Emergency Care Textbook Professional Responders-part-5.pdf

5 Assessment Key Content Scene Assessment................... 80 Primary Assessment................ 82 Reassessment.......................... 90 Secondary Assessment........... 91 Treatment/Interventions........ 103 Documentation of Findings.... 103 Ongoing Assessment.............. 103 Introduction H...

5 Assessment Key Content Scene Assessment................... 80 Primary Assessment................ 82 Reassessment.......................... 90 Secondary Assessment........... 91 Treatment/Interventions........ 103 Documentation of Findings.... 103 Ongoing Assessment.............. 103 Introduction Having a clear plan of action will help you to respond effectively in any emergency situation. The important questions are “What are my priorities?” and “What interventions may be necessary?” The general steps in this section will provide answers to these questions (Figure 5–1). ASSESSMENT When you arrive at the scene of an emergency, after ensuring the safety of yourself and others, you must quickly determine whether the patient has any life-threatening injuries or conditions by conducting a primary assessment. This includes assessing the patient’s level of responsiveness and his or her airway, breathing, and circulation. Once the primary assessment is complete, you can begin your secondary assessment, which includes interviewing the patient (or bystanders), assessing and documenting vital signs, and conducting a thorough physical exam. 79 These steps, conducted in this order, help to ensure your safety and that of the patient and bystanders. They will also increase the patient’s chance of a positive outcome. This assessment model may be modified depending on the situation. For example, a responsive patient may complain of an ankle injury. In this case, a full head-to-toe assessment is probably unnecessary, unless you have reason to suspect that additional injuries or conditions may be present. Scene Assessment Hazards and Environment Mechanism of Injury (MOI) and Chief Complaint Number of Patients Additional Resources Required Forming a General Impression Donning PPE (if not already done) Primary Assessment Chief Complaint Level of Responsiveness Spinal Motion Restriction Airway, Breathing, and Circulation (ABCs) Pulse Oximetry (SpO2) Rapid Body Survey Transport Decision Patient Positioning Reassessment Secondary Assessment Interview with Patient and Bystanders Vital Signs Head-to-Toe Physical Examination Treatment/Interventions ASSESSMENT Documentation of Findings 80 Ongoing Assessment Figure 5–1: Look for indicators of what may have happened. SCENE ASSESSMENT Whenever you respond to an emergency, you must make sure the emergency scene is safe for you, the patient(s), and any bystanders. It is important not to make assumptions that could put you or others at risk. Take time to assess the scene and answer these questions: Hazards and Environment What are the potential hazards at the scene? Does anything about the environment create a risk? Are there any specific processes to mitigate hazards (e.g., workplace lock-out-tag-out procedures)? Mechanism of Injury (MOI) and Chief Complaint What happened? What is the problem? Number of Patients How many people are ill or injured? Additional Resources Required What other resources are required (e.g., law enforcement, utilities)? Forming a General Impression What is your initial overall impression of the scene and the patient? Donning PPE Are you wearing appropriate PPE for the situation? When you assess the scene, look for anything that may threaten your safety or that of bystanders or the patient. Examples of hazards and strategies to mitigate them are given in Chapter 2. If you do not have the necessary qualifications or equipment to manage hazards at the scene, do not approach the patient. Request the necessary personnel, and ensure that the scene is safe before you enter. Do not put your personal safety at risk. An emergency that begins with one injured person could end up with two if you are hurt. While waiting for additional personnel, monitor the scene from a safe distance. If conditions change, you may be able to approach the patient safely. As You Approach the Patient Consider the mechanism of injury (MOI) as you approach the patient by looking around the scene for clues as to what caused the emergency. This will help you to determine the possible type and extent of the patient’s injuries or illness. As you approach the patient, take in the whole picture and act appropriately. For example, if the mechanism of injury indicates a potential spinal injury, you should approach the patient from an angle that allows him or her to see you without turning his or her head. This simple choice could prevent further harm to the spine. Clues at the scene such as a fallen ladder, a damaged helmet, or drug paraphernalia may suggest the MOI. If the patient is unresponsive, assessing the scene may be the only way you can determine what has happened. This may involve some detective work on your part. When you assess the scene, always look carefully for more than one patient. You may not see everyone at first. For example, in a vehicle collision, an open door may be a clue that an injured person has left the vehicle. If one person is hemorrhaging blood or screaming, you may overlook another person who is unresponsive. It is also easy in any emergency situation to overlook an infant or a small child. Ask anyone present how many people may be involved. Bystanders may be able to tell you what happened or to help in other ways. A bystander who knows the patient may know whether the patient has any medical conditions or allergies. Bystanders can meet and direct further personnel to your location, help keep the area free of unnecessary traffic, and help you provide care, especially if there is more than one patient at the scene. Once You Reach the Patient Once you reach the patient, quickly assess the scene again to see if it is still safe. At this point, you may see other hazards, clues to what happened, or other injured people or bystanders that you did not notice before. Ensure that you are wearing the appropriate PPE for the situation. You may also decide that it is necessary to relocate a patient prior to your primary assessment. Moving a patient always involves a level of risk, so you should avoid moving a patient unless the situation makes an urgent relocation necessary. Situations that may require an emergency move include: Moving a patient away from dangerous materials or situations. Moving a patient with minor injuries to reach someone who may have a life-threatening condition. Moving a patient to provide appropriate care. Chapter 19 provides more detailed information about how to move patients safely. If the scene is unsafe to enter and the patient is able to do so, ask the patient to move to a safe location where you can provide care without putting yourself at risk. If the situation becomes dangerous once you have started to provide care and you cannot move the person, cease care and retreat to safety. Forming a General Impression Once you reach the patient and begin your assessment, you will be able to form a general impression of the patient’s condition. This includes determining the following details: The patient’s chief complaint or problem If the patient is injured or ill The patient’s sex and approximate age ASSESSMENT Before You Approach the Patient 81 Donning PPE Before beginning the primary assessment, ensure that you are wearing appropriate PPE for the situation (Figure 5–2). Depending on your role and the demands of the scene, you may already be wearing PPE at this point, but before you begin your primary assessment you should ensure that the PPE you have donned is appropriate based on all the information you have collected during your scene assessment. For example, you might be wearing gloves and eye protection, but may realize that a gown is also necessary once you see that the patient is hemorrhaging. Figure 5–2: Ensure that you are wearing appropriate PPE before you begin the primary assessment. PRIMARY ASSESSMENT The primary assessment is a rapid systematic check of the patient to identify conditions that pose an immediate threat to the patient’s life. It is ordered so that it will typically identify the highest priority conditions first. The primary assessment has several components: Introducing yourself Assessing level of responsiveness (LOR) Assessing cervical spine (C-Spine) Simultaneously assessing airway, breathing, and circulation (including pulse check) Performing a rapid body survey (RBS), including skin check Figure 5–3: Ask the patient what the chief complaint is with a question such as “What seems to be the problem?” Chief Complaint The chief complaint is the injury or condition that the patient verbally identifies as the most serious. If the patient does not do this spontaneously as you approach, ask the patient a question such as “What seems to be the problem?” (Figure 5–3). The patient’s answer is the chief complaint. The chief complaint is always an injury or condition: It is not the mechanism of injury. ASSESSMENT If a patient is unresponsive, the chief complaint is unresponsiveness. 82 Level of Responsiveness To determine whether a patient is responsive, gently tap the patient on the shoulder and ask, “Are you okay?” (Figure 5–4). Do not jostle or Figure 5–4: Determine the patient’s level of responsiveness. A patient’s LOR can range from full alertness to unresponsiveness (Table 5–1). A patient’s LOR can be identified using a four-level scale. The letters A, V, P, and U each refer to a stage of awareness. A = Alert: If a patient spontaneously responds to your presence (e.g. makes eye contact as you approach) and is able to speak and respond to your commands, this indicates that the patient is alert. It is important to note that a patient can be deemed alert but still be confused or disoriented. If the patient is not alert, proceed to check his or her response to verbal stimuli. TABLE 5–1: LEVELS OF RESPONSIVENESS LEVEL OF RESPONSE CHARACTERISTIC BEHAVIOUR Alert Eyes are open; patient is able to verbalize. Verbal Patient responds to commands or questions. Painful Patient exhibits facial grimace; flexion, extension, or withdrawal of body part; or moan or groan. Unresponsive Patient makes no response. V = Verbal: Sometimes a patient only reacts to sounds, such as your voice. This patient may appear to be lapsing into unresponsiveness. State a command or ask a question. If the patient responds, the patient is said to be responsive to verbal stimuli. If the patient is not responsive to verbal stimuli, proceed to check response to painful stimuli. P = Painful: If a patient responds only when someone inflicts pain, the patient is described as responding to painful stimuli. Pinching the nail bed or inside the arm is an example of a painful stimulus used to try to get a response. Avoid pinching anywhere above the collarbone as this could cause the patient to move his or her head, which could aggravate a potential spinal injury. U = Unresponsive: A patient who does not respond to any stimuli is considered to be unresponsive, sometimes referred to as unresponsive to stimuli. Any deterioration in the level of responsiveness can indicate a life-threatening condition. If you must leave a patient who has a decreased level of responsiveness alone for any reason, place the patient in the recovery position to maintain an open airway (Figure 5–5). Place the patient on one side, bend the top leg, and move the knee forward to hold the patient in that position. Position the head so the face is angled slightly toward the ground, and reassess the patient’s ABCs. Spinal Motion Restriction Spinal motion restriction is the reduction or limitation of spinal movement. It reduces the risk of additional injury to a patient who has suffered damage to the spine. You should initiate spinal motion restriction procedures whenever you suspect a spinal injury, unless doing so would interfere with care for life-threatening conditions. Even if you must move a person with a suspected spinal injury, you should take all possible precautions to minimize movement of the spine while performing these interventions. Consider the mechanism of injury to help you determine whether someone has suffered a spinal injury. Survey the scene and think about the forces that may have been involved in the injury: Strong Figure 5–5: The recovery position. ASSESSMENT move the patient, as this could exacerbate any injuries that he or she may have. A patient who can speak or cry is responsive. Unresponsiveness usually indicates a serious medical emergency, so it is important to establish immediately whether the patient is responsive in any measure, but a more specific indicator of the patient’s condition is the level of responsiveness (LOR). 83 forces are likely to cause severe injury to the head and spine. For example, a diver who hits his or her head on the bottom of a swimming pool may have a serious head and/or spinal injury. Examples of situations in which you should suspect a spinal injury include (but are not limited to): Unresponsiveness in the patient or an unknown cause of injury. A fall from a height greater than 1 metre (3.3 feet) or 5 stairs. Any motor vehicle collision or ejection from a motor vehicle. Any injury in which a patient’s helmet is broken. Any injury involving a severe blunt force to the head or trunk. Any injury, such as a gunshot wound, that penetrates the head or trunk. Any diving mishap. Techniques for spinal motion restriction are described in Chapter 12. Airway, Breathing, and Circulation (ABCs) ASSESSMENT The next step is to evaluate the patient’s airway, breathing, and circulation (ABCs). Try to move the patient as little as possible when checking the ABCs, especially if you suspect that the patient has a head and/or spinal injury. If the patient’s position prevents you from checking the ABCs effectively, roll the patient gently onto his or her back, keeping the head and spine in as straight a line as possible. 84 Figure 5–6: The jaw thrust. CHECK A: AIRWAY Check whether the patient’s airway is open. If a patient is speaking, moaning, or crying, the patient has an open airway. If a patient is unresponsive, it may be difficult to determine whether there is an open airway. Open an unresponsive patient’s airway by tilting the head back and lifting the chin. These two complementary motions, called the head-tilt/chin-lift, reposition the tongue and epiglottis so that they do not block the airway. If you suspect a head and/or spinal injury, attempt to open the airway using the jaw thrust technique (Figure 5–6). This opens the airway without repositioning the patient’s neck. If the jaw thrust is unsuccessful, use the head-tilt/chin-lift, keeping the neck in line with the body. Sometimes a head-tilt/chin-lift or jaw thrust will not open the airway. This may occur when a patient’s airway is blocked by a foreign object, such as a piece of food, or by something anatomical, such as swelling in the throat. Chapter 6 describes how to care for an obstructed airway. CHECK B: BREATHING Position yourself so that you can hear and feel air from the patient’s nose and mouth on your cheek. At the same time, watch for the patient’s chest to rise (Figure 5–7). If the patient is breathing normally, you will observe the rise and fall of the chest and be able to assess ease of breathing and approximate respiratory rate. Figure 5–7: Look, listen, and feel for breathing for no more than 10 seconds. A patient who is experiencing dyspnea (difficulty breathing) may have the following signs and symptoms: Inadequate rise and fall of the chest Increased effort on respiration Very slow or very fast respiratory rates Assess the patient’s breathing for a maximum of 10 seconds. Assessing the quality of the patient’s respiration (along with determining the mechanism of injury) will help you to determine whether interventions such as assisted ventilations or supplemental oxygen are necessary. Agonal Respirations Agonal respirations are an inadequate pattern of breathing sometimes associated with cardiac arrest states. Because they can be confused with ordinary respiration, it is important that professional responders recognize the differences between the two. Agonal respirations originate from lower brainstem neurons as higher brain centers become increasingly hypoxic (oxygen-deprived) during cardiac arrest. In agonal respirations, the diaphragm is receiving intermittent residual impulses from the brain, resulting in sporadic, gasping breaths. Agonal respirations can present as a snorting, gurgling, moaning, or gasping sound, a gaping mouth, or laboured breathing. The duration differs from person to person, from a few minutes to several hours. While normal respirations follow a regular pattern, agonal respirations are irregular and sporadic. It is important to remember that agonal respirations are not sufficient for delivering oxygen to the body. A person experiencing agonal respirations is not breathing and requires immediate interventions. Figure 5–8: The location of the radial artery. radial artery (Figure 5–8). If the adult or child is unresponsive, check the pulse at one of the carotid arteries in the neck. Checking a pulse is a simple procedure. It involves placing either two or three fingers on a major artery where it is located close to the skin’s surface. Do not use your thumb to take a patient’s pulse. To find the carotid pulse, feel for the Adam’s apple at the front of the neck and then slide your fingers into the groove at the side of the neck closest to you (Figure 5–9). Sometimes the pulse may be difficult to find, especially if it is slow or weak. If at first you do not find a pulse, relocate the Adam’s apple and slide your fingers into place. To find an infant’s pulse, place one or two fingers over the brachial artery, located on the underside of the infant’s arm, halfway between the elbow and the shoulder (Figure 5–10). CHECK C: CIRCULATION The method of assessing circulation is different for infants than for adults and children. If an adult or child is responsive, check his or her pulse using the Figure 5–9: The location of the carotid artery. ASSESSMENT When checking the patient’s ABCs, circulation refers to the patient’s pulse. You must determine whether the patient’s heart is beating. 85 Pulse oximetry should be applied whenever a patient’s oxygenation is a concern, and also for: All patients with neurologic, respiratory, or cardiovascular complaints. All patients with abnormal vital signs. All patients under the effect of respiratory depressants (morphine, diazepam, midazolam). Multi-system trauma patients. Figure 5–10: The location of the brachial artery. If no pulse is detected after a maximum of 10 seconds, initiate the applicable CPR/AED protocol (described in Chapter 7). You should also quickly check the patient’s skin for signs of a circulation emergency. Any abnormalities in the colour, temperature, or moisture of the skin can indicate an underlying problem with circulation. Touch the back of your hand (with appropriate PPE) to the patient’s forehead. If the patient’s skin is cold, pale, or clammy, for example, this may indicate that the patient is in shock, which is a life-threatening condition. You must check to ensure that the ABCs are present at least every 5 minutes for an unstable patient (a patient with a life-threatening condition) and every 10 minutes for a stable patient. This check is just to confirm that the ABCs haven’t changed: These findings are not recorded. Pulse Oximetry (SpO2) ASSESSMENT PURPOSE 86 Pulse oximetry is a simple, rapid, safe, and noninvasive method used to measure the percentage of oxygen saturation in the blood. The reading is taken by a pulse oximeter, which is a device that measures the percentage of hemoglobin that is saturated with oxygen. To ensure that the instrument measures arterial and not venous oxygenation, pulse oximeters assess only pulsating blood vessels. Pulse oximeters also measure the patient’s pulse. Each hemoglobin molecule has the capacity to hold oxygen molecules. How much of that capacity is filled with oxygen is known as the oxygen saturation. This is written as a percentage of the amount of oxygen actually bound to the hemoglobin compared with the total oxygencarrying capacity of the hemoglobin. If a given volume of blood is carrying 97% of the total oxygen that it could carry, its oxygen saturation is 97%. The capacity depends on the amount of hemoglobin in the blood, and the amount of bound oxygen depends on the partial pressure of the oxygen. Higher pressure causes oxygen to bond more readily with hemoglobin. The partial pressure of oxygen in the lungs is high, so oxygen bonds well with hemoglobin there. When hemoglobin travels through the body’s tissues, the partial pressure is lower, so the bond between the oxygen and the hemoglobin weakens and the oxygen is released into the cells of the body. This binding can be affected by several factors, including blood pH, temperature, the presence of carbon monoxide, and hemoglobin disorders. The reading from the oximeter appears as a percentage of hemoglobin saturated with oxygen. Normal saturation is approximately 95 to 100%. The saturation reading is documented as SpO2 (e.g., 97% SpO2). A 100% saturation measurement means all the hemoglobin molecules are carrying oxygen; 80% saturation means only 80% of these molecules are carrying oxygen. Oxygen saturation below 80% is considered insufficient to support life. RANGE Normal Mild hypoxia Moderate hypoxia Severe hypoxia VALUE TREATMENT 95 to 100% None 91 to 94% Administer emergency oxygen using a nasal cannula or standard oxygen mask. 86 to 90% Administer emergency oxygen using a nonrebreather mask or bag-valve-mask with oxygen reservoir. 85% or lower Administer emergency oxygen using a nonrebreather mask or bag-valve-mask with oxygen reservoir. A healthy, non-smoking adult who is breathing room air should have oxygen saturation of around 95 to 100%. Smokers who are breathing room air can have oxygen saturation around 94 to 96%. People with chronic lung disease may have oxygen saturations as low as 90% on room air, even when they are not otherwise ill. See Table 5–2. When possible, the responder should attempt to get an SpO2 reading before administering supplemental oxygen to a patient. This initial reading is referred to as room air saturation. This reading gives the responder an idea of the patient’s respiratory function before treatment is started (i.e., when the person has been breathing the normal air in the room, as opposed to supplemental oxygen). Once treatment is initiated, pulse oximetry is also used to assess the adequacy of oxygen delivery. A pulse oximeter is a tool that supports patient assessment. Pulse oximetry data should be one component of your assessment: You must always consider the clinical presentation of the patient in addition to the SpO2 reading. For example, if a patient appears to be in respiratory distress but has an SpO2 percentage of 95%, you should not withhold supplemental oxygen based on the pulse oximetry reading alone. Like any electronic device, pulse oximeters can malfunction, run out of power, etc. You should not rely on it exclusively to guide your patient assessment. When treating the patient, all symptoms should be assessed along with the data provided by the device. Treat the patient, not the pulse oximeter. PROCEDURE Apply the pulse oximeter. Usually, the patient’s fingertip is the most convenient site; otherwise, use an earlobe or a toe (if a proper probe is available). Refer to the manufacturer’s directions to ensure that you are using it properly. Once the device registers the oxygen saturation level, record the time and the saturation percentage. Assess the patient’s pulse manually and compare this number with the pulse oximeter’s reading. If you are recording a one-time reading, be sure to monitor the patient for a few minutes, as oxygen saturation can vary. Pulse oximetry should be taken and recorded with vital signs at least every 15 minutes for stable patients, and reassessed and recorded every 5 minutes for unstable patients. LIMITATIONS Some factors may reduce the reliability of the pulse oximetry reading, including: Hypoperfusion (i.e., poor perfusion) or shock (fewer circulating red blood cells to carry oxygen). Hypotension. Decreased circulation to the extremities (insufficient blood flow to obtain an accurate reading). Cardiac arrest (absent perfusion to fingers). Excessive motion of the patient during the reading. Fingernail polish. Carbon monoxide poisoning (carbon monoxide binds to hemoglobin more easily than oxygen and saturates the hemoglobin). Hypothermia or other cold-related illness. Sickle cell disease or anemia (because there are fewer red blood cells present to carry oxygen). Smoking cigarettes (due to carbon monoxide). Edema (swelling). A delay in detecting respiratory insufficiency. The pulse oximeter could warn too late of a decrease in respiratory function based on the amount of oxygen in circulation. ASSESSMENT TABLE 5–2: PULSE OXIMETRY 87 Ambient light, which can affect your ability to read the equipment. False positives from CPR. Continue administering high-concentration oxygen to all patients with suspected carbon monoxide (CO) poisoning, regardless of the saturation readings. OXYGEN DECISION Based on all of the information you have gathered about the patient—including signs, symptoms, chief complaint, and SpO2—decide whether the patient requires supplemental oxygen. If oxygen is indicated, set the flow rate and then apply the appropriate oxygen delivery device. When monitoring a conscious patient’s oxygen saturation, you may reduce the flow of oxygen and change to a lower-flowing delivery device if the patient’s oxygen level reaches 100%. Consider discontinuing supplemental oxygen if the patient is not distressed and the saturation is greater than 95% on room air. A patient who uses low-flow oxygen regularly for a chronic condition (such as COPD) should usually be kept on low-flow maintenance oxygen unless higher-concentration oxygen is necessary to increase the patient’s SpO2 levels. Rapid Body Survey The rapid body survey (RBS) is a hands-on check that allows you to quickly identify life-threatening injuries and conditions. If you discover the need for a critical intervention, pause the RBS and perform the intervention before continuing the survey. ASSESSMENT The RBS is a systematic check of the patient’s body, starting with the highest-priority areas. An RBS should check the patient in the following order: head, neck, chest, abdomen, pelvis, lower extremities, upper extremities, and back. 88 Palpate each of these areas, checking for abnormalities such as inflammation, deformities, and fractures. You should look, listen, and feel as you conduct this check. For example, you may hear crepitus (bones scraping) if the patient has a fracture, feel deformities at the site of a dislocation, or see contusions that indicate internal bleeding. If you discover any abnormalities under the patient’s clothing, you should expose and examine the area to determine the extent of the injury. Because fractures of the pelvis can cause other serious internal injuries, use caution and handle the area gently. Do not push down on the iliac crests. The RBS also includes checking for external hemorrhaging. External bleeding is lifethreatening when blood spurts from the wound or cannot be easily controlled. As you palpate each section of the patient’s body, check your gloves for blood or other bodily fluids. If you see any bodily fluids on your gloves, expose and examine the area of origin before proceeding. Be aware of any risks to your own safety. Watch for sharp objects such as broken glass or syringes. Do not put your hands anywhere you cannot see. To avoid aggravating any injuries, avoid moving the patient unless it is absolutely necessary to provide care for life-threatening conditions. Transport Decision You must now decide whether the patient requires immediate transport. If so, the patient is considered to be in the rapid transport category (RTC). A patient with a life-threatening condition will fall into the rapid transport category. This decision is made quickly based on whether you have found any life-threatening conditions in your assessment thus far. If at any point the patient’s condition deteriorates, you must reevaluate whether rapid transport is necessary. This decision can occur at any point in your assessment or during care for the patient, even before you have completed your primary assessment (though the assessment should still be completed once any necessary interventions are performed). If you arrive on scene, for example, and immediately see a patient with an amputated leg, you know that he or she will be in the rapid transport category regardless of the results of your assessment. If you are working in a team, one responder can prepare the stretcher and make other preparations for transport while the other begins the assessment and cares for the patient. If delaying transport could have a negative effect on the patient’s condition, transport the patient immediately. Do not delay transport at any time to perform additional assessments or treatment, aside from immediate life-saving interventions. You may be able to perform other steps en route. IMMEDIATE TRANSPORT EMERGENCIES If a life-threatening condition is found, this requires an immediate transport response. Transporting the patient is high priority. Examples of immediate transport emergencies can include: Severe or multi-system trauma. Instability or absence of the ABCs. Internal or external hemorrhage. Neurological deficits. Decreased level of responsiveness (LOR) or unresponsiveness. Ongoing seizures. Chest pain (if disorder or heart attack is suspected). Burns with signs of inhalation injury. Extensive burns. Abdominal distension and tenderness. Unstable pelvic injury. Fractured femur. Amputation. Childbirth complications. Severe hypothermia. Electrocution. Decompression illness. When possible, transport any of the patient’s medications with the patient. Patient Positioning Most injured patients will find the most comfortable position for themselves. For example, a patient with a chest injury who is having trouble breathing may be sitting up and supporting the injured area. In general, it is best to keep a patient in the position you find him or her. However, there are several cases where moving a person can be beneficial: The patient’s position prevents you from performing a proper assessment or from providing critical interventions. A different position could improve the patient’s condition or reduce pain. The patient’s position could aggravate an existing injury or condition. Whenever possible, you should assist the patient in changing positions to reduce the risk of injury. Some positions are better suited to certain situations than others. For example, a patient in respiratory distress will usually find it easier to breathe if he or she is in the Fowler or Semi-Fowler position than if he or she is supine. Common positions include: Lateral: The patient is lying on his or her side. Supine: The patient is lying on his or her back. Lateral recumbent (recovery): The patient is lying in a semi-prone position, half-way between prone (lying on his or her stomach) and lateral. Fowler: The patient is lying on his or her back with the body elevated at a 45-degree to 60-degree angle. Semi-Fowler: The patient is lying on his or her back with the body elevated at an angle less than 45 degrees. Trendelenburg: The patient is lying on his or her back with legs elevated higher than the head and the body on an inclined plane. ASSESSMENT Seriously injured patients have the best chance of survival when emergency care is provided as soon as possible after the injury. The first hour after the injury is sometimes referred to as the Golden Hour because patients who receive hospital care within this time are considered significantly more likely to survive. 89 Lateral Fowler Supine Semi-Fowler REASSESSMENT ASSESSMENT Lateral recumbent 90 Trendelenburg Reassessment is an ongoing process. It is included here as a step to ensure that it is consciously considered, but you should get into the habit of monitoring the condition of any patient you are providing care for, thinking about whether additional resources are required to deal with changes on the scene or with the patient, and considering whether your transport decision is still appropriate for the situation. For example, if your assessment of the patient changes as a result of your RBS findings, you may decide that the patient is in the rapid transport Reassessing a patient’s ABCs should occur frequently throughout the assessment and care process. Performing a rapid body survey, for example, requires you to move away from the patient’s airway to check his or her extremities. Once this survey is complete you should immediately reassess the patient’s airway, breathing, and circulation to ensure that there has been no change in the patient’s presentation. SECONDARY ASSESSMENT Once you have made a decision about transport, you can begin gathering more information through a secondary assessment. This assessment may take place at the scene (if the patient does not require immediate transport) or en route to a hospital or other emergency medical facility. The secondary assessment is more thorough than the primary assessment and focuses on gathering detailed information about the patient’s history and condition. Immediately life-threatening conditions are usually identified during the primary assessment, but the secondary assessment can reveal injuries or conditions that may become lifethreatening without immediate care. For example, you might find broken bones, minor bleeding, or a specific medical condition, such as diabetes. The secondary assessment is made up of the following three steps: 1. Interview the patient and bystanders to get information about the MOI and chief complaint. 2. Check the patient’s vital signs. 3. Do a head-to-toe physical examination. As you perform the secondary assessment, try not to move the patient. Interview with Patient and Bystanders Begin by asking the patient and bystanders simple questions to learn more about what happened and the patient’s condition. Asking about any existing conditions the patient has, the circumstances of the incident, and the chief complaint are collectively known as obtaining a patient’s history. While the patient is answering your questions, you should listen carefully but also watch for signs of injury or illness, such as an unusually pale skin colour or a rasping sound during inhalation. Begin the interview by asking the patient’s name. Using a patient’s name will make the patient more comfortable. Using the acronym SAMPLE will help you gather information on all of the necessary topics: S Signs and symptoms (e.g., “What’s bothering you?”) A Allergies (e.g., “What allergies do you have?”) M Medications (e.g., “What medications are you currently taking? Have there been any recent changes?”) P Past/present medical history (e.g., “What medical conditions do you have?”) L Last oral intake (e.g., “When did you last eat or drink? What did you last eat or drink?) E Events before the incident (e.g., “What happened to cause the problem?”) If the patient is experiencing pain of any kind, use the mnemonic OPQRST to ask all the relevant questions about the pain (Table 5–3). Be careful not to lead the patient with your questions: For example, asking “What does the pain feel like?” lets the patient choose how to characterize it, but “Is the pain sharp?” will only provoke a yes or no response. ASSESSMENT category. If this is the case, prepare the patient for immediate transport, and begin the secondary assessment once you are en route or while awaiting transport. Notify or update the hospital and any personnel who are on their way to the incident of your updated transport decision. 91 TABLE 5–3: QUESTIONS ABOUT PAIN: OPQRST MNEMONIC EXAMPLES OF QUESTIONS Onset Did it start suddenly or develop over days, hours, etc.? Provocation What provokes the pain or causes it to get worse? Quality What does the pain feel like (sharp, dull, stabbing, moving, etc.)? Region and Radiation Where exactly is the pain located? Does it radiate to other areas? Severity On a scale of 0 to 10, how bad is the pain? Time When did the pain start? Sometimes the patient will be unable to give you this information. This can be the case with children (who may be shy or intimidated by your presence) or with adults who have altered levels of responsiveness. Be calm and patient. Speak normally, in simple terms, and offer reassurance. You can also ask family members, friends, or bystanders what happened. They may be able to give you helpful information, such as telling you if the patient has a medical condition that you should be aware of or describing the circumstances of an injury. They may also be able to help calm the patient if necessary. Vital Signs ASSESSMENT The next step is to gather more detailed physiological information about the patient by taking clinical measurements of the patient’s vital signs. These are indicators of the body’s overall function and can be used to guide your assessment and treatment. 92 The vital signs that you document can vary based on your qualifications and scope of practice. They may include: Level of responsiveness (AVPU/Glasgow Coma Scale). Respiration. Pulse. Skin characteristics. Pupils. Blood pressure. SpO2. Body temperature. Blood glucose level (BGL). The first set of vital signs taken from the patient is considered to be the baseline vital signs. You must always record the time when taking vital signs. If the patient’s vital signs vary from the baseline, you can evaluate the effectiveness of your treatment. For example, if a patient’s skin is initially pale but presents normally after a period of time on supplemental oxygen, this suggests that the patient is responding positively to the oxygen. Vital signs should be reassessed and recorded every 5 minutes for unstable patients and every 15 minutes for stable patients. ASSESSING A RESPONSIVE CHILD OR INFANT If possible, assess an infant or a child in a parent or guardian’s arms or lap. When assessing an infant or child: Approach the patient slowly. Kneel so that you are at eye level with the patient. Give the patient a few minutes to get used to you if possible. Use the patient’s name. Tell the patient what you are going to do and why you need to do it. Demonstrate on a stuffed animal or doll if possible. Allow the patient to inspect safe and nonsterile items such as bandages. If the patient is not responding to your questions, ask the parent or guardian to relay your questions to the child. LEVEL OF RESPONSIVENESS You learned how to assess a patient’s LOR earlier in the chapter using the AVPU scale. Another evaluation, typically used for assessing patients with head trauma, is the Glasgow Coma Scale. Glasgow Coma Scale The Glasgow Coma Scale (GCS) is a standardized system used to determine a patient’s level of responsiveness and is considered a good indicator of eventual clinical outcome for head trauma. The scale is often used to assess patients with neurological damage. The assessment process involves assigning a numerical score to the patient’s responses in three areas: the patient’s eye-opening responses, verbal responses, and the patient receives a score of 4. If the patient’s response consists of comprehensible but inappropriate words, the patient receives a score of 3. If the patient’s response is incomprehensible (e.g., moaning), the patient receives a score of 2. If the patient does not reply at all or is unresponsive, he or she receives a score of 1. EYE OPENING E Spontaneous 4 To voice 3 To pain 2 No response 1 BEST VERBAL RESPONSE V Best Motor Response Oriented and converses 5 Disoriented and converses 4 Inappropriate words 3 Incomprehensible sounds 2 No response 1 Give the patient a command, such as “Wiggle your fingers.” If the patient responds to your command, he or she receives a score of 6. If the patient does not follow your command, apply a painful stimulus, as described earlier, and score the response accordingly. If the patient pushes away the stimulus or (correctly) says something like “Stop pinching my finger,” this is considered localizing the pain, and the patient receives a score of 5. A patient who withdraws from the painful stimuli receives a score of 4. Responses lower than 4 indicate that the patient is responding at the reflex level only: A patient who demonstrates flexion receives a score of 3, and a patient who demonstrates extension receives a score of 2. A patient who does not manifest a motor response of any kind receives a score of 1. BEST MOTOR RESPONSE M To verbal command: Obeys command 6 To painful stimulus: Localizes pain 5 Withdrawal 4 Abnormal flexion 3 Abnormal extension 2 No response 1 E + V+ M = 3 to 15 motor responses (E,V,M). These three sections are scored individually, with the values then added together to produce the overall score (Table 5–4). Eye Opening If a patient spontaneously opens his or her eyes, he or she receives a score of 4. If the patient does not spontaneously open his or her eyes, give a verbal command, such as “Open your eyes.” If the patient complies, he or she receives a score of 3. If the patient still does not open his or her eyes, apply a painful stimulus, as with the AVPU assessment. If the patient responds, he or she receives a score of 2. If there is no response to the painful stimulus, the patient receives a score of 1. Best Verbal Response Ask a question. If the patient responds coherently, he or she receives a score of 5. If the answer is confused but still comprehensible and appropriate, A score of 15 indicates a perfect score in each category: Neurological damage is unlikely. A score of 14 can indicate minor damage, especially if this assessment is supported by other indicators that you have observed. A score of 13 or lower indicates neurological damage. Any patient with a score of 13 or lower requires rapid transport. Use judgment when assessing children and infants, as they might not be able to respond to methods used to assess the level of responsiveness in adults. When possible, have someone who knows the child remain present to confirm whether the child is responding normally. A child who does not reply to your question may simply be shy, for example, and not suffering from an underlying medical condition. When assessing any patient, try to evaluate the person’s responses as compared against the normal behaviour of that person. Family members, friends, or colleagues of the patient who are at the scene may be able to help you establish what is outside of the normal parameters. ASSESSMENT TABLE 5–4: GLASGOW COMA SCALE 93 RESPIRATION PULSE A healthy person breathes regularly, quietly, and effortlessly. The normal respiratory rate for an adult is between 12 and 20 breaths per minute. However, some people breathe slightly slower or faster. Excitement, fear, and exercise cause breathing to become faster and deeper. Certain injuries or illnesses can also cause the respiratory rate and quality to change. With every heartbeat, a pressure wave of blood moves through the blood vessels. This creates the patient’s pulse. You can feel it with your fingertips in arteries near the surface of the skin. In the primary assessment, you are concerned only with whether or not a pulse is present. In the secondary assessment, you are trying to determine pulse rate, rhythm, and quality. This is most often done by checking the radial pulse located on the thumb side of the patient’s wrist. During the primary assessment, you are concerned with whether a patient is breathing at all, whereas in the secondary assessment, you are concerned with the rate, rhythm, and volume of breathing. Look, listen, and feel again for breathing. Look for the rise and fall of the patient’s chest or abdomen. Listen for sounds as the patient inhales and exhales. Count the number of times a patient breathes (inhales or exhales) in 15 seconds and multiply that number by four. This is the number of breaths per minute. Try to assess breathing without the patient’s knowledge. If a patient realizes that you are checking breathing, he or she may change his or her breathing pattern without being aware of doing so. Assume the same position you will be in when you are checking the pulse. Watch and listen for any changes in breathing. Abnormal breathing may indicate a potential respiratory or airway problem. Signs and symptoms of abnormal breathing include: Gasping for air. Noisy breathing, including whistling sounds, crowing, gurgling, or snoring. Excessively fast or slow breathing. Painful breathing. A normal pulse for an adult is between 60 and 100 beats per minute. A well-conditioned athlete may have a pulse of 50 beats per minute or lower. Table 5–5 lists average pulses at different ages. If the heartbeat changes, so does the pulse. An abnormal pulse may be a sign of a potential problem. These signs include: Irregular pulse. Weak and hard-to-find pulse. Excessively fast or slow pulse. When the body is injured or unhealthy, the heart may beat irregularly. The rate at which the heart beats can also vary. The pulse speeds up when a person is excited, anxious, in pain, losing blood, or under stress. It slows down when a person is relaxed. Some heart conditions can also speed up or slow down the pulse rate. Sometimes changes may be difficult to detect, so be careful and attentive in your assessment to ensure that you note even subtle variations in the patient’s pulse. The most important change to note is a pulse that changes from being present to absent. TABLE 5–5: AVERAGE* VITAL SIGNS BY AGE ASSESSMENT AGE 94 PULSE RESPIRATIONS BLOOD PRESSURE Up to 28 days 120−160 40−60 80/40 1−12 months 100−120 30−40 80/40 1−8 years 80−120 16−24 90/50 Over age 8 60−100 12−20 120/80 *These values vary among individuals and should not be considered normal values. They are averages for each age group. a b c Figure 5–11, a-c: Checking for: a, the carotid pulse; b, the radial pulse; and c, the brachial pulse. Pulse sites that are easy to locate are the carotid arteries in the neck, the radial artery in the wrist, and, for babies, the brachial artery in the upper arm (Figure 5–11, a-c). There are other pulse sites you may use (Figure 5–12). To check the pulse rate, count the number of beats in 15 seconds and multiply that number by four. The number you get is the number of heartbeats per minute. If you find that the pulse is irregular, you may need to check it for more than 15 seconds to determine the average rate accurately. A patient with severe hypothermia, for example, may have a severely depressed heart rate, so you may need to check for 45 to 60 seconds. A patient’s pulse may be hard to find. Take your time. Remember that if a patient is breathing, his or her heart is also beating. However, there may be a loss in circulation to an injured area, causing a loss of pulse. If you cannot find the pulse in one location, check it in another major artery. SKIN CHARACTERISTICS In patients with darker skin, cyanosis may be harder to recognize: Skin may appear ashen-grey, yellow-brown, or greyish-green. Changes may be most easily visible on the inside of the lips, the nail beds, or the skin around the mouth. The important thing is to note any changes from the patient’s normal skin tone, if possible. Neck (Carotid) Arm (Brachial) Leg (Femoral) Wrist (Radial) The colour, temperature, and condition of the skin often indicate something about the patient’s condition. For example, a patient with a breathing problem may have a flushed or pale face. Foot (Posterior tibial) (Dorsalis pedis) Figure 5–12: Easily located pulse sites. ASSESSMENT The skin looks red when the body is forced to work harder. The heart pumps faster to get more blood to the tissues. This increased blood flow causes reddened skin and makes the skin feel warm. In contrast, if the blood flow is directed away from the skin’s surface, the skin may lose its underlying red tones, becoming pale or bluish, and feel cool and moist. When the blood below the skin is oxygen-deficient, it can give the skin a bluish tint. This is referred to as cyanosis. 95 Illness and/or injury may also cause the skin to become dry, moist, or clammy, for example. Any changes in these skin characteristics may indicate a problem. CAPILLARY REFILL Capillary refill is a method of estimating the amount of blood flowing through the capillary beds, such as those in the fingertips. The capillary beds in the fingertips are normally rich with blood, which causes the pink colour under the fingernails. Capillaries in the extremities are among the first blood vessels to constrict. When an injury or condition (such as shock) reduces blood flow to an extremity, this will be evident as reduced blood flow through the capillaries, reducing the speed at which they refill when emptied by external pressure. To check capillary refill, squeeze the patient’s nail bed and then release (Figure 5–13, a-b). In a healthy person, the area beneath the nail will turn pale as you press it and turn pink again as you release and it refills with blood. If the area does not return to pink within 2 seconds, this indicates that circulation to the fingertip is impaired. PUPILS ASSESSMENT Look closely at the size of the pupils, as well as whether they react to light and are of equal size. You can check the reaction to light by shading each eye and then allowing light to enter, or by 96 a shining a light into each eye and then removing it. Pupils should be equal, round, and reactive to light. Pupils that are unequal, fully dilated, fully constricted, or unresponsive to light may indicate a serious head injury or illness (Figure 5–14). BLOOD PRESSURE Blood pressure (BP) is the force exerted by the blood against the blood vessel walls as it travels throughout the body. Blood pressure is necessary to move blood through the circulatory system. Blood pressure is a good indicator of how the circulatory system is functioning. Blood pressure is created by the pumping action of the heart. The pumping action involves two phases: the contracting (working) phase and the refilling (resting) phase. During the contraction phase, the ventricles of the heart contract, pumping blood through the arteries to all parts of the body. During the refilling phase, the ventricles relax and the heart refills with blood before the next contraction. Stress, excitement, illness, and injury often affect blood pressure. When a patient is ill or injured, a single blood pressure measurement is often of little value. Immediately following an injury or the onset of an illness, a more accurate indicator of a patient’s condition is whether his or her b Figure 5–13, a-b: To check capillary refill: a, squeeze the patient’s nail bed and then release; b, assess how quickly colour returns to the area beneath the nail. blood pressure changes over time. For example, a patient’s initial blood pressure reading could be uncommonly high due to the stress of the emergency. Providing care, however, usually relieves stress and anxiety, and blood pressure may return to a normal range. At other times, blood pressure will remain unusually high or low, depending on the nature of the injury or illness. Changes in a patient’s blood pressure can indicate a change in the patient’s condition, and may indicate a need for interventions to return the blood pressure to the normal range. Before taking a patient’s blood pressure, check his or her arm for abnormalities, such as swollen lymph nodes (e.g., in a cancer patient), a dialysis fistula (a dialysis port in the lower arm), or trauma. To accurately assess a patient’s blood pressure, you need a blood pressure cuff. Cuffs come in sizes for small, average, and large arms. Inside the cuff is a rubber bladder, similar to an inner tube that can be inflated. A pressure gauge, inflation bulb, and regulating valve are connected to the bladder by rubber tubing. Blood pressure is measured in units called millimetres of mercury (mmHg). These units, written on the blood pressure gauge, range from 20 mmHg to 300 mmHg. In measuring blood pressure, two different numbers are usually recorded. The first number reflects the pressure in the arteries when the heart is contracting. This pressure is called the systolic blood pressure. The second number reflects the pressure in the arteries when the ventricles are relaxed and the heart is refilling. This is called the diastolic blood pressure. You report blood pressure by giving the systolic number first and the diastolic second (S/D). For example, BP 120/80 means the patient has a systolic pressure of 120 mmHG and a diastolic pressure of 80 mmHG. Palpation uses a blood pressure cuff and involves feeling the patient’s radial pulse. It is used only to assess the systolic pressure. Auscultation uses both a blood pressure cuff and a stethoscope and involves listening for the patient’s pulse. It is used to assess both systolic and diastolic pressure. ASSESSMENT Figure 5–14: Pupils that are unequal, fully dilated, fully constricted, or unresponsive to light may indicate a serious head injury or illness. There are two methods used to assess a patient’s blood pressure: palpation and auscultation. 97 Palpation Auscultation To determine blood pressure using palpation, begin by having the patient sit or lie down. Wrap the blood pressure cuff around the patient’s arm so that the lower edge is about 2.5 cm (1 in.) above the crease of the elbow. The centre of the cuff should be over the brachial artery, the major artery of the arm (Figure 5–15). The cuff should be directly against the skin. Next, locate the radial pulse (Figure 5–16). Close the regulating valve on the blood pressure cuff, and inflate the cuff until you can no longer feel the radial pulse. Note the number displayed on the gauge. Before auscultation, it is best to begin by determining the systolic pressure using the palpation method. This will rapidly provide a baseline against which you can compare the results of auscultation, as well as a starting pressure for the blood pressure cuff. ASSESSMENT Continue to inflate the cuff for another 20 mmHg beyond this point. Slowly reduce the pressure in the cuff by releasing the valve slowly (referred to as bleeding it down). Allow the cuff to deflate at a rate of about 2 mmHg per second. Continue to feel for the radial pulse as the cuff deflates. The point at which the pulse returns is the approximate systolic blood pressure by palpation. Using this method, the systolic pressure found is (on average) about 10 to 20 mmHg less than the systolic pressure found by auscultation. This blood pressure reading is expressed as one number only, such as 130/P. In this example, the systolic pressure is 130, and P refers to palpation. Once you know the approximate systolic pressure, quickly deflate the cuff. Record the systolic pressure and whether the patient was sitting or lying down when the blood pressure was taken. 98 Figure 5–15: The centre of the cuff should be placed over the brachial artery, about 2.5 cm (1 in.) above the crease of the elbow. Next, locate the brachial pulse. Place the earpieces of the stethoscope in your ears and the other end, the diaphragm, over the brachial pulse (Figure 5–17). Apply the cuff as for palpation (or leave it in place after performing palpation) and begin to inflate the cuff. Inflate the cuff to 20 mmHg above the approximate systolic blood pressure (as determined during palpation). Slowly deflate the cuff at a rate of about 2 mmHg per second. As you deflate the cuff, listen carefully for the pulse (it will make a tapping sound). The point at which the pulse is first heard is the systolic pressure. As the cuff deflates, the sound of the pulse will fade. The point at which the sound disappears is the diastolic pressure. Release the remaining air quickly. Record the blood pressure as two numbers, for example: 130/80. Also, be sure to record whether the patient was sitting or lying down. Figure 5–16: Assessing systolic blood pressure requires you to feel for a radial pulse. (Figure 5–18). The test requires obtaining a drop of blood by piercing the skin of a finger pad with a sterile lancet. The drop of blood is then placed on a test strip, which is then inserted into the glucometer. Because this procedure requires you to break the patient’s skin to obtain the blood sample, it is considered an invasive diagnostic technique. Using a Glucometer Figure 5–17: To auscultate blood pressure, position the cuff, find the brachial pulse, and position the stethoscope over it. To determine both the systolic and the diastolic pressure, you must use auscultation, which requires a stethoscope. The stethoscope enables you to hear the pulsating sounds of blood moving through the arteries with each contraction of the heart. Sometimes you may not have a stethoscope or, because of background noise, find it very difficult to use effectively. You can still determine the systolic blood pressure through palpation. In many situations, blood pressure can be taken using an automatic blood pressure cuff. Nevertheless, it is important that you are able to take blood pressure manually in case the automated equipment fails or is unavailable. BLOOD GLUCOSE LEVEL (BGL) When using a glucometer, follow the manufacturer’s directions in conjunction with these general steps: 1. Ensure that you are wearing proper PPE, you have a sharps container ready, and your glucometer is ready for use. 2. Prepare the lancet and lancet device. 3. Insert the test strip into the glucometer. Some are self-calibrating, and others require you to match a code on the screen to the test strip vial for calibration. 4. Wipe the pad of the patient’s finger with an alcohol swab, or clean the finger with soap and water. Allow the skin to dry completely. Force blood into the finger by squeezing. 5. Using a sterile lancet, prick the side of the fingertip and wait for a drop of blood to appear. 6. Bring the glucometer to the patient’s finger and touch the tip of the test strip to the drop of blood. Glucose is a form of sugar that is naturally present in the bloodstream. A patient’s blood sugar refers to the glucose that is carried in his or her blood. Glucose can move from the bloodstream to the body’s cells, where it is used for energy. This transfer is carried out with the aid of insulin, a hormone produced in the pancreas. Quantifying a patient’s blood glucose level can provide important information about a patient’s condition. This is especially true in patients suffering from diabetes. People with diabetes check their BGL regularly, often using a portable device called a glucometer Figure 5–18: An example of a glucometer kit. ASSESSMENT Testing BGL with a Glucometer 99 7. Most glucometers will alert you that the sample has been received with either an audible sound or a change in the display. 8. Document the results when they are displayed. 9. Bandage the patient’s finger. 10. Remove the test strip. Place the lancet in the sharps container and dispose of the test strip and any other contaminated materials in a biological waste container. 11. Ensure that your glucometer is ready for its next use. What the Numbers Mean Blood glucose is measured in millimoles per litre (mmol/L), and a normal BGL ranges from 4 mmol/L to 8 mmol/L. Hypoglycemia (low blood sugar) is most often defined as a BGL of less than 4 mmol/L, whereas hyperglycemia (high blood sugar) is defined as a BGL of greater than 8 mmol/L. Although the result may vary depending upon the patient and the testing device used, it is generally accepted that the normal range before meals is 4 to 6 mmol/L, and for the 2 hours after meals it is 5 to 8 mmol/L. Professional responders should remember that a glucometer is just one assessment tool. Responders should use this reading, along with the patient’s history and other information gathered during the assessment, to determine whether to treat the situation as a diabetic emergency. Head-to-Toe Physical Examination Begin the physical exam by explaining to the patient what you are going to do and confirming that you have consent. Next, direct the patient to keep still while you systematically inspect and palpate each part of the body, starting with the head. Handle the patient gently to avoid aggravating any existing injuries, and avoid moving the patient unless it is necessary to complete the examination. At the same time, a balance is necessary: You must always ensure that you are palpating effectively. Always maintain the patient’s dignity and privacy while conducting the exam. Ask the patient to tell you if he or she experiences any pain or discomfort during the examination. Avoid touching any painful areas or having the patient move any area in which there is discomfort. Watch the patient’s facial expressions and listen for a tone of voice that may reveal pain. If you encounter a painful area, have the patient characterize the pain by asking the OPQRST questions outlined in Table 5–3. If you find that palpating a specific point (one or two finger-widths) on the patient’s body is especially painful for the patient, this is referred to as point tenderness and can indicate the presence of an injury, often a fracture. Look for a medical identification product such as a necklace or bracelet that the patient might be wearing. (Figure 5–19). This tag may help you determine what is wrong, who to call for help, and the level of care that may be required. ASSESSMENT Once you have assessed and recorded the patient’s vital signs, you must complete a headto-toe physical examination to gather additional information about injuries or conditions that may require care. These injuries or conditions may not be immediately life-threatening, but they could become so if not cared for. For example, you might find minor bleeding or possible broken bones as you conduct your examination of the patient. 100 The physical exam process involves inspection (exposing and examining), auscultation (listening), and palpation (feeling). You may even smell something that provides additional information, such as the smell of bleach on the breath, which may indicate poisoning. Figure 5–19: There are many forms of medical identification products. Begin by checking the head (Figure 5–20, a). Look for blood or clear fluid in or around the ears, nose, and mouth. Blood or clear fluid can indicate a serious head injury. Check the level of responsiveness again and note any change. Check the pupils again and note any changes. To check the neck, look and feel for any abnormalities. If the patient has not suffered an injury involving the head or trunk and does not have any pain or discomfort in the head, neck, or back, there is little likelihood of a spinal injury. You should proceed to check other body parts. However, if you suspect a possible head and/or spinal injury because of the mechanism of injury (e.g., a motor vehicle collision or a fall from a height), minimize movement of the patient’s head and spine. If you suspect head and/or spinal injuries, you must address these concerns before continuing with the secondary assessment. You will learn techniques for stabilizing and immobilizing the head and spine in Chapter 12. Check the clavicles (collarbones) and shoulders, including scapulas and associated muscles. If you find no abnormalities, direct the patient to shrug his or her shoulders and note whether the movement seems impaired. Place your hands gently on the lower anterior portion of the patient’s ribs, one on each side. Check the chest by having the patient inhale and exhale, feeling for equal expansion of the lungs. Ensure that there are no injuries or abnormalities in the chest, and ask whether the patient experiences any pain. If your findings suggest an injury or illness, expose and examine the affected area. Expose the patient’s back and palpate both sides of the spine from the neck downward with your fingertips. It may be necessary to expose the CHEST AUSCULTATION If your scope of practice includes chest auscultation, expose the chest and perform the following steps: 1. Place the stethoscope below the clavicle at the mid-clavicular line (the imaginary line running parallel to the body’s midline and passing through the midpoint of the clavicle). Listen to one full inhalation and exhalation on each side of the chest by asking the patient to take a deep breath in and out through the mouth. 2. Place the stethoscope at the fourth or fifth intercostal space (the space between the ribs) on the mid-axillary line (below the axilla, or armpit). Listen to one full inhalation and exhalation on each side of the chest. When auscultating, listen for equal breath sounds in both lungs, at the top and bottom. You should hear equally good air entry in each lung. Absent, diminished, or abnormal breath sounds may indicate a respiratory condition. patient’s entire torso, but balance this against the need to protect the patient’s privacy. As always, expose only as much of the patient’s body as is necessary to perform the assessment. Check the entire posterior side of the patient’s torso, including the scapulas, ribs, and upper pelvis (Figure 5–20, b). Expose the abdomen: In addition to looking for discolouration, deformity, and bleeding, check the area for distension. A pulsating mass beneath the skin can indicate a life-threatening internal hemorrhage, which is an urgent medical emergency. Otherwise, apply light pressure to each of the abdominal quadrants, avoiding any areas where the patient has indicated pain. The abdomen should be soft. Abdominal muscles clench in response to trauma to protect ASSESSMENT As you examine each part of the body, be alert for any sign of injuries—anything that looks or feels unusual. You are looking especially for discolouration, deformity, and bleeding. Abnormalities often cause the body to be asymmetrical: If you are uncertain as to whether something is unusual, compare it to the other side of the patient’s body. 101 underlying structures: If any of the abdominal quadrants are rigid, this can indicate an underlying injury or condition. This can be a clue to an unknown MOI or the resulting condition. Check the hips, asking the patient if he or she is experiencing any pain there. Place your hands on the sides of the hips (lateral) and gently rock the pelvis, listening for crepitus and watching for any sign of pain or discomfort. Assess joint rotation and check for shortening of limbs. Because fractures of the pelvis can cause other serious internal injuries, use caution and handle the area gently. Palpate each leg individually (Figure 5–20, c). Assess the continuity of the bones to ensure there are no fractures, and check the knee and ankle joints for signs of injury. If any abnormalities are found, expose and examine the area. Assess circulation in the lower extremities by checking the dorsalis pedis pulse on the anterior side of the patient’s foot or the posterior tibialis pulse on the back of the ankle (see Figure 5–12). The pulse should be the same on each side: Any inequalities can indicate circulatory impairment. Check the capillary refill on the toes. If there is no apparent sign of injury, perform a motor-sensory assessment by instructing the patient to move his or her toes, foot, and leg and watching for any signs of impaired function. As the patient moves each part, ensure that each joint has a normal range of motion (ROM). Finally, physically assess each arm individually, beginning at the shoulder and working towards the tips of the fingers. This assessment mirrors the assessment of the lower extremities (above). Check circulation by assessing the radial pulse and capillary refill in the fingers. Compare both sides (as for the legs). Perform a motor-sensory assessment and range of motion assessment as above. ASSESSMENT When you complete the head-to-toe physical examination, reassess the patient’s ABCs. 102 a b c Figure 5–20, a-c: To do a physical exam: a, check the neck, then the shoulders and collarbones; b, examine the chest and abdominal areas (checking the four quadrants), then check the pelvis and hips (do not push down on the iliac crests); c, check the legs, feet, and toes, and finish with checking the arms, hands, and fingers. Document the information you find during the physical examination. This information will help you provide a complete and accurate written and verbal report, which helps to preserve the continuity of care for the patient after care is transferred. TREATMENT/INTERVENTIONS If the patient is stable, perform the appropriate treatment/interventions, beginning with the most pressing injury or condition (e.g., splinting a limb, cleaning and dressing a wound). DOCUMENTATION OF FINDINGS It is essential on every call that you take the time to document your findings thoroughly, as described in Chapter 1 on page 22. Documentation should be completed immediately or as soon as possible after the call, based on the specific incident and the patient’s needs. As important as documentation is, patient care cannot be delayed to fill out paperwork. ONGOING ASSESSMENT Once you have completed the secondary assessment and provided care for any injuries and conditions, monitor the patient (ABCs, vital signs) and keep the patient calm and comfortable until the transfer of care takes place, you determine that the patient does not require medical care, or the patient refuses additional treatment. Reinspect any injuries, bandages, etc. periodically. A patient’s condition can change unexpectedly. A life-threatening condition, such as a respiratory or cardiac arrest, can occur suddenly, even in a patient whose ABCs and vital signs were initially normal. The physical exam and patient history do not need to be repeated unless there has been a relevant change (e.g. if an unresponsive person becomes responsive). If any life-threatening emergencies develop, stop whatever you are doing and provide appropriate interventions immediately. Continue to document all pertinent information. ASSESSMENT The documentation you create can simplify the transfer of care by ensuring that all relevant information is available for the receiving personnel. It may also protect you from legal action by showing that you acted appropriately in the situation. 103 SUMMARY SCENE ASSESSMENT SCENE ASSESSMENT CHANGING PATIENT CHANGING CONDITIONS TRANSPORT DECISION TREATMENT PATIENT ASSESSMENT Hazards and Environment Mechanism of Injury (MOI) and Chief Complaint Number of Patients Additional Resources Required Forming a General Impression Donning PPE (if not already done) PRIMARY ASSESSMENT Chief Complaint Level of Responsiveness Spinal Motion Restriction Airway, Breathing, and Circulation (ABCs) Pulse Oximetry (SpO2) Rapid Body Survey Transport Decision Patient Positioning SECONDARY ASSESSMENT Interview with Patient and Bystanders Vital Signs Head-to-Toe Physical Examination TREATMENT/INTERVENTIONS DOCUMENT FINDINGS ASSESSMENT ONGOING ASSESSMENT 104