Patient Assessment - Medical First Responder - PDF

Chapter 10 Patient Assessment Assessment process Symptom: subjective condition the patient feels and tells you about 1. Scene size-up Sign: objective condition you can observe about the patient 2. Primary assessment 3. History taking 4. Seco...

Chapter 10 Patient Assessment Assessment process Symptom: subjective condition the patient feels and tells you about 1. Scene size-up Sign: objective condition you can observe about the patient 2. Primary assessment 3. History taking 4. Secondary assessment 5. Reassessment Scene Size Up Scene Size-up: evaluation of the conditions in which Some forms of hazards: you will be operating. Environmental Situational awareness is necessary throughout the Physical (sharp metal, broken glass, slip-and-fall entire call to ensure safety. hazards) Dispatch provides basic information about the request Chemical (hazardous materials) for assistance. Electrical Ensure scene safety. Water If a scene is not safe for you and your team to Fire enter the scene and approach and manage the Explosions patient, do what you can to make it safe or call Physical violence for additional resources. o Be aware of scenes that have the Consider traffic safety issues and issues related potential for violence. to scene safety if you must approach a patient o Violent patients on a working roadway. o Distraught family members Consider environmental conditions at the scene o Angry bystanders o Gangs o Unruly crowds Standard precautions and personal protective equipment (PPE): protective measures that have traditionally been recommended by the Centers for Disease Control and Prevention for use in dealing with: Objects Blood Body fluids Other potential exposure risks of communicable disease The concept of standard precautions assumes that all blood, body fluids (except sweat), non-intact skin, and mucous membranes may pose a substantial risk of infection. When you step out of the EMS vehicle and before actual patient contact, standard precautions must have been taken or initiated. o At a minimum, gloves must be in place before any patient contact. o Also consider glasses and a mask. Mechanism of injury (MOI)/nature of illness & NOI: Medical conditions, Traumatic injuries, or both. MOI Traumatic injuries are the result of physical forces applied to the outside of the body, usually from an object striking the body or the body striking an object. Blunt trauma: The force occurs over a broad area. o Skin is usually not broken, Tissues and organs below the area of impact may be damaged. Penetrating trauma: The force of the injury occurs at a small point of contact between the skin and the object. o Open wound with high potential for infection NOI: Be aware of scenes with more than one patient with similar signs or symptoms. Example: carbon monoxide poisoning 1 Scarlet Oaks Number of patients During scene size-up, it is important to accurately identify the total number of patients. When there are multiple patients, you should use the incident command system, identify the number of patients, and then begin triage. o Triage is the process of sorting patients based on the severity of each patient’s condition Consider Additional/Specialized Resources Questions to ask when determining the need for Specialized resources include: additional resources: a. Advanced life support (ALS) Does the scene pose a threat to you, your b. Air medical support patient, or others? c. Fire departments may handle hazardous How many patients are there? materials management, technical rescue services Do we have the resources to respond to their including complex extrication from motor vehicle conditions? crashes, wilderness search and rescue, high-angle rope rescue, or water rescue. d. Law enforcement personnel 2 Scarlet Oaks Primary Assessment Patient assessment begins when you greet your patient. The single, all-important goal of the primary assessment is to identify and begin treatment of immediate or imminent life threats. You must physically examine the patient and assess level of consciousness (LOC) and airway, breathing, and circulation (ABCs). General Impression Determines the priority of care and is the first part of your primary assessment. Age Note the patient’s position and whether the patient is moving or still. Sex Avoid standing over the patient, if possible. Race Address the patient by name. Level of distress Introduce yourself to the patient. Overall appearance Ask about the chief complaint. The patient’s response can give insight into the LOC, air patency, respiratory status, and overall circulatory status. Life-threatening problems should be treated immediately. Define whether your patient’s condition is stable, stable but potentially unstable, or unstable to direct further assessment and treatment Stable, Unstable, Potential for Unstable Scan for signs of uncontrolled external bleeding Assess level of consciousness (LOC) Assess for responsiveness AVPU Unconscious patient focuses first on airway, Awake and alert breathing, and circulation (ABCs). Responsive to Verbal stimuli Sustained unconsciousness: critical Responsive to Pain respiratory, circulatory, or central Unresponsive nervous system problem or deficit might exist Stimulus tests: for patient who does not respond to verbal stimuli will respond to a painful stimulus. OR Pinching the patient’s skin Conscious with an altered LOC may be due to Back of the upper arm inadequate perfusion, medications, drugs, Trapezius area alcohol, or poisoning Applying upward pressure along the ridge of the orbital rim along the underside of the eyebrow A patient who moans or withdraws is responding to the stimulus Orientation tests mental status by checking a patient’s memory and Altered mental status thinking ability. Any deviation from alert Evaluates a patient’s ability to remember: and oriented to person, Person—remembers his or her name place, time, and event, or Place—identifies the current location from a patient’s normal Time—the current year, month, and approximate date baseline, is considered an Event—describes what happened 3 Scarlet Oaks Identify and Treat Life-Threats: ABC vs CAB Assess the airway As you move through the primary assessment, stay alert for signs of airway obstruction. Ensure that the airway remains open (patent) and adequate. Responsive patients Unresponsive patients Patients of any age who are talking or crying have an Immediately assess the patency of the airway. open airway. If there is a potential for trauma, use the A conscious patient who cannot speak or cry jaw-thrust maneuver to open the airway. most likely has a severe airway obstruction. If you cannot obtain a patent airway using If you identify an airway problem, stop the the jaw-thrust maneuver or if it can be assessment process and work to clear the confirmed that the patient did not patient’s airway. experience a traumatic event, use the head If your patient has signs of difficulty breathing tilt–chin lift maneuver to open and maintain or is not breathing, immediately take corrective a patent airway. actions. Signs of obstruction in an unconscious patient: Obvious trauma, blood, or other obstruction Noisy breathing, such as snoring, bubbling, gurgling, crowing, stridor, or other abnormal sounds Extremely shallow or absent breathing Assess breathing Once you have made sure the patient’s airway is open, make sure the patient’s breathing is present and adequate. Airway is open and clear: if no you help As you assess the patient’s breathing, ask the following questions: if any are no: breath for them Is the patient breathing? Is the patient breathing adequately? Is the patient hypoxic? Positive pressure ventilations should be performed for patients who are not breathing or whose breathing is too slow or too shallow. If the patient is breathing adequately but remains hypoxic, administer oxygen. The goal for oxygenation for most patients is an oxygen saturation of approximately 94% to 99% (pulse ox) If a patient seems to develop difficulty breathing after your primary assessment, you should immediately reevaluate the airway. Consider providing positive pressure ventilations with an airway adjunct when: (ineffective breathing) o Respirations exceed 28 breaths/min o Respirations are fewer than 8 breaths/min o Respirations too shallow to provide adequate air exchange o Shallow respirations can be identified by little movement of the chest wall (reduced tidal volume) or poor chest excursion. Respiratory distress Observe how much effort is required for the patient to breathe. Increased work of breathing Presence of retractions Increased effort and rate Use of accessory muscles Nasal flaring Respiratory failure Two- to three-word dyspnea Occurs when the blood is inadequately oxygenated, or ventilation Tripod position is inadequate to meet the oxygen demands of the body. Sniffing position 4 TheScarlet ultimate result Oaks of respiratory failure if it is not corrected. Labored breathing Identify and Treat Life-Threats: ABC vs CAB Assess circulation Evaluated by assessing the patient’s mental status, pulse, and skin condition Assess pulse To determine if a pulse is present, you will need to palpate the pulse. In responsive patients who are 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, located at the medial area (inside) of the upper arm, in children younger than 1 year. If you cannot palpate a pulse in an unresponsive patient, begin CPR Skin color Skin condition Poor peripheral circulation will cause the skin to appear Perfusion is assessed by evaluating pale, white, ashen, or gray. a patient’s skin color, High blood pressure may cause the skin to be abnormally temperature, moisture, and flushed and red. capillary refill. When the blood is not properly saturated with oxygen, it appears blue. Skin temperature Poor peripheral circulation will cause the skin to appear Normal skin temperature will be pale, white, ashen, or gray. warm to the touch. High blood pressure may cause the skin to be abnormally Abnormal skin temperatures are flushed and red. hot, cool, cold, and clammy. Skin moisture When the blood is not properly saturated with oxygen, it Dry skin is normal. appears blue. Skin that is wet, moist, or excessively dry and hot suggests a Capillary refill problem Evaluated to assess the ability of the circulatory system to restore blood to the capillary system To test capillary refill, gently compress Press on the patient’s fingernail. the fingertip until it blanches. B. Release Remove the pressure. the fingertip, and The nail bed should restore to its normal pink color count until it returns to its normal pink color. Assess and control external bleeding Should occur before addressing airway or breathing Controlling external bleeding is often concerns. very simple. Bleeding from a large vein is characterized by a steady Apply direct pressure. flow of blood. If direct pressure is not quickly Bleeding from an artery is characterized by a spurting flow successful or if there is an of blood obvious arterial hemorrhage of an extremity, apply a tourniquet Perform a rapid scan to identify life threats. Identify injuries that must be managed or protected before the patient is transported. Take 60 to 90 seconds to perform the rapid scan. This is not a systematic or focused physical examination. 5 Scarlet Oaks Determine priority of patient care and transport. The Golden Hour (Golden Period): time from injury High-priority patients include those with any of the to definitive care, during which treatment of shock following conditions: and traumatic injuries must occur in order to Unresponsive maximize the patient’s chance of survival. Difficulty breathing Uncontrolled bleeding Transport decisions should be made at this point. Altered level of consciousness Transport decisions are based on: Severe chest pain Patient’s condition Pale skin or other signs of poor perfusion Availability of advanced care Complicated childbirth Distance of transport Severe pain in any area of the body iv. Local protocols History Taking: Provides detail about the Investigate the chief complaint (history of present illness). patient’s chief complaint and an account of the Begin by making introductions, make the patient patient’s signs and symptoms. feel comfortable, and obtain permission to treat. Be sure to document the following information: Ask a few simple and direct questions. Date of the incident Refer to the patient as Mr., Ms., or Mrs., using the Patient’s age patient’s last name. Patient’s gender Open-ended questions will help determine the Patient’s race chief complaint. Past medical history Use eye contact to encourage the patient to Patient’s current health status continue speaking and repeat statements back to show understanding. If the patient is unresponsive, information about the patient, pertinent past medical history, and clues about the immediate incident may be obtained from: Family members present A person who may have witnessed the situation Bystanders Medical alert jewelry Other patient medical history documentation SAMPLE: OPQRST: assess symptoms. Signs and symptoms Onset Allergies Provocation or palliation Medications Quality: describe the quality of their discomfort in Pertinent past medical history their own words. Dull, ache Last oral intake Region/radiation Events leading up to the injury/illness Severity: scale of 1-10 Timing Identify pertinent negatives. Critical thinking in assessment Gathering: seeking facts to help your clinical decision making and scene management Evaluating: considering what the information gathered means Synthesizing: putting together the information that you have gathered and validated and synthesizing it into a plan to manage the scene and/or care for the patient. 6 Scarlet Oaks Taking history on sensitive topics Physical abuse or violence. Alcohol and drugs Report all physical abuse or domestic Signs may be confusing, hidden, or disguised. violence to the appropriate authorities. Many patients may deny having any problems. Follow state laws and local protocols. The history gathered from a chemically Do not accuse; instead, immediately involve dependent patient may be unreliable. law enforcement. Do not judge the patient and be professional in your approach Sexual history Consider all female patients of childbearing Silence age who report lower abdominal pain to be Patience is extremely important when dealing pregnant unless ruled out by history or other with patients and their emergency crises. information. Using a closed-ended question that requires a Ask about the patient’s last menstrual simple yes or no answer may work best. period. Consider whether the silence is a clue to the Inquire about urinary symptoms with male patient’s chief complaint. patients. When appropriate, ask about the potential for sexually transmitted diseases in all Overly talkative Multiple symptoms patients. Reasons why a patient may be overly talkative: Prioritize the patient’s complaints as you would in Excessive caffeine consumption triage; start with the most serious and end with the Nervousness least serious. Ingestion of cocaine, crack, or methamphetamines Anger and hostility Underlying psychological issue Friends, family, or bystanders may direct Anxiety their anger and rage toward you. Consider the context of the situation and Remain calm, reassuring, and gentle. recognize that the observed anxiety may be a If the scene is not safe or secured, retreat sign of a serious underlying medical condition. until it is secured. Frequently, anxious patients can be observed in emergency scenes that involve a large number Intoxication of patients, such as during a disaster. Do not put an intoxicated patient in a Some anxious patients show signs of position where he or she feels threatened psychological shock, such as: and has no way out. o Pallor The potential for violence and a physical o Diaphoresis confrontation is high when a patient is o Shortness of breath intoxicated. o Numbness in the hands and feet Alcohol dulls a patient’s senses. o Dizziness or light-headedness o Loss of consciousness Depression Anxiety can be an early indicator of: leading causes of disability worldwide. o Low blood glucose level Symptoms include: o Shock o Sadness o Hypoxia o A feeling of hopelessness o Restlessness Crying o Irritability A patient who cries may be sad, in pain, or o Sleeping and eating disorders emotionally overwhelmed. o A decreased energy level Remain calm and be patient, reassuring, and The most effective treatment in handling a patient’s confident, and maintain a soft voice depression is being a good listener. 7 Scarlet Oaks Taking history on sensitive topics Confusing behavior or history Conditions such as hypoxia, stroke, diabetes, trauma, medication use, and other drug use could alter a patient’s explanation of events. Hypoxia is the most common cause of confusion. In older patients, it is not uncommon to encounter a patient who has dementia, delirium, or Alzheimer disease Limited cognitive abilities Cultural challenges Keep your questions simple, and limit the use of Do not use medical language. medical terms. Patients from some cultures may prefer Be alert for partial answers, and keep asking to speak only with health care providers questions. of the same gender. In cases of patients with severely limited cognitive Gain the assistance of the patient’s function, rely on the presence of family, caregivers, friends or family members and enlist the and friends to supply answers to your questions. help of health care providers of the same culture or background, if possible. Language barriers Hearing problems Find an interpreter, if possible. Ask questions slowly and clearly. If not, determine whether the patient understands Use a stethoscope to function as a who you are. hearing aid for the patient. Keep questions straightforward and brief, and use Learning simple sign language during hand gestures. your career will help in the Be aware of the language diversity in your communication process. community. Use a pencil and paper. Visual impairments Identify yourself verbally when entering the scene. It is important that you put any items that have been moved back into their previous position. During the assessment and history-taking process, explain each step in the assessment of vital signs. Notify the patient before preparing to lift the patient and move him or her on the stretcher. 8 Scarlet Oaks  Secondary Assessment The goal is to identify hidden injuries or identify causes that may not have been identified during the 60- to 90-second exam during the primary assessment. If the patient is in stable condition and has an isolated complaint, you may choose to perform the secondary assessment at the scene. If the secondary assessment is not performed at the scene, it is performed in the back of the ambulance en route to the hospital. However, there will be situations where you may not have time to perform the secondary assessment. You may have to continue to manage life threats identified during the primary assessment en route to the hospital. The purpose is to perform a systematic physical examination of the patient. An assessment that focuses on a certain area or system of the body, often determined through the chief complaint (a focused assessment). How and what to assess during a physical examination: DCAP-BTLS: inspecting and palpating various Inspection—Look at the patient for abnormalities. body regions. Palpation—Touch or feel the patient for abnormalities. Compare findings on one side of the body with Auscultation—Listen to the sounds a body makes by using a the other side when possible. stethoscope Deformities Contusions Focused assessment Abrasion Performed on patients who have sustained Penetrations nonsignificant MOIs or on responsive medical patients Burn Typically based on the chief complaint. Tenderness The goal of a focused assessment is to focus your Lacerations attention on the body part or systems affected by the Swelling priority problems Respiratory system Expose the patient’s chest. Look again for signs of airway obstruction, as well as trauma to the neck and/or chest. Inspect the chest for overall symmetry. Listen carefully to breath sounds, noting abnormalities. Measure the respiratory rate, chest rise and fall (for tidal volume), and effort. Look for retractions. Look for increased work of breathing. When assessing breathing obtain the following information: Respiratory rate A normal rate in adults ranges from 12 to 20 breaths/min. Rhythm Children breathe at even faster rates. Quality of breathing Count the number of breaths in a 30-second period and multiply by two. Depth of breathing Respiratory rhythm Depth of breathing Regular: The time from one peak chest rise to the next is fairly Amount of air the consistent. patient exchanges Irregular: vary or the rate changes frequently. depends on the rate and tidal volume. Breath sounds Quality of breathing better from the Normal breathing is silent. patient’s back. Breathing accompanied by other sounds may indicate a significant respiratory problem. 9 Scarlet Oaks Auscultating breath sounds Normal breath sounds Snoring breath sounds Wheezing breath sounds Crackles Rhonchi Stridor 10 Scarlet Oaks Cardiovascular System Pulse rate Look for trauma to the chest and listen for Normal resting pulse for an adult is between 60 and breath sounds. 100 beats/min. Consider the pulse, respiratory rate, and The younger the patient, the faster the pulse. blood pressure. Pay attention to rate, quality, and rhythm. Consider your findings when assessing the skin. Check and compare distal pulses. Consider auscultation for abnormal heart sounds Pulse quality Describe a stronger than normal pulse as “bounding.” A pulse that is weak and difficult to feel is described as “weak” or “thready. Pulse rhythm Regular: The interval between each contraction Blood pressure cuff with gauge (sphygmomanometer) should be the same. contains the following components: The pulse should occur at a constant, A wide outer cuff regular rhythm. An inflatable wide bladder sewn into a portion of the Irregular: If the heart periodically has an early or cuff late beat. A ball-pump with a one-way valve If a pulse beat is missed. A pressure gauge calibrated in millimeters of mercury Auscultation: most common means of measuring blood Blood pressure: Pressure of circulating blood pressure. against the walls of the arteries Palpation: method does not depend on the ability to A drop in blood pressure may indicate: hear sounds. A loss of blood or fluid components A loss of vascular tone and sufficient Check for a dialysis fistula, central line, previous arterial constriction mastectomy, and injury to the arm. If any are A cardiac pumping problem present, use the brachial artery on the other Decreased blood pressure is a late sign of arm. shock. Apply the cuff snugly. Abnormally high blood pressure may The lower border of the cuff should be about 1 result in a rupture or other critical inch (2.5 cm) above the antecubital space. damage in the arterial system Normal blood pressure Hypotension: Blood pressure is lower than normal. Hypertension: Blood pressure is higher than normal. 11 Scarlet Oaks Neurologic system Evaluate the LOC and orientation to determine the patient’s ability to A neurologic assessment should think. be performed any time you are AVPU scale if appropriate to determine the patient’s mental status. confronted with a patient who has: Changes in mental status A possible head injury Stupor Dizziness Drowsiness Glasgow Coma Scale (GCS) score can be helpful in providing additional Pupil: information on patients with mental status changes black center portion of the Syncope eye Normally round and of approximately equal size and adjust their size depending on the available light. The diameter and reactivity to light of the patient’s pupils can reflect the status of the brain’s perfusion, E + V+ M= total oxygenation, and condition. In the absence of light, the pupils will become fully relaxed and dilated. Anisocoria: unequal pupils Causes of depressed brain function: Injury of the brain or brainstem Trauma or stroke Brain tumor Inadequate oxygenation or perfusion Drugs or toxins Assessing neurovascular status a. Perform a hands-on assessment to determine sensory and motor response. b. Check for bilateral muscle strength and weaknesses. PEARRL c. Complete a thorough sensory assessment. Pupils d. Test for pain, sensations, and position, and compare distal and Equal proximal sensory and motor responses and one side with the other. And Round Regular in size React to Light 12 Scarlet Oaks Head, neck, and cervical spine ❖ Palpate the scalp and skull. ❖ Check the patient’s eyes. ❖ Check the color of the sclera. ❖ Assess the patient’s cheekbones. ❖ Check the patient’s ears and nose for fluid Chest ❖ Inspect, visualize, and palpate. ❖ Watch for both sides of the chest to rise and fall together with normal breathing. ❖ Observe for abnormal breathing signs. Abdomen ❖ Palpate for tenderness, rigidity, and patient guarding. ❖ Four quadrants:  Left upper quadrant (LUQ)  Left lower quadrant (LLQ)  Right upper quadrant (RUQ)  Right lower quadrant (RLQ) Pelvis ❖ Inspect for symmetry and any obvious signs of injury, DCVAP-BTLS Extremities ❖ Inspect for symmetry, DCAP-BTLS ❖ Palpate for deformities. ❖ Check for PMS (pulses and motor and sensory) functions. Posterior body ❖ Inspect the back for DCAP-BTLS, symmetry, and open wounds. ❖ Palpate the spine from the neck to the pelvis for tenderness and deformity. 13 Scarlet Oaks Vital Signs Pulse oximetry The pulse oximeter is a device that measures the saturation of oxygen in the blood as a percentage. ❖ Measures the oxygen saturation of hemoglobin in the capillary beds ❖ Patients with difficulty breathing should receive oxygen regardless of their pulse oximetry value. Capnography Blood glucometry Sphygmomanometer Can quickly provide information on a Measures the level of glucose in the Measures blood pressure patient’s ventilation, circulation, and bloodstream metabolism Reassessment Perform a reassessment at regular intervals during the assessment process. The purpose of reassessment is to identify and treat changes in a patient’s condition. Repeat the primary assessment. Reassess vital signs. Compare the baseline vitals obtained during the primary assessment with any and all subsequent vital signs. Look for trends. Reassess the chief complaint. Ask and answer the following questions: o Is the current treatment improving the patient’s condition? o Has an already identified problem gotten better? o Has an already identified problem gotten worse? o What is the nature of any newly identified problems? Recheck interventions. Check all interventions. Most important are the patient’s ABCs. Ensure management of bleeding. Ensure adequacy of other interventions, and consider the need for new interventions. Identify and treat changes in the patient’s condition. Document any changes, whether positive or negative. Reassess the patient. o Unstable patients: approximately every 5 minutes o Stable patients: approximately every 15 minutes 14 Scarlet Oaks