Patient Assessment in Emergency Care

• Assessment involves scene size-up, primary assessment, history taking, secondary assessment, and reassessment
• Symptom refers to what the patient tells you they feel
• Sign is what you can observe about the patient

Scene Size Up

• Evaluating conditions is a scene size-up
• Situational awareness is needed throughout the call
• Dispatch provides basic information about the request for help
• Scene safety is paramount

Hazards

• Examples include environmental, physical, chemical, electrical, water, fire, explosions, and potential violence
• Recognize the potential for violence involving violent patients, distraught family members, angry bystanders, and gangs

Standard Precautions and PPE

• PPE protects against objects, blood, body fluids, and communicable diseases
• Treat all blood, body fluids (except sweat), non-intact skin, and mucous membranes as potentially infectious
• Standard precautions should be taken or initiated before patient contact
• At a minimum, gloves must be in place before any patient contact

Mechanism of Injury (MOI) / Nature of Illness (NOI)

• Includes Medical conditions, Traumatic injuries, or both
• Traumatic injuries result from physical forces applied to the body
• Blunt trauma involves force over a broad area, with potential damage below the skin's surface
• Penetrating trauma involves force at a small point of contact, creating an open wound with infection risk

Nature of Illness (NOI)

• Be aware of scenes with multiple patients showing similar signs or symptoms
• Carbon monoxide poisoning is an example

Number of Patients and Triage

• Accurately identify the total patients during size-up
• Use incident command system when multiple patients are involved
• Triage: Process of sorting patients based on the severity of each patient's condition

Additional/Specialized Resources

• Includes Advanced Life Support (ALS), air medical support, fire departments, and law enforcement
• Fire departments handle hazardous materials, technical rescue, wilderness search and rescue, high-angle/rope rescue, or water rescue

Determining Need for Additional Resources

• Consider whether the scene is a threat, the number of patients, and available resources

Primary Assessment

• Primary goal is to identify and treat immediate or imminent life threats
• It involves physically examining the patient, assessing level of consciousness (LOC), airway, breathing, and circulation (ABCs)
• General impression determines care priority

General Impression

• Note the patient's position and whether they are moving
• Address the patient by name and introduce yourself
• Ask about the chief complaint
• The patient's response can give insight into the LOC, air patency, respiratory status, and overall circulatory status
• Define whether patient's condition is stable, stable but potentially unstable, or unstable

Assess for Uncontrolled External Bleeding

• Check for adequate breathing and circulation
• Unconscious patient focuses first on airway, breathing, and circulation (ABCs) when assessing for uncontrolled external bleeding
• Sustained unconsciousness: critical respiratory, circulatory, or central nervous system problem or deficit might exist
• Conscious with altered LOC may be due to inadequate perfusion, medications, drugs, alcohol, or poisoning

Level Of Consciousness (LOC) using AVPU

• AVPU:*
• Awake and alert
• Responsive to Verbal stimuli
• Responsive to Pain
• Unresponsive

Stimulus tests for LOC

• The patient who does not respond to just verbal stimuli will require a painful stimulus
• Pinch skin, use back of upper arm or the trapezius area
• Apply upward pressure under eyebrow
• Patient will moan or withdraw to the stimuli

Altered mental status

• Any deviation from alert and oriented to person, place, time, and event, or from a patient's normal baseline, is considered an altered mental status

Orientation tests

• Mental status testing of the patients memory and thinking ability

Airway Assessment: Responsive vs. Unresponsive

• Talking or crying patients have an open airway
• A conscious patient who cannot speak or cry most likely has a severe airway obstruction
• Clear the patient's airway if there problems
• If patient shows breathing difficulty or not breathing take corrective action immediately

Signs of airway obstruction

• Obvious trauma, blood, or other obstruction
• Noisy breathing, snoring, gurgling
• Extremely shallow or absent breathing

Airway assesment of unresponsive individuals

• Immediately asses the patency of the airway
• If there is a potential for trauma, use the jaw-thrust maneuver to open the airway
• If cannot obtain a patent airway using the jaw-thrust maneuver, head tilt-chin lift is okay

Assess Breathing

• Airway is open and clear before you can help
• Patient breathing adequately and not hypoxic

Positive pressure ventilations

• For patients not breathing or breathing too slow or shallow
• Patients breathing adequately but remain hypoxic, administer oxygen
• Oxygen saturation of approximately 94% to 99% for patient's
• Difficulty breathing after primary assessment: immediately reevaluate the airway
• Provide positive pressure ventilations if respirations exceed 28 breaths/min or are fewer than 8 breaths/min
• Provide positive pressure ventilations if respirations too shallow to provide adequate air exchange
• Shallow respirations identified little movement of chest wall (reduced tidal volume) or poor chest excursion

Respiratory distress

• Increased work of breathing
• Increased effort and rate

Respiratory failure

• Blood inadequately oxygenated, or ventilation is inadequate to meet the oxygen demands of the body

Assess circulation

• Evaluate by patients mental status, pulse, and skin condition

Assessing Pulse

• Palpate to determine if patients has one
• In responsive patients older than 1 year, you should palpate the radial pulse at the wrist
• In unresponsive patients older than 1 year, you should palpate the carotid pulse in the neck
• Palpate the brachial pulse in children younger than 1 year
• If pulse cannot be found in unresponsive patient, Begin CPR

Skin Color

• Poor color appearance is pale, white, ashen, or gray
• High blood pressure appearance is cause the skin to be abnormally flushed and red
• Blood isn't saturated properly with oxygen, the appearance is blue

Skin Temperature

• Normal is warm to the touch

Skin Moisture

• Normal is dry
• Wet, moist, or excessively dry and hot suggests aproblem

Capillary Refill

• Assess circulatory system
• Press fingertip and remove pressure Nail bed should restore to normal pink color

Assess and control external bleeding

• Should occur before addressing airway or breathing concerns.

Bleeding

• Stead flow is bleeding from a vein
• A spurting flow is bleeding from an artery

Perform a rapid scan to identify life threats

• The Rapid scan identifie injuries that must be managed or protected before the patient is transported
• Takes 60 to 90 seconds to perform the rapid scan
• Not a systematic or focused physical examination

Determine the patient's need for care and transport.

• High-priority patients include those with any of the following conditions: unresponsive, difficulty breathing, uncontrolled bleeding, altered level of consciousness, severe chest pain, Pale skin or other signs of poor perfusion, complicated childbirth

The Golden Hour (Golden Period)

• Is the time from injury to definitive care, treatment of shock and traumatic injuries must occur in order survive
• Base transport decisions on patient condition, availability of advanced care and distance of transport

Investigate the chief complaint

• Patient history of present illness
• By making introductions, make the patient feel comfortable, and obtain permission to treat.
• Ask a few simple and direct questions.
• Refer to patient as or Mrs., using the patient's last name
• Open-ended questions will help determine the chief complaint
• Use eye contact to encourage speaking and repeat statements back to show understanding.

If the patient is unresponsive

• Seek information about of the patient, pertinent past medical history, and clues about the immediate incident from family members present, medical jewerly Bystanders.

Medical questions to ask

• SAMPLE:
• Signs and symptoms
• Allergies
• Medications
• Pertinent past medical history Last oral intake Events leading up to the injury/illness

Assess the patient's symptoms

• OPQRST:
• Onset
• Provocation or palliation
• Quality
• Region/radiation
• Severity
• Timing and Identify pertinent negatives

Critical thinking in assessment helps

• Gathering: seeking facts to help your clinical decision making and scene manage Evaluating: considering what information gathered means Synthesizing: putting together information that you have gathered and validated and synthesizing it into a plan to manage the scene and/or care for the patient

Taking history on sensitive topics, such as

Alcohol and drug usage

• Signs may be confusing, hidden, or disguised
• Many patients may deny problems
• The history gathered from chemistries may be unreliable
• Don't judge a patient and should be professional

Mental state

• Patience is needed when dealing with paitents
• Using a closed-ended question that requires to provide a yes or no answer
• Consider whether answer provides clue to a patient's chief complaint

Someone who is overly talkative

• Excessive energy from caffeine consumption
• A sense of Nervousness
• Taking illegal substance

Having Anxiety

• Take situation into context
• Recognize the observed and may be cause
• Shortness of breath, Numbness in the hands and feet
• Anxiety can be an early indicator
• Low blood glucose level

Crying

• May be sad, in pain, or emotionally overwhelemd
• Remain calm and confident

Physical or violence patient

• Report to proper authorites and follow local protocol and law
• Don't accuse and notify the law

Sexual Historical background

• Ask about the patient's last menstrual period, and urinary symptoms
• Consider for potential for multiple symptoms
• Prioritize the patient's complaints from serious to least

Be kind

• Speak calmlly and gentle even towards angry family

Take patient into consideration

• Do not put an intoxicated that feels threatened

Depression

• Symptoms are sadness, restlessness
• Irritability

Ask about

• Confusing behavior or if have an
• History of a event
• The history for hypoxia is the most explanation
• Limited or have a disability with cognitive ablilites,
• Or understand the language

Neurologic system

• A neurologic assessment done for any patient with
• Changes in mental status and a possible head injury
• Evaluate the LOC and and determine the patient is able to state The AVPU scale as the patient's orientation

Glasgow Coma Scale

Eye Opening Response

• 4 = Spontaneous
• 3 = To verbal stimuli,
• 2 = To pain
• 1 = None

Verbal Response

• 5 = Oriented
• 4 = Confused,
• 3 = Inappropriate words
• 2 = Incoherent
• 1 = None

Motor Response

• 6 = Obeys commands
• 5 = Localizes to pain
• 4 = Withdraws from pain
• 3 = Flexion to pain or decorticate
• 2 = Extension to pain or decerebrate

Pupils

• Pupil diameter will react to light and to what the status is of: Brain's perfusion, oxygenation, and condition

PEARRL

• Pupils, Equal, And, Round, Regular in size and React to Light

Body examination process of

Head, neck, and cervical spine

• Palpate the scalp and eyes
• And color of sclera

Check

• The patient's cheekbones, ears and nose
• For fluid

Chest

• Visualize the patient

Abdomen

• Palpate for tenderness, rigidity and check for - Patient guarding to the four quadrants
• Left and right, and up and low

Check

• Check the four quadrant
• Inspect Pelvis and for symmetry

Inspect symmetry,DCAP-BTLS

• Extremities for,Palpate deformities
• For PMS
• Pulses and motor function

Posterior body

• Inspection of the back -symmetry open wounds and symmetry with the patient is

Palpate

• Reassess
• At regular intervals

Vital Signs

• Heart rate,Capnography
• And glucose meter,blood pressure
• And blood oxygen

Reassessment

• Perform at regular intervals
• Is to identify
• Is to provide treatment
• Is to improve
• Repeat primary
• Reassess vitals and compare with first reads

Test your knowledge of patient assessment techniques used in emergency medical services. Questions cover DCAP-BTLS, SAMPLE history, abdominal quadrants, and the importance of the Golden Hour. Evaluate your understanding of essential assessment skills.