HLTOUT004 Student Learner Guide V1.3_21 EDITABLE PDF

Student Learner Guide HLTOUT004 Assess and deliver basic clinical care Insert Course and Code name Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care Copyright © Australian Paramedical College 2020 Copyright protects this material. Except as permitted by the Copyright Act...

Student Learner Guide HLTOUT004 Assess and deliver basic clinical care Insert Course and Code name Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care Copyright © Australian Paramedical College 2020 Copyright protects this material. Except as permitted by the Copyright Act 1968 (Cth), reproduction by any means (photocopying, electronic, mechanical, recording or otherwise), making available online, electronic transmission or other publication of this material is prohibited without the prior written permission by Australian Paramedical College. Enquires can be addressed to [email protected] Disclaimer Every effort has been made to provide accurate and complete information. However, Australian Paramedical College assumes no responsibility for any direct, indirect, incidental, or consequential damages arising from the use of information in this document. Data and case study examples are intended to be fictional and or represent actual scenarios in the context of the health industry. Any resemblance to real persons or organisations is coincidental. HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 1 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 2 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 3 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 4 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care HLTOUT004 Assess and deliver basic clinical care Contents Copyright ............................................................................................................................... 1 Disclaimer.............................................................................................................................. 1 Introduction ................................................................................................................... 2 Academic Integrity ............................................................................................................... 3 Student Support ................................................................................................................... 3 HLTOUT004 Assess and deliver basic clinical care ............................................... 5 Welcome ........................................................................................................................ 9 Required resources .............................................................................................................. 9 Are there any special requirements? ............................................................................... 11 Section 1 | Patient Assessment .................................................................................12 What will I learn? ................................................................................................................ 12 Pre-Planning ................................................................................................................................ 12 Scene information .............................................................................................................. 12 Be Prepared......................................................................................................................... 13 Being mentally prepared............................................................................................................ 14 Scene Survey ...................................................................................................................... 15 Scene safety ................................................................................................................................ 15 Local Work Practices and Protocol .......................................................................................... 15 Primary Survey ................................................................................................................... 16 DRABCD ...................................................................................................................................... 16 Danger .......................................................................................................................................... 17 Response ..................................................................................................................................... 17 Airway ........................................................................................................................................... 19 Breathing ...................................................................................................................................... 19 Circulation .................................................................................................................................... 21 Vital Signs ........................................................................................................................... 23 Blood Pressure............................................................................................................................ 23 Pulse ............................................................................................................................................. 27 Respirations ................................................................................................................................. 28 Temperature ................................................................................................................................ 32 Pulse Oximetry ............................................................................................................................ 32 Blood Glucose Level .................................................................................................................. 33 Vital Signs in Children ................................................................................................................ 35 Secondary Survey (Assessment) ..................................................................................... 35 Head to Toe Assessment .......................................................................................................... 36 HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 5 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care Detailed Assessments ....................................................................................................... 41 Neurological Status Assessment.............................................................................................. 41 Respiratory Status Assessment ............................................................................................... 43 Perfusion Status Assessment ................................................................................................... 44 History Taking ............................................................................................................................. 45 APGAR Score ...................................................................................................................... 49 Section 2 | Anatomy, Physiology, Illness and Management..................................50 Skin and Membranes.......................................................................................................... 50 The Skeletal System ........................................................................................................... 52 Muscular System ................................................................................................................ 55 The Nervous System .......................................................................................................... 56 Endocrine System .............................................................................................................. 58 Cardiovascular System ...................................................................................................... 60 Electrical Conduction System of the Heart ............................................................................. 61 ECG | The 6 Step Method................................................................................................... 67 Step 1 – Rate .............................................................................................................................. 67 Step 2 – Regularity ..................................................................................................................... 68 Step 3 – P waves ........................................................................................................................ 69 Step 4 – PR Interval ................................................................................................................... 69 Step 5 – QRS Complex ............................................................................................................. 69 Step 6 – Everything else!........................................................................................................... 69 Bringing it together ..................................................................................................................... 70 Lethal Rhythms ................................................................................................................... 72 Rhythm 1 ...................................................................................................................................... 72 Rhythm 2 ...................................................................................................................................... 73 Rhythm 3 ...................................................................................................................................... 73 Blood Vessels ..................................................................................................................... 74 Resuscitation ...................................................................................................................... 76 Danger .......................................................................................................................................... 77 Response ..................................................................................................................................... 77 Send for Help .............................................................................................................................. 77 Airway ........................................................................................................................................... 78 Breathing ...................................................................................................................................... 78 Circulation and CPR ................................................................................................................... 79 Defibrillation ................................................................................................................................. 80 Stopping Resuscitation .............................................................................................................. 82 Respiratory System ............................................................................................................ 84 Mechanics of Respiration .......................................................................................................... 85 Digestive System ................................................................................................................ 93 Urinary System............................................................................................................................ 94 HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 6 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care Assessing GI pain, injury and illness ....................................................................................... 94 The Reproductive System ................................................................................................. 96 Obstetric Emergencies ...................................................................................................... 97 Cord Prolapse ............................................................................................................................. 97 Miscarriage .................................................................................................................................. 97 Placental Abruption .................................................................................................................... 98 Placenta Praevia ......................................................................................................................... 98 Pre-eclampsia ............................................................................................................................. 98 Post-Partum Haemorrhage ....................................................................................................... 98 Nuchal cord.................................................................................................................................. 99 Normal Cephalic Delivery ........................................................................................................ 100 Lymphatic System ............................................................................................................. 104 Special Senses .................................................................................................................. 107 Eye Injuries ................................................................................................................................ 107 Ear Injuries ................................................................................................................................. 107 Trauma Skills ..................................................................................................................... 108 C-Spine Collar ........................................................................................................................... 108 Helmet Removal ....................................................................................................................... 108 Splints ......................................................................................................................................... 110 Tourniquet .................................................................................................................................. 111 Pelvic Binder.............................................................................................................................. 112 Extrication .......................................................................................................................... 112 Stretcher ..................................................................................................................................... 112 Stair-chair ................................................................................................................................... 113 Scoop stretcher ......................................................................................................................... 113 Other devices ............................................................................................................................ 113 Section 3 | Pharmacology......................................................................................... 114 Storage and Care ............................................................................................................... 114 Monitoring pharmacological outcomes .......................................................................... 115 Rights of Drug administration ......................................................................................... 115 Routes of administration .................................................................................................. 116 Oral Drug administration .......................................................................................................... 116 Inhaled Drug administration .................................................................................................... 117 Nebulised drug administration ................................................................................................ 117 Intramuscular drug administration .......................................................................................... 117 Section 4 | Beyond Patient Care .............................................................................. 120 Basic cares ......................................................................................................................... 120 Time and Transport Criticality ......................................................................................... 120 Receiving Facility .............................................................................................................. 123 HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 7 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care Clinical Handover ...................................................................................................................... 124 Documentation .......................................................................................................................... 126 Clinician Safety .................................................................................................................. 126 Infection control ......................................................................................................................... 127 Safe Lifting ................................................................................................................................. 127 Ethico-Legal Considerations ........................................................................................... 128 Children in the Workplace ....................................................................................................... 128 Continuing Professional Development .................................................................................. 129 Workplace Health and Safety ................................................................................................. 130 Consent ...................................................................................................................................... 132 Privacy, Confidentiality and Disclosure ................................................................................. 134 Respectful behaviour ............................................................................................................... 136 Duty of care ............................................................................................................................... 136 Human Rights............................................................................................................................ 137 Mandatory Reporting ................................................................................................................ 137 Children and Young People .................................................................................................... 138 Practitioner and Client Boundaries ........................................................................................ 139 Anti-Discrimination.................................................................................................................... 139 Drugs and Poisons ................................................................................................................... 140 Mental Health ............................................................................................................................ 140 Health Records and Information Privacy .............................................................................. 142 Industrial Relations ................................................................................................................... 142 National Safety and Quality Health Service (NSQHS) Standards .................................... 143 Scope of practice ...................................................................................................................... 144 References .................................................................................................................. 145 HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 8 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care Welcome Welcome to HLTOUT004 Assess and deliver basic clinical care. By completing this unit, you will be able to: • • • • • • • • • • • • Conduct a thorough scene assessment Conduct detailed patient assessments including: primary survey, secondary survey and vital signs Obtain incident history and medical history of the patient Prioritise initial treatment and time critical interventions Determine appropriate transportation methods and preferred designation for best patient outcome Develop a treatment plan, identify the need for assistance and formulate contingency plans Implement basic cares Develop reassessment techniques, monitoring skills and clinical decision-making abilities Apply infection control measures Apply safe working and lifting techniques Record clinical documentation Maintain patient confidentiality HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 9 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 10 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 11 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care Section 1 | Patient Assessment What will I learn? In this section you will learn the various components of patient assessment and how it relates to your clinical care. Pre-Planning Pre-planning aims to ensure students consider various elements of pre-hospital care that can assist in making the job “flow” without the stress or confusion that poor preparation can generate. Prehospital care is not an environment where you can be presumptuous and pre-planning will assist you to be prepared for whatever comes your way. Imagine it’s 2am and the call comes in that a two-year-old is having a seizure. The family, who live out of town, are driving to the hospital when en-route, the child starts convulsing and now has an altered level of consciousness. The call indicates that the father thinks he is somewhere between two rural towns and has pulled the car to the side of the road. This is a common call and potentially a very difficult situation and made a lot harder because of the time of the day. Where is the incident? What could be happening with the patient? What is the drug dose for a two-year-old? What is the best hospital to transport to at this time of the morning? The answer to this question and many more depends on a number of variables, but good decision-making often comes down to being prepared. Scene information Knowing as much about the scene as possible can save valuable time when arriving at the location. In the scenario above, the caller cannot give an exact location so asking how long he has travelled from home or the last town can help. Having a cross street, river or even public phone booth nearby can also assist in locating the scene. Always ask the caller to park the vehicle and remain with the vehicle with hazard lights on. If the patient continues to drive their vehicle, then the paramedics are effectively chasing a moving target. When attending a house, mine site, workplace, or public area, knowing the correct address as well as a cross street sounds basic but quite often this information is given incorrectly. Asking about security gates, dogs, access, and egress points and whether the scene is safe can all save a great deal of time. If at all possible, assigning someone to wave the paramedics down when arriving at the location is always of great assistance. HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 12 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care Activity 1 - Think Think about your own house, workplace, sports club, and any other location that you are familiar with and look at some variables that could make access difficult. Q. What are some important points to make when requesting emergency services? Be Prepared Arriving on scene can be confronting and poor preparation can have the responder behind the eight ball from the start. The most vital aspect to ensuring that you are prepared is having all the equipment ready to go. Whether you are operating from a rescue helicopter or are carrying a backpack at the local football carnival, having everything ready to go and knowing your kit well, saves a lot of stress when on scene. If possible, consider having a number of kits. This may not be necessary if working at a sporting event where you are likely to see only musculoskeletal injuries however, in a metropolitan ambulance service, separating kits into groups can make it a lot easier. Kits can be broken into • Airway • Observations • Trauma • Major Haemorrhage • Obstetric • Burns • Intravenous and intraosseous access HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 13 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care • Oxygen therapy • Decontamination equipment Having additional equipment such as personal protective equipment (PPE), multi casualty cards, documentation, radios, and wet weather gear all within easy access and ready to go enables you to focus on the job without the added stress of looking for equipment. Being mentally prepared Getting your mind on the job and being mentally prepared is just as vital as having your equipment ready to go. Thinking back to that 2am job of a two-year-old child having a seizure, there is a lot to consider. Think about the possible cause of the seizure. Is the child hypoxic, septic, hypoglycaemic, dehydrated, hyponatraemic or has there been some sort of trauma? There is a lot to consider and being mindful of possible causes and treatments will allow you to focus on the patient when your body and mind is under stress. Remaining calm and focused on a scene allows the flow of treatment to be effective and decreases the stress levels of all involved. When treatment flows and your system is working well there is better outcomes for patients. Being prepared and knowing that you treated the patient appropriately also makes it easier to accept an adverse outcome. In the situation with the child, working out the calculations for paediatric dose of anticonvulsant and/or antiemetic prior to arrival will save time, decrease stress levels, and limit the possibility of making a drug error at 0200 when you may be stressed and tired. Tips – Take Note Having disposable gloves can be an asset, not only as PPE. Disposable gloves can serve a dual purpose at the scene. Consider the approximate weight of the child and drug doses. Discuss with your team partner or colleague so that you come to the same calculation. You can write this information on your gloves to prompt you when on scene. This can also reduce the occurrence of drug errors, as discussed above, scene attendance can be intense and stressful and it is in these times attending health practitioners are more likely to have difficulties with calculations. The Ready Glove Of recent times and due to some innovative thinking, the health care environment and organisations are utilising the Ready Glove or a version of it, the same as the one pictured, that supports clinical practitioners at the scene with patient note taking. HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 14 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care Scene Survey Conducting a scene survey is all about making sure the scene is safe and if any additional resources need to be dispatched or have already arrived. Every clinician will have a slightly different approach to a scene assessment, and over time you will develop your own way of doing things. Scene safety Ensuring that the scene is safe for the clinicians, patient and bystanders is the first priority. Conducting scene survey when walking into a private residence can be very quick and easy. As long as there is no violence on scene or emotional, irrational bystanders, your average house may have pets that need to be contained, young children kept out of the way as well as usual trip and electrical hazards. In the case of violent scenes, the police may need to be called to control the scene prior to your arrival to ensure the safety of the paramedic and others involved. The golden rule is that you never place yourself in harm’s way. Instead, utilise all resources required to allow you to do your job. Local Work Practices and Protocol Utilise local guidelines and protocols when making the scene safe. Some services have operational supervisors that need to be dispatched when at scenes similar to the above photos. Supervisors, or even an additional team of experienced clinicians can be of great assistance on scene, so utilise all the resources you require to get the job done safely. Activity 2 Review the following three (3) scenes/photographs from real jobs attended by paramedics. Make a detailed list of all possible hazards that can be found in each of the three scenes. Consider accessing and egressing issues. Think about and note the other agencies that will be required for hazardous materials, traffic control, lift assist, fuel, and oil spills, clearing vehicles from the road and crowd control. Additionally, make some notes regarding: are there water hazards, trip hazards, sharp objects, risk of falling objects and anything else you observe that needs to be considered Scene 1 - MVA HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College Scene 1 Notes V1.3 22 May 2017 Page 15 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care Scene 2 – Building Site Scene 2 Notes Scene 3 Motorbike Accident Scene 3 Notes Primary Survey The primary survey is a very quick assessment of imminent threats to life. This may be a very quick assessment, but it is a critical part of pre-hospital care. Rapidly identifying life-threatening issues saves lives and promotes a better recovery so becoming a master of the Primary Survey is a skill all pre-hospital clinicians must have. DRABCD No matter how long you have been working as a clinician, the basics of a primary survey remain the same. DRABC, or Doctor ABC, is the systematic approach to conducting the initial patient assessment when first arriving on scene. D – Dangers R – Response A – Airway B – Breathing C – Circulation HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 16 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care In most circumstances, it is important to conduct the survey in order. As you move away from being a ‘first aid officer’ and towards becoming a pre-hospital clinician, it is sometimes appropriate to rearrange the primary survey and systematic activity as required. For example, if the patient is not responding, check for circulation before checking the airway and breathing (that is, DR CAB). We do this by checking for a pulse. Critical time can be wasted assessing airway and breathing when it is obvious that the patient is in cardiac arrest. If the patient looks like they are in cardiac arrest and there is no pulse present after only a few seconds, then start CPR. Some believe that doing CPR on someone who is not in cardiac arrest can be detrimental to the patient however; delaying CPR has been proven to be significantly worse. For this reason, if in doubt, begin CPR. If it is unnecessary, the patient will soon let you know! Danger We have covered danger in scene survey. It’s important to ensure that there is no danger to yourself, the patient, and others. Anything that can be controlled must be addressed. Unplug power appliances if needed or turn the power off at the mains. Seeking assistance from other agencies and health care workers to control dangers is also vital for ensuring the best outcome for the patient and others on scene. Response There are a variety of ways to assess a patient’s responsiveness. As a pre-hospital clinician, you are required to use the ‘AVPU’ acronym. AVPU stands for Alert, Voice, Pain or Unresponsive. During your assessment, you are required to use ‘talk and touch’ to escalate your attempts to gain a response from your patient. The following table outlines the steps you may need to take to determine a patient’s alertness (responsiveness). It is important that you understand that you attempt the least invasive method of deeming alertness first, before increasing the attempt. HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 17 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care AVPU Scale Patient’s appearance First Aid Intervention Result A = Alert Awake with eyes open Proceed with care as required Patient is Alert V = Voice Eyes closed Use your voice to gauge responsiveness e.g. ‘Hello, can you open your eyes please’ a. Patient opens eyes = ‘V’ on AVPU scale Eyes closed, did not Use clinically respond to voice appropriate painful stimuli to waken patient e.g. pinch trapezius muscle, pressure on angle of jaw a. Patient opens Eyes = ‘P’ on AVPU scale Eyes closed, did not Standard actions for respond to pain unconscious patient a. Patient is unconscious ‘U’ on AVPU scale P = Pain U = Unconscious b. Patient does not respond – move on to next step b. Patient does not respond – move onto next step If the patient is responsive, you do necessarily need to continue your Primary Assessment much further. If they respond to you, it indicates that they have an open airway, that they are breathing, and that they have a pulse. You may still need to send for help, depending on the condition of the patient. If a patient is unresponsive, you need to continue to assess using the Primary Assessment process. Important AVPU is not a comprehensive consciousness assessment. As the primary survey is a rapid assessment taking 10-30 seconds, the AVPU is conducted as appropriate. Access and review the Clinical Practice Procedure from QAS below for specific information for the AVPU or the ‘neurological assessment’. https://www.ambulance.qld.gov.au/docs/clinical/cpp/CPP_Neurological%20assessment.pdf HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 18 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care Airway Look as well as listen to a patient’s airway. On scene we are very limited in how much of the airway we are able to visualise. For this reason, listening is just as important as looking for anything that is obstructing the airway. It’s important that we address any ‘quick fixes’ while at the phase of the primary survey. For example, if the patient is ‘snoring’, try adjusting their airway to improve the flow of air. Important It is important to note that there are some considerations prior to tilting the patient’s heads. Firstly, if there is a foreign body, movement of the airway can cause it to fall deeper into the airway and worsen the obstruction. Also, in the case of suspected spinal injury, you must be cautious of worsening any injuries. If you refer to DRABCD, spinal is not included, therefore it is still essential to manage the airway, but it is important to be as careful as possible supporting the neck and spine (if relevant) in a neutral position at all times to prevent twisting or bending movements. If you don’t have to move the airway, don’t! An unconscious patient in a motor vehicle who is supported in the upright position by a seatbelt can often be positioned with their chin on their chest, which can obstruct the airway. It may be a bystander’s job to hold the head back against the headrest of the seat to ensure the airway remains open. Vomit, blood, broken teeth, or foreign bodies that are in the airway must be quickly removed during this phase of the primary survey. Even if it will take a few seconds longer, clearing the airway early is vital. If the patient is unconscious it might be appropriate to insert an oropharyngeal airway (OPA). As we will discuss when we deal with the respiratory system, an open airway is vital. Breathing Breathing is a necessity for life. Assessing for breathing in a primary survey is not a complex skill – simply observe if the patient is breathing or not, and if they are, assess if it is normal breathing. Normal breathing is good ventilation at a rate of 12 to 20 breaths per minute. If the patient is breathing too shallow or too slow, they will require ventilation support. This is to be done after the rest of the primary survey is complete. HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 19 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care Tips If you are working in a team with multiple people, others can begin to set up equipment (such as ventilatory support equipment) while you complete your primary survey. Ensure you use effective communication with your team to ensure the message is conveyed. If the patient seems to be breathing too fast, this can be addressed once the primary survey is complete. More in-depth respiratory status assessments can be completed after the primary survey. Absent or agonal respirations are a life-threatening emergency and require immediate attention. Agonal respirations are characterised by gasping breaths that are very irregular, can be at a rate of only one or two per minute. See the link for an example of agonal respirations. Activity 3 Access the following video of agonal respirations https://www.youtube.com/watch?v=CBMxH4xtE8w Using a watch that has ‘seconds’ capacity, count the patient’s respiration rate. Q. Do you think the agonal breathing in the video is sufficient to sustain life? HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 20 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care Circulation If a patient is conscious, it is a very good indicator of circulation. Patients with very poor or absent circulation will not be conscious as the brain requires circulation to sustain consciousness. In the unconscious patient, we can check pulses at the wrist first and if this is not present, check for a carotid pulse. When locating a radial pulse, ensure clothing and watches are removed and cock the wrist back slightly to move the artery closer to the skin. In some patients, you can see the artery pulsate as soon as you bend the wrist back. Next, place the fingertips of your 1st and 2nd fingers on the base of the thumb and then place both fingers below the base of the thumb onto the wrist and you will feel the pulsations of the radial artery. Never use your thumb for this as there is a pulse in your thumb that can be confused for a radial pulse. If the radial pulse is not present, move to see if a carotid pulse is present. To find a carotid pulse, feel for the trachea under the chin and move two fingers over to the side of this large ‘windpipe’. Keeping high on the neck and under the chin, the artery will be located at the edge of the windpipe and is normally very easy to locate. Activity 4 Watch this youtube video on taking a pulse https://www.youtube.com/watch?v=nJ5IsNETswA Activity: Now practice taking your own pulse, and pulses on family and friends. • Focus particularly on radial and carotid pulses as these are used most readily in the pre-hospital environment. Q. What was your pulse rate and was it within normal range? Resource: How to take a pulse. Step Procedure Rationale 1 Explain and discuss the procedure to the patient (unless implied consent) This is vital for both consent purposes and for relaxing the patient to support a more accurate reading 2 Time piece with second hand or a digital second capacity Used to measure while you count the heartbeats. HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 21 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care 3 4 Thumb should not be used as it has a strong pulse which may be mistaken for the patient’s pulse. Place first and second finger along the artery and press gently Pressing hard will occlude the artery making it difficult to palpate the pressure wave in the artery Measure pulse for a count of 30 seconds (minimum) and multiply by 2 to provide the heart rate beats per minute. If the beat is irregular, to slow or rapid, a full 60 second count will assist in accuracy An irregular, rapid or slow pulse may be poorly estimated using the 15 second count, a longer 60 second count will estimate the pulse with more accuracy. Make note of the strength and character of the pulse 5 Counting starts from 1 Always start counting from 1 6 Record the Pulse rate on the patients Patient Care report /record. Supports capacity to identify any trends to be recognised over specific time periods Palpate the opposite artery in the same manner (where possible) If either pulse feels diminished in volume confirm the difference by simultaneously palpating the arteries. This may indicate conditions such as coarctation, blockage of any artery or aneurysm. 7 8 *This should not be undertaken with the carotid artery In carotid artery palpation the patient should be lying down. You should not palpate both carotid arteries as this will reduce cerebral blood flow Palpation of the carotid artery may cause a reflex bradycardia; this may in turn cause a reduction in blood pressure and subsequent syncope. As explained in the above video, the body will appropriately shunt blood away from the peripheries when the body is in a shocked state. This means that in very unwell patients, you may experience someone who is cool to touch, pale and yet has no radial pulse present. Further examination may show a carotid pulse – this information tells you that their body has shunted blood flow to vital organs only and is not permitting normal blood flow to the peripheral limbs. Clinically we refer to this as ‘poor peripheral perfusion’ or stating that the patient is ‘peripherally shut-down’. If you cannot locate a radial or carotid pulse, this means there is no adequate circulation and you must commence CPR. HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 22 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care Vital Signs Vital signs are a way of determining how the bodies systems are functioning. A healthy person at rest will have vital signs within normal limits and knowing what is normal and what is abnormal can go a long way to determining the health of a patient. Not only that, vital signs can tell us what is happening to a patient with illness as well as trauma. For example, a patient who is feeling short of breath could have a chest infection or may have congestive heart failure resulting in acute pulmonary oedema (APO). While it is not an exact science, vital signs for both patients will be somewhat different and therefore will guide you on the diagnostic pathway. It is important to understand that vital signs alone do not make a diagnosis – you must couple this with a comprehensive patient assessment. Patient assessments will be explored further as we move along. Blood Pressure Blood pressure is a combination of cardiac output (the amount of blood being ejected from the heart in each pump) and peripheral resistance (the ‘push-back’ from the peripheral blood vessels). Blood pressure is composed of two numbers – a systolic blood pressure and diastolic blood pressure. The upper reading is the systolic pressure, which represents the pressure of the blood coming from the heart when it ejects blood from the verticals. The contractility (strength of pump) of the heart as well as the filling pressure of the ventricles affects the systolic pressure. The cardiac output portion of blood pressure largely affects this. The lower reading is the diastolic and is the pressure on the walls of the blood vessels when the heart is at rest, or the diastolic phase of the heartbeat. This changes as the blood volume increases or decreases as well when the blood vessels contract or dilate. The peripheral resistance portion of blood pressure largely affects this. Normal blood pressure varies slightly depending on what resource you access, however generally speaking, systolic pressures between 100 and 150 with diastolic between 60 and 90 can be considered normal. An average blood pressure would be 120/80 or anywhere within the limits mentioned. This is just a guide as some people are normally low while others are normally higher. A patient that normally has a low blood pressure of 110/60 can be considered to be hypertensive at 150/90. This is why blood pressure is to be taken into account with other vital signs as well as the history and presentation of the patient. The perfusion equation chart below gives a good example of the factors that go together to make up blood pressure. The main factors that make up the blood pressure include the function of the heart, the blood volume, and the diameter of the blood vessels. The function of the heart can affect blood pressure in a number of ways. A failing heart has an inadequate pump. A heart that is diseased and pumps too fast or slow affects blood pressure. The top chambers of the heart (atriums) fill the lower chambers of the heart (ventricles) and the amount of blood that is in the ventricles before they contract to pump it around the body has a massive effect on blood pressure, particularly the systolic reading. The more blood in the ventricles, the more there is available to pump, and therefore the higher the pressure of the pump. This ventricular filling HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 23 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care is done during the relaxation phase of the heart’s cycle. Therefore, the faster the heartbeat, the relaxation and filling time is decreased, and may result in a reduction of blood pressure. Scenario Consider the football player who is running with the ball and has a high heart rate. He looks behind him and he sees that he is being chased by some of the biggest, most intimidating players he has ever seen, thus increasing the heart rate even more. He then gets excited as he realises that if he keeps going as hard as he can he might score and win the game, increasing the heart rate even more. This athlete’s heart is beating so fast that it would explode, and his BP would go through the roof if it wasn’t for the stroke volume (amount of blood pumped with every heart beat) being reduced to compensate for the rapid heart rate. Additionally, and more importantly, the blood vessels dilate to allow for the increased blood flow coming from the heart. All this works to balance the increased need for oxygen without blowing out the blood pressure. Important CO is cardiac output. This is the amount of blood that is ejected from the ventricles in a minute. HR is the heart rate or the amount of times the heart beats in one minute. SV is the stroke volume or the amount of blood ejected from the heart during each contraction. PR is the peripheral resistance or the diameter of the blood vessels. This diameter can change to help control blood pressure. @Mark Ward HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 24 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care The perfusion equation is very important in understanding BP and the factors that affect it. We can see that the blood pressure is made up of the cardiac output and the peripheral resistance. However, a change in stroke volume or heart rate will affect the blood pressure therefore, all of these factors are relevant when looking at BP and the condition of a patient. The Main factors of perfusion are HR, SV and PR. If one or more of these are compromised, the body tries to balance out the BP by adjusting the others. Let’s look at some examples. Consider we have a trauma patient. They have a low BP however they are pale and sweaty with a very fast heart rate. This may be because stroke volume is affected due to hypovolemia. If the patient has lost a lot of blood, there just isn’t enough blood returning (venous return) to the heart for an adequate SV. Therefore, the HR increases to increase the CO and the PR increases to try to increase the BP. The sweaty, pale appearance is the body shunting blood away from the skin to increase the blood volume in the main vessels, which is a good indication of shock. In this scenario, we have a reduced cardiac output which will drop our systolic pressure but increased peripheral resistance, which increases our systolic pressure. This narrows the difference between the systolic and the diastolic pressure, which is referred to as pulse pressure. Therefore, this is known as a narrow pulse pressure. Hypovolemia and heart failure often cause a narrow pulse pressure. In another example consider a patient who is stung by a bee and goes into anaphylaxis shock. This causes the blood vessels to dilate causing a drop in blood pressure. In this case we would see the HR increase in an attempt to normalise the CO. In effect we have the opposite happening. We have an increase in CO (higher systolic) and a fall in peripheral resistance (low diastolic) causing a wide pulse pressure. Main causes of widening pulse pressures are anaphylaxis and septic shock. You can see how vital it is to understand blood pressure and how it works. We see doctors, nurses and clinical health care professionals take blood pressures all day long, however they often give little thought to the significance this provides when assessing a patient. The reading below attempts to make it very clear how the body has mechanisms to maintain a normal blood pressure even when it is losing massive amounts of blood or has illness that can affect one or more of the main factors of perfusion. You may have a patient with a BP of 100/60 which falls into the normal BP class however, if this patient looks pale and has a HR of 130, you can be assured that there is something that is not quite right, and the body is compensating well. Studying this even more, a patient with a BP of 100/85 (narrow pulse pressure) would be even sicker than the patient whose pressure was 100/60. This is a good indicator for massive peripheral vascular resistance in the presence of major haemorrhage. This patient would need to be treated and transported very quickly before they deteriorate rapidly. HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 25 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care Activity 5 Research Starling’s Law online or via another research method to identify how this ‘law’ relates to the contractility of the heart and cardiac output. Q. In your own words, explain Starling’s Law. Research Access the following video regarding taking blood pressure. It is a comprehensive guide to this skill. https://www.youtube.com/watch?v=lKtfwiwHjLI For your own learning, write a step-by-step guide to taking blood pressures so you can review later and bring to your workshop. This video gives you some guidance as to what you will hear when taking a blood pressure. Watch until 2:12. https://www.youtube.com/watch?v=kih1_IOgjic HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 26 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care Pulse Checking for a patient’s pulse can tell us a lot about the physical status of a patient. We have already discussed its importance in a patient with compromised blood pressure, but we also need to assess if a pulse is too slow, irregular, weak out bounding. A normal pulse for someone at rest is considered to between 60 and 100 although it’s often seen in the lower half of that range. A slow heart rate is known as bradycardia and a fast heart rate is tachycardia. The potential causes for bradycardia include: • Hypoxia • Infection (myocarditis) • Underactive thyroid (hypothyroidism) • Drug toxicity (especially beta blockers) • Fluid around the heart (cardiac tamponade) • Complete heart block (most common cause in elderly patients) Potential causes for tachycardia include: • Anxiety • Abnormal conduction pathways in the heart • Re-entry syndromes (SVT and Wolff Parkinson-White syndrome) • Sepsis • Hypotension • Drugs and stimulants • Overactive thyroid (hyperthyroidism) • Electrolyte imbalance • Anaemia • Stress and exercise Some patients can suffer from an irregular pulse rate. Irregular beats are most commonly caused by a condition known as Atrial Fibrillation. Other causes are rare but can be from sodium or potassium imbalances and heart muscle disease. HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 27 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care The pulse we feel when palpating an artery is the difference between the diastolic pressure and systolic pressure. This is known as the pulse pressure. A narrow pulse pressure such as a BP of 120/100 will have a weak pulse while a wide pulse pressure such as 190/100 will have a bounding pulse. Causes of wide and narrow pulse pressures vary but some examples include: Wide pulse pressure – Caused by an increase in systolic pressure and/or a drop in diastolic pressure. Hardening of the arteries (arteriosclerosis) reduces the elasticity of the blood vessels and can give a wide pulse pressure. Other causes are anxiety, disease if the aorta, cardiac tamponade, and severe head injuries. Narrow pulse pressure is a good sign of heavy blood loss or dehydration. Other causes are congestive heart failure and sepsis. Narrow pulse pressure can be from a poor systolic function, which can be due to a weak heart, or poor venous return (often from hypovolemia). Document whether the pulse is normal, fast, slow, regular, irregular, bounding or weak. Respirations Assessing whether a patient is breathing normally is very quick and easy. Basically, if the patient is able to talk in a full sentence, they are breathing normally. It’s when they are unable to talk in full sentences or unable to talk at all that it starts to get tricky. There are some simple rules to make assessing a patient’s breathing relatively quick and simple. Some common calls paramedics receive is a patient that is short of breath. On arrival the paramedic takes a quick look at the patient and the patient seems to appear well, so introductions are made before the paramedic asks what the problem is. This is a common reply. “Thanks for getting here so quickly. Last time I had to wait for about 20 minutes. I woke up this morning and just haven’t been myself. I guess it all started a few weeks back when I was out catching a few flathead with my grandson on his birthday. You see… he just got a new boat and has promised to take me fishing……” There is no way that this patient is short of breath and this can be obtained by the fact that it takes a lot of air to talk for that long. Have you ever been out for a run and had to stop to talk to somebody? It’s very hard to talk a full sentence without having to stop and catch your breath. Important Just because you assess a patient as having ‘normal respirations’ does not remove the fact that they feel short of breath. This is still clinically significant and should be documented and considered when deciding on a management plan. HLTOUT004 | Student Learner Guide QMS-17.13_7 |Learning 2017© Australian Paramedical College V1.3 22 May 2017 Page 28 of 151 Student Learner Guide HLTOUT004 – Assess and deliver basic clinical care Some medical conditions that can make you feel as though you are short of breath include • Acute myocardial infarction (heart attack) • Stroke • Anxiety • Anaemia • Tachycardia • Pericarditis • Autoimmune Diseases (e.g. Myasthenia Gravis and Guillan-Barre syndrome) Never take the fact that the patient is able to breathe well enough to talk as an indicator that the patient is not unwell. If a patient states that he/she is short of breath, this should be a huge red flag and further investigation is required. So, what about the patient that is actually short of breath? This patient may be taking in short phrases or one breath per word. Worse yet, they may be unable to speak at all. This patient is unable to move enough air into the lungs to allow them to talk normally and this is a medical emergency. Normal respirations are between 10 and 20 breaths per minute. This is simply converted to a breath every 3 to 6 seconds. If the patient has a regular respiratory rate and they are breathing every 3-6 seconds, then they have a normal respiratory rate. If they are breathing every 1-2 seconds, they are hyperventilating (breathing quickly) and every seven seconds are more they are hypoventilating (breathing too slowly). Use this guide for rapid assessme