Advanced Patient Assessment

1. Advanced Patient Assessment

2. General Phases of Assessment Review of dispatch information Scene Survey/Environmental Safety Primary Survey Secondary Survey Vital Signs Patient History

3. Review of Dispatch Information Location of the incident Nature of the incident Potential problems at the location Information on appropriate equipment Mental preparation

4. Scene Survey/Environmental Safety Note expressions of bystanders Identify scene hazards Poisonous or caustic substances Biological/Germ infested agents Water hazards Confined spaces Extreme heights Bloodborne or airborne pathogens Traffic Hazards Other hazards Determine special needs Evaluate mechanism of injury

5. Primary Assessment Completing the ABCDE�s Goals To detect immediate life threats To treat life-threatening conditions To make decisions regarding immediate transport vs.. further on-scene assessment and transport

6. Sequence of Assessment Steps Airway assessment & management Breathing assessment & management Circulation assessment & management Disability assessment Expose & examine

7. Airway Assessment & Mgmt. Universal Precautions Identify self & establish rapport Open airway of unconscious patient using simple manual maneuver Modified-jaw thrust - suspected C-spine injury Head-tilt/chin lift non trauma

8. Listen For Presence of breathing Noisy respirations Snoring Tongue in posterior airway Try repositioning the head Stridor or crowing May indicate laryngeal obstruction Difficult to correct in the field Wheezing Lower airway constriction Difficult to correct in the field

9. Insert Airway Adjunct if Necessary Look for chest rise & fall & airway obstruction in the mouth Feel for air movement OPA for unconscious patients NPA for conscious patients requiring airway management High concentration of O2 with nonrebreather mask for patients with altered mental status or airway problems

10. Breathing Assessment & Mgmt. Evaluate respiratory rate & tidal volume Expose and assess chest for equal & symmetrical chest rise Identify & stabilize flail chest/paradoxical movement Identify & stabilize sucking chest wounds Identify collapsed lung & stabilize Chest decompression if necessary & within your protocols

11. Identify airway & correct obstructions Auscultate both lungs Identify tension pneumothorax Provide immediate airway & ventilatory management with diminished tidal volume or respiratory rate Breathing Assessment & Mgmt.

12. Circulation Check patient for gross hemorrhage Palpate carotid & radial pulses at the same time (rate, quality, & rhythm) Bradycardia Cardiac problem, head injury, parasympathetic nervous system stimulation Tachycardia Sympathetic nervous system stimulation (pain, shock, hypoxia, anxiety) Assess skin temp., moisture, color Check capillary refill time

13. Disability Perform a quick check for LOC A - Alert V - Responds to verbal stimuli P - Responds to painful stimuli only U - U responsive to voice or pain Check pupil quality size & response to light (PEARL) Check ability to move extremities

14. Expose Expose pertinent areas Scan for obvious signs of trauma Bleeding, bruising, deformity, edema, discoloration (DCAPBTLS) Respect privacy of patient Use common sense

15. Evaluate the Primary Assessment Administer patient care according to local protocols Remember Golden Hour & transport suspected trauma patients quickly Stable trauma patients, consider secondary assessment on scene Decide whether to involve high-level EMS personnel & where to meet them

16. Secondary Assessment Trauma Patient

17. Secondary Assessment Purpose is to do a complete head to toe exam to ensure that you do not miss any subtle signs or symptoms of injury. Remember that any life-threatening injuries must be taken care of in the primary survey

18. Methods of Physical Examination Inspection - visual exam Look for obvious abnormalities Note any DCAPBTLS Palpation - exam by touch Feel for any DCAPBTLS Look for guarding Auscultation - exam of internal organs by listening Use a stethoscope Listen for diminished breath sounds, rales & wheezing Used to recognize normal findings

19. Head Check the scalp for lacerations Palpate for open wounds, depressions, protrusions, & lack of symmetry Basilar skull fractures allow blood & fluid from the brain to seep into soft tissue Periorbital ecchymosis (raccoon's eyes) Battle�s sign Late signs & not usually visible on scene

20. Ears Look for presence of fluid Blood or cerebrospinal fluid Halo test can confirm presence of CSF Never block the flow of fluid from the ears

21. Eyes Check orbits for instability and asymmetry, signs of fracture or dehydration Check PEARL Look for unequal (anisocoria), dilated or pinpoint pupils Evaluate eye movement Dysconjugate gaze, doll�s eyes (not with suspected spinal injury Cornea for contact lenses or lesions

22. Face Palpate facial bones for stability & crepitus Look for maxilla/mandible instability or asymmetry

23. Nose & Mouth Examine nares for flaring Examine both for fluids or obstructions Use suction to remove blood, vomitus, secretions or other fluids Note unusual orders Alcohol, feces, acetone, almonds, etc.

24. Neck Inspect for tenderness, soft tissue injuries, and any (DCAPBTLS) Inspect for Tracheal deviation JVD Subcutaneous emphysema Crepitus Medic Alert Tag

25. Chest & Back Check for DCAPBTLS Note chest dimension & air exchange Palpate anterior & posterior thorax Note abnormal breathing patterns Kussmaul�s - rapid deep (diabetic coma) Cheyne-Stokes - progressive increase in rate & later gradually subsides , periods of apnea (brain stem injury) Biot�s - short, gasping, irregular breaths, hyperapnea (severe brain injury) Auscultate all lung fields

26. Abdomen & Lower Back Inspect & palpate for bruising & guarding Note signs of intra-abdominal hemorrhage Cullen�s sign - Bruising around the umbilicus Grey-Turner�s sign - bruising over the flanks Palpate all four quadrants Rebound tenderness Guarding or distension Abdominal mass, ascites, pulsating mass

27. Pelvis Apply pressure to illiac crest & symphysis pubis If pain, crepitation, or instability is elicited, suspect fracture

28. Male Genitalia Examine for external trauma & hemorrhage Note priapism sign of possible spinal cord injury

29. Female Genitalia Examine for external trauma & hemorrhage Sexual abuse or rape Try to have examiner of same sex Conduct exam limited to patient stabilization Encourage patient not to douche, bathe, or brush teeth Provide emotion support & reassurance Note volume & character of blood or discharges in OB emergencies

30. Lower Extremities Examine for DCAPBTLS Perform PMS check Look for Medic Alert Tag

31. Upper Extremities Examine for DCAPBTLS Perform PMS check Look for Medical Alert bracelet

32. Neurological Assessment Evaluate neurological status & compare to primary assessment (AVPU) Continuum of diminishing responsiveness Alert & oriented Disoriented To place To time To persons To self A & O x 4

33. Vital Signs Blood Pressure Pulse Respirations Skin Condition

34. Blood Pressure Must measure in all patients with pulse Auscultation Palpation Systolic Diastolic Pulse pressure

35. Pulse Valuable indicator of circulatory function Note findings Location (carotid, femoral, radial) Rate Quality (strong, weak) Regularity

36. Respiration Normal rates for adults at rest range from 12-20 breaths per minute Normal tidal volume approximately 500 ml. If patient does not appear to be moving enough air Administer supplemental O2 Provide at least 800 ml ventilation with BVM Intubate as needed

37. Skin Color Pale (pallor) - decreased blood flow Red (flushed) - increased blood flow Blue (cyanosis) - severe hypoxia Blotchy red - allergic reaction Mottled - signifies shock Yellow (jaundice) - liver problems

38. Skin Temperature Cool skin (vasoconstriction) Cold skin - rapid loss of body heat Hot skin - vasodilation (heat stroke, fever)

39. Moisture Clammy skin - compensatory shock Dry skin - may indicate failure of body�s normal sweating mechanism, such as burn injuries, heat stroke

40. Keys to Assessment Vital signs keys to internal body conditions Other diagnostic signs include pulse oximetry blood glucose determination

41. Secondary Assessment Medical Patient

42. Developing a Patient History Structures include Introductions Chief complaint History of present illness Past medical history Family & social history

43. Introductions Done best at eye level Attention to non-verbal signs Genuine concern and compassion Request to use patients name as provided

44. Chief Complaint Reason patient called for help Starting point for interview Report and record patient�s own words

45. History of Present Illness Elicit subjective symptoms with OPQRST format O - Onset P - Provocation Q - Quality R - Radiation S- Severity T - Time Elicit associated symptoms Identify pertinent negatives

46. Past Medical History Use AMPLE format A - Allergies M - Medications P - Past medical history L - Last oral intake E - Events leading to problem

47. Family/Social History Pertinent hereditary & lifestyle factors Record smoking history in packs/years Modified physical exam Inspect, palpate & auscultate only areas pertinent to the patient�s problem

48. Communications Patient Report Requires standardized format & terminology SOAP format - Subjective -Objective -Assessment - Plan Sloppy, rambling report indicates the same quality of care

49. Written Documentation Same standardized format as verbal report Becomes permanent part of patient�s medical history Becomes best legal defense in court