauma patient

15
Scene Size-up
  • Identify mechanism of injury
  • Impact 1

A car collides head on with a tree.
16
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.
17
Scene Size-up
  • Identify mechanism of injury
  • Impact 3

The impact of the steering wheel to the drives
chest area cause additional damage to inner
organs.
18
Scene Size-up
  • Identify nature of illness
  • In medical situations
  • Determined from the patient, family, or
    bystanders
  • Why was EMS called?

19
Scene Size-up
  • Identify nature of illness

20
Scene Size-up
  • Determine the number of patients and additional
    resources needed
  • It is important to account for all patients
    involved.
  • Request additional resources if needed
  • Fire department
  • Police
  • ALS crews (Advanced Life Support)
  • Rescue
  • Utilities
  • Call for resources early.

21
Initial Assessment
  • Form a general impression of the patient.
  • Assess the patients mental status.
  • Assess the patients airway.
  • Assess the patients breathing.
  • Assess the patients circulation.
  • Make a decision on the priority the patient
    (notify dispatch)

22
Initial Assessment
  • The initial assessment is completed to assist the
    First Responder in identifying Immediate Threats
    to Life.

23
Initial Assessment
  • Form a General Impression of the Patient
  • Based on the First Responders immediate
    assessment of the environment and the patients
    chief complaint.

24
Initial Assessment
  • Form a general impression of the patient
  • Assess the Patients Mental Status
  • Classify the patients mental status into one of
    the following categories
  • Alert
  • Verbal
  • Painful
  • Unresponsive

25
Initial Assessment
  • Assess the patients mental status.
  • Assessing the apparently unresponsive patient

26
Initial Assessment
  • Assess the patients mental status
  • Assessing the apparently responsive patient

27
Initial Assessment
  • Assess the patients airway
  • Head-Tilt Chin-Lift

28
Initial Assessment
  • Assess the patients airway
  • Jaw-thrust maneuver (with suspected neck injury)

29
Initial Assessment
  • Assess the patients airway
  • Suction of needed

30
Initial Assessment
  • Assess the patients airway
  • Insert an airway adjunct as needed

31
Initial Assessment
  • Assess the patients breathing
  • Look at the effort of breathing.
  • Look, listen, and feel for presence of
    ventilations.
  • Ventilate as needed.

32
Initial Assessment
  • Assess the patients circulation
  • Check for a pulse (carotid artery in adults and
    brachial artery in infants).
  • Check for serious bleeding (control bleeding).
  • Check skin color.

33
Initial Assessment
  • Make a decision on the priority of the patient
    and alert dispatch.
  • High priority
  • Poor general impression
  • Unresponsiveness
  • Breathing difficulties
  • Severe bleeding or shock
  • Complicated childbirth
  • Chest pain
  • Severe pain

34
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
35
Focused History and Physical Exam
  • Trauma PatientSignificant MOI
  • Significant mechanisms of injury include
  • 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

36
Focused History and Physical Exam
  • Trauma PatientSignificant MOI
  • Significant mechanisms of injury in a child
    include
  • Falls greater than 10 feet
  • Bicycle collision
  • Medium-speed vehicle collision

37
Focused History and Physical Exam
  • Physical Exams or Assessments
  • Deformities
  • Contusions
  • Abrasions
  • Punctures and Penetrations
  • Burns
  • Tenderness
  • Lacerations
  • Swelling

38
Focused History and Physical Exam
  • Trauma patient Rapid trauma assessment
  • Stabilize the head and neck, and check the head
    (scalp and face).

39
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.

40
Focused history and physical exam
  • Trauma patient rapid trauma assessment
  • Check the chest
  • Check each quadrant of the abdomen (note any
    abnormalities, tenderness, or foreign bodies)

41
Focused History and Physical exam
  • Trauma PatientRapid Trauma Assessment
  • Check the pelvis, pressing gently down and
    inward.

42
Focused History and Physical Exam
  • Trauma PatientRapid Trauma Assessment
  • Check the extremities, legs, and then arms (look
    for any deformity, swelling, or discoloration).

43
Focused History and Physical Exam
  • Trauma PatientRapid Trauma Assessment
  • Check for distal pulse, motor function, and
    sensation in each extremity.

44
Focused History and Physical Exam
  • Trauma PatientRapid Trauma Assessment
  • Check the back and buttocks while maintaining
    c-spine immobilization
  • keep arms close to center of body and patient is
    moved keeping the entire body aligned while
    rolling patient on his side.
  • the patient is rolled on the count of the person
    holding c-spine.

45
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46
Focused History and Physical Exam
  • Trauma PatientNo Significant MOI
  • 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

47
Focused History and Physical Exam
  • Trauma PatientFocused Trauma Assessment
  • Examine the area that is injured.
  • Take vital signs.
  • Provide appropriate care (i.e. stabilize any
    injuries, control bleeding, dress wounds)

48
Focused History and Physical Exam
  • Trauma Patient
  • SAMPLE History
  • Signs and symptoms
  • Allergies
  • Medications
  • Pertinent past medical history
  • Last oral intake
  • Events leading to the illness or injury

49
Focused History and Physical Exam
  • Medical PatientUnresponsive
  • Steps of assessment include
  • Perform a rapid physical exam (head-to-toe).
  • Take vital signs (pulse, respirations, blood
    pressure if equipment available, mental
    status).
  • Gather SAMPLE history.

50
Focused History and Physical Exam
  • Medical PatientResponsive
  • Steps of assessment include
  • Gather SAMPLE history.
  • Take vital signs (pulse, respirations, blood
    pressure-if equipment available, mental status)
  • Perform a focused physical exam.
  • Area of chief complaint
  • Note any medical identification devices (i.e.
    allergy bracelets)

51
Vital Signs
  • Pulse
  • Assess for three characteristics
  • Rate (number of beats per minute)
  • Strength (weak, bounding, thready, absent)
  • Rhythm (regular or irregular)
  • Carotid pulse in the neck (most distinct pulse
    felt)
  • Radial pulse in the lateral portion of the
    forearm, on the thumb side of the wrist (most
    easily accessible)

52
Vital Signs
  • Pulse
  • To measure a radial pulse rate (number of
    beats/minute)
  • 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.

53
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
RiverNJ.
54
Vital Signs
  • Pulse
  • The normal pulse rate for adults is 60100 bpm.
  • Rate gt 100 Tachycardia
  • Rate lt 60 Bradycardia
  • 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

55
Vital Signs
  • Respirations
  • Assess for 2 characteristics
  • Rate
  • Slow
  • Normal
  • Rapid
  • Character
  • Rhythm(Regular or Irregular)
  • Depth(Normal, Shallow, or Deep)
  • Sound(Abnormal Sounds)
  • Ease(Labored, Difficult, or Painful)

56
Vital Signs
  • Respirations
  • 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.

57
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
RiverNJ.
58
Vital Signs
  • Respirations
  • The normal respiratory rate for adults is 1220
    breaths per minute.
  • gt 28 or lt 8 are considered serious.
  • Newborn infants 2550 breaths per min.
  • Up to 5 years old 2030 breaths per min.
  • 5 to 12 years of age 1530 breaths per min.

59
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
HallNJ.
60
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
RiverNJ.
61
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
RiverNJ.
62
Ongoing Assessment
  • While awaiting the additional EMS resources, the
    First Responder should continue to assess the
    patient.

63
Ongoing Assessment
  • 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.

64
Hand-off Report to EMS
  • Verbal Report
  • Patients mental status
  • Age and sex
  • Chief complaint
  • Airway, breathing, and circulatory status
  • Physical findings
  • SAMPLE history
  • Interventions applied
  • Patients response to interventions
  • Accurate Documentation if Required

65
Summary
  • Scene Size-up
  • Initial Assessment
  • Focused History and Physical Exam
  • Vital Signs
  • Hand-off to EMTs

66
References
  • 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.
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