Unit 2- Lesson 2 Patient Assessment PDF

Unit 2 Respond to a Medical Emergency Lesson 2 Patient Assessment Lesson Goal At the end of this lesson, you will be able to conduct an initial assessment for level of con- sciousness, a primary assessment following the MARCH guidelines, a secondary assessment that includes a comprehensive...

Unit 2 Respond to a Medical Emergency Lesson 2 Patient Assessment Lesson Goal At the end of this lesson, you will be able to conduct an initial assessment for level of con- sciousness, a primary assessment following the MARCH guidelines, a secondary assessment that includes a comprehensive physical examination and patient medical history, as well as how to record and relay vital signs to EMS. Every patient you encounter in an emergency needs an assessment while you wait for EMS to arrive. Your approach will usually go from general to specific. Begin with a scene size-up and gener- ally observe the patient, scanning for whether they are conscious and whether they are breath- ing normally. Following the initial assessment, there are two types of patient assessments—primary and second- ary. Perform a primary assessment to identify and address any immediate life-threatening condi- tions. The secondary assessment is a thorough, full head-to-toe assessment of the patient. Assess for Level of Consciousness When you first approach a patient, quickly check their level of consciousness (LOC). Level of consciousness is used to indicate how awake, alert, and aware someone is of their surroundings. ✅ HL222.1. Describe how to conduct an assessment for level of consciousness (LOC) and if the patient is alert, verbal, in pain, or unresponsive (AVPU) The AVPU scale can be useful when measuring a patient’s level of consciousness. AVPU stands for: alert, verbal, pain, and unresponsive. Alert—is the patient fully awake? A patient who is alert will be aware of their surround- ings and can react to their environment. They are fully awake and their eyes usually open spontaneously. Verbal—does the patient respond when you talk to them? A patient who might not seem alert or awake but is verbally responsive will usually respond in some way when you talk to them (such as grunting in response to a question or moving slightly when you prompt them). Pain—does the patient respond to pain with a voluntary or involuntary movement? Do they only respond to painful stimulation? If the patient is not alert or verbal, check whether the 62 / Florida Basic Recruit Training Program (HL): Volume 2  patient responds when you apply gentle pressure to their hand or shoulder. The patient who is responsive to pain may moan, make a sound, or attempt to withdraw. Unresponsive—is the patient not responding to anything at all? An unresponsive or uncon- scious patient will not respond to any stimuli or make any movements or sounds. If you determine that the patient is unresponsive, follow the steps for CPR. When determining the LOC of an infant or child, visual assessment is your most valuable tool. If an infant or child appears drowsy or is in obvious respiratory distress, consider this condition serious. This could be a symptom of head trauma or severe infection. If the patient is a criminal justice officer and they drop below the level of alert, disarm them to avoid possible safety concerns. Complete the Primary Assessment Regardless of their LOC, you will need to do a primary assessment of the patient. During the primary assessment, the priority for care is the rapid identification and management of life-threatening conditions. A patient that is unresponsive will not be able to provide information and will immedi- ately require a primary assessment. Make sure to relay all vital information to responding medical personnel. Primary Assessment Guidelines Complete the primary assessment in the exact order and priority outlined in the mnemonic MARCH. ✅ HL222.2. Describe the primary assessment guidelines MARCH Massive hemorrhage Is the patient experiencing life-threatening bleeding? Airway Is the patient’s airway obstructed or closed? Respirations Is the patient’s chest rising and falling? Circulation Does the patient have a pulse and blood flow? Hypothermia/Head injury Does the patient have low body temperature or decreasing LOC? Assess and Manage Life-Threatening Injuries Massive Hemorrhage ✅ HL222.3. Describe how to conduct an assessment for a massive hemorrhage Massive hemorrhage or uncontrolled severe bleeding is the number one preventable cause of trauma-related deaths. It is critical to focus on stopping life-threatening bleeding first. Very low blood pressure, rapid heart rate, loss of consciousness, paleness, and weak pulse can accompany Chapter 2 First Aid for Criminal Justice Officers / 63 severe bleeding. If you see signs of severe bleeding, look for the source. Some helpful bleeding control techniques include: applying direct pressure to the wound with a sterile dressing to stop the bleeding, packing the wound, or applying a tourniquet, if possible (in later lessons you will learn more about the techniques for treating and controlling life-threatening bleeding). Airway ✅ HL222.4. Describe how to conduct an assessment for an open airway An obstructed airway will restrict or completely impede a patient’s ability to breathe. Refer to your CPR training to safely clear objects in the airway and the various methods of airway management, such as head tilt/chin lift and jaw thrust. Do not move forward to the respirations assessment until you establish and maintain an open airway. Respirations ✅ HL222.5. Describe how to conduct an assessment for respirations To assess for respirations or breathing, look for the rise and fall of the chest or abdomen. Does the patient’s chest have equal rise and fall on both sides? If the patient is breathing, are they breathing adequately? Look for signs of movement around the mouth and lips. Signs of inadequate breathing include labored or painful breathing, wheezing, snoring, blue or purplish color inside of the lips or fingernails, and skin color changing to a pale or gray color. Pay attention to the depth or manner of breathing. No visible rise and fall of the chest or abdomen are a sign that the patient has stopped breathing. A patient that is not breathing may rapidly dete- riorate into cardiac arrest, meaning the heart is no longer pumping blood throughout the body, which can lead to death. This requires rescue breathing to provide supplemental ventilations with a barrier mask. Remember that you need an open airway to effectively provide rescue breaths. Immediately request an automated external defibrillator (AED) and be prepared to perform CPR. Circulation ✅ HL222.6. Describe how to conduct an assessment for circulation Assess for blood circulation by confirming the existence of a pulse and note skin color and skin temperature. Find a pulse by placing your fingers (not your thumb) on a pulse point. For an infant, always check the brachial pulse on the upper arm, located near the inside of the elbow. For an unconscious adult or child, check the carotid pulse on the neck. For a conscious adult or child, check the radial pulse on the inside of the wrist, below the thumb. Assume that a conscious patient has a pulse. 64 / Florida Basic Recruit Training Program (HL): Volume 2 Determine the force or strength of the pulse. A patient with no pulse or an absent pulse may be in cardiac arrest and require immediate intervention through effective CPR and an AED. Another way to assess for adequate circulation is by performing a capillary refill time test. This test is used to rapidly assess changes in blood flow in the arms and legs. Apply pressure by squeezing the patient’s finger or toe nail bed for two seconds. After releasing pressure, if the squeezed nail bed returns to a pink color within two seconds, blood flow is adequate. Blue skin coloring can indicate possible circulation problems. Change in normal body temperature can also indicate poor circulation or death. Hypothermia/Head Injury ✅ HL222.7. Describe how to conduct an assessment for hypothermia and a head injury Rapidly decreasing body temperature can be a main concern when treating trauma patients, as it can make bleeding symptoms worse by decreasing the blood’s ability to clot or gel, leading to more bleeding and other complications. To prevent the patient from suffering from dangerously low body temperature, minimize their exposure to the elements and protect them from wind and water. Keep the patient warm and dry and remove any wet clothing. Consider moving them to an insulated surface such as a rescue blanket or a climate-controlled vehicle or structure. For head injury, a possible concern is permanent brain damage from lack of oxygen or proper blood flow to the brain. Assess the patient for unequal pupil size and any fluids coming out of their ears. Check for an impaled object or deformity to their skull. The patient may have decreasing LOC. You will learn more about treating head injuries in the lesson on spinal, head, and neck injuries. Complete the Secondary Assessment Once all immediate life-threatening injuries have been addressed and the patient is stabilized, the patient will require a secondary assessment. During the secondary assessment, you will complete a comprehensive physical examination of the patient for all injuries and take a detailed patient medical history. In some cases, you might not always be able to complete a secondary assessment, especially if you do not successfully address all primary assessment concerns before EMS arrives. Secondary Assessment Guidelines ✅ HL222.8. Describe the secondary assessment guidelines The following acronyms, DOTS and PMS, can be useful to keep in mind and will help guide you when performing the secondary assessment. DOTS can be used when examining each body part while PMS can help you when examining the extremities. Chapter 2 First Aid for Criminal Justice Officers / 65 ✅ HL222.9. Describe how to conduct an assessment for deformities, open injuries, tenderness, and swelling (DOTS) DOTS Deformities An abnormal shape of a body part that may indicate fractures. Compare an injured body area to a similar, uninjured area. Open injuries Wet clothing may indicate external bleeding. Carefully remove or cut open the clothing to find the bleeding, and try to control it immediately. Tenderness A conscious patient may complain of a pain when touched. In an unresponsive patient, observe the face for pain response (such as a grimace). Swelling Raised skin that may indicate soft-tissue injury and fractures. ✅ HL222.10. Describe how to conduct an assessment for pulse, motor, and sensory (PMS) functions PMS Pulse Assess for presence or absence of pulse. Motor Assess for motor function (movement). Sensory Assess for sensation before movement. Ask the patient if they have feeling in the area you touch. Perform a Comprehensive Physical Assessment ✅ HL222.11. Describe how to perform a comprehensive physical assessment during a secondary assessment Complete a head-to-toe physical examination of the patient. Systematically inspect and touch each body part before moving to the next. Look, listen, and feel for DOTS. 1. Head—start at the top of the head, gently examine by touching the scalp and skull, assess- ing for and feeling for depressions. Observe anything out of the ordinary, such as fluid loss from the ears or nose, discoloration around the eyes (raccoon eyes), mouth injuries that may obstruct the airway, and discoloration behind the ears (Battle’s sign) that may indicate brain trauma. 2. Eyes—look at the patient’s pupils, the small dark holes in the center of the eyes. Normal pupils appear round and equally sized. Constricted pupils appear smaller or pinpoint and dilated pupils appear enlarged. If you have a low candlepower penlight, flash it at each pupil. They should both react equally by constricting briskly in response to the light. Nonre- active pupils are often associated with severe brain damage. This test can also help you detect the presence of alcohol, drugs, or other substances. 66 / Florida Basic Recruit Training Program (HL): Volume 2  3. Neck—gently feel the neck area. Look at the throat for signs of trauma, asymmetry, swelling, and airway obstructions. While doing this, ask the conscious patient to wiggle their fingers and toes. Ask if the patient’s extremities feel numb or tingly and if they have neck pain. 4. Shoulders—gently squeeze the shoulders inward feeling and listening for grinding which may indicate a fracture. 5. Chest and abdomen—look to see if both sides of the chest rise and fall equally during breathing, for bruising, and for holes in the chest wall. Listen for noises coming from the chest wall. Feel the chest for areas of pain or tenderness and feel for fractured ribs. Squeeze lightly on the ribcage. Continue to the abdomen, following the same touching procedures. Tenderness and swelling in the abdomen may indicate internal injury or pregnancy. 6. Pelvis and groin—gently squeeze inward, checking for tenderness or deformities, and whether the pelvis is stable. Note any bleeding or injury in the groin area; the pelvis has a lot of blood vessels and bleeding in this area may be life threatening. 7. Lower extremities—individually and systematically assess the lower extremities. If you find that one leg is shorter, this may indicate a fracture of the femur. Place your hands along the soles of the patient’s feet and ask them to press them against your hands. You should feel equal pressure from both feet. 8. Upper extremities—after assessing both arms for DOTS, check for circulation, movement, and sensation on both sides. Check circulation in the fingers. Does the patient feel their hands and fingers? Can the patient move their hands and fingers? Ask the patient to hold your fingers and squeeze them simultaneously. Both hands should have equal strength. 9. Spine and back—if you have the necessary assistance and a compelling medical reason such as blood pooling under the patient, roll the patient to check their back while trying to maintain strict spinal precautions (you will learn more about moving patients in a follow- ing lesson). Feel along the spine for possible spinal fractures and deformities. Look for any bruising or swelling that could indicate internal bleeding. Gather Patient Medical History ✅ HL222.12. Describe how to gather patient medical history during a secondary assessment While conducting your comprehensive physical assessment, talk to the patient. Try to gather relevant medical information or history to relay to EMS. If the patient is unconscious, begin by questioning family members or bystanders. Any information you get helps in providing care for the patient. Ask if the patient is experiencing any symptoms and whether they have allergies or wear medi- cal alert jewelry. If the patient is taking medication, note when the last dose was. Ask about past history, such as other medical problems that may contribute to the patient’s current condition. Record the time the patient last ate or drank. Lastly, you will want to note what events led to the emergency and the time of injury or sudden illness (some medications may be harmful if given too long after time of injury). Chapter 2 First Aid for Criminal Justice Officers / 67 All this information can help you determine the extent of injuries or illness. Include the informa- tion in your report when handing the patient off to appropriate medical personnel. Remember, you may be the last person to speak to the patient, so gathering this information could be critical. Record Vital Signs ✅ HL222.13. Describe how to record pulse and breathing rates while providing emergency first aid The primary assessment addressed all necessary life functions and the secondary assessment addressed injuries or illnesses that required basic intervention. Once both assessments are complete and the patient is stable, there may be time to record the patient’s pulse and breathing rate. This information helps responding EMS determine if the patient’s condition is improving, stable, or deteriorating. To take a patient’s pulse, place your fingers on a pulse point. Count the number of beats for 15 seconds. Multiply this number by four to arrive at the patient’s average pulse rate. To calculate a patient’s breathing rate, watch the patient’s chest rise; count the number of breaths taken over 15 seconds. Multiply this number by four to arrive at the average breathing rate. Complete an Ongoing Assessment ✅ HL222.14. Describe how to conduct an ongoing assessment while awaiting additional EMS resources If the patient is stable, reassess every 15 minutes. If unstable, reassess every five minutes. Continue an ongoing assessment until EMS relieve you. In your ongoing assessment, reassess the patient’s responsiveness level, airway and breathing, and pulse rate and quality. You may need to repeat parts of the secondary assessment to detect changes in the patient’s condition. Update EMS Once EMS arrives, relay scene and patient information to medical responders. In some situations, you will provide information by radio to dispatch while EMS is on their way. Doing so prepares them to treat the patient as soon as they arrive. ✅ HL222.15. Describe how to communicate with EMS during a medical emergency Here are some typical questions EMS may ask: “How many patients are there?” “Where are they?” 68 / Florida Basic Recruit Training Program (HL): Volume 2  “Who are the high priority patients?” “What treatment did you render?” Specialized personnel, such as firefighters and EMS, may become involved in a rescue, based on local protocol and department policy. EMS may ask you to render emergency first aid, provide protection to a patient, or assist with moving a patient. As a criminal justice first-aid provider, do what you can safely do, use the equipment available to you, and stay within the limits of your train- ing and qualifications. Chapter 2 First Aid for Criminal Justice Officers / 69