Patient Assessment

1. Patient Assessment Condell Medical Center EMS System July 2011 CE Site Code #107200E-1211 Sharon Hopkins, RN, BSN, EMT-P

2. Objectives • Upon successful completion of this module, the EMS provider will be able to: • 1. Define mechanism of injury. • 2. Define nature of illness. • 3. Define general impression. • 4. Discuss purpose of a general impression. • 5. Discuss In-field Spine Clearance components.

3. Objectives Cont’d • 6. Describe assessment of the patient’s circulation status during the initial assessment. • 7. Describe normal and abnormal findings of assessment of skin color, temperature, and condition. • 8. Describe the physical examination of the patient with a medical complaint. • 9. Describe components of the on-going physical examination.

4. Objectives Cont’d • 10.Describe purpose of trending of the patient’s physical assessment. • 11.Actively participate in a patient assessment when given a scenario. • 12. Demonstrate placing the HARE traction splint working in a group. • 13. Demonstrate placing the KED device in a group. • 14.Successfully complete the post quiz with a score of 80% or better.

5. Mechanism of Injury • What exactly is this? • Officially “the combined strength, direction, and nature of forces that injured your patient” • Basically – this is what causes an injury; what happened to your patient • Determined by information received by dispatch (how call came in) and confirmed by your observational and interview skills once on the scene

6. Nature of Illness Complaint • This is the medical complaint your patient has called EMS for • Not always readily apparent • May even differ from the chief complaint • The true nature of illness may not be what the patient initially thought was the problem Example: Called for difficulty breathing Patient thought it was allergies Patient eventually diagnosed with pneumonia

7. General Impression • An impression of what you think is wrong with the patient • Formed during the initial impression • Based on your observations of • Patient’s appearance • Patient’s environment • Patient’s chief complaint

8. General Impression • Becomes a working diagnosis based on: • Your experience • History obtained of present and past illnesses • Data obtained • Vital signs • Breath sounds • EKG monitor; 12 lead EKG • Glucose level

9. Benefit of Forming General Impression • Drives the choice of protocol followed • Used to guide your treatment options • May be changed as the call unfolds • May change as you gather more data • May change based on patient response to treatment initiated • May involve the use of more than one SOP based on the complaint

10. Scenario for Group Discussion: What is this general impression? • You are called to the scene for difficulty breathing • Upon arrival you observe the patient to be sitting upright in obvious distress • You hear audible noisy breathing • The patient is pale, diaphoretic, and tachycardic • You auscultate bilateral crackles • What’s your initial general impression?

11. Are you thinking acute pulmonary edema? • As you begin to assess the patient, more information comes forth • The patient has had chest pain 7/10 for the last 5 hours • The chest pain is non-radiating, feels like a vise grip on their chest • They have taken multiple doses of their NTG • Now what is your general impression?

12. The general impression now includes a possible acute MI complicated with acute pulmonary edema

13. Scene Size-up • First part of any patient assessment process • Begins as you arrive at the scene • Remember to consider information conveyed, including possible prior knowledge of caller • Can start some formulation of ideas before actually pulling up to the curb • Scene safety is a priority • Includes determination of mechanism of injury or nature of illness • Number of patients; need for equipment

14. Spinal Motion Restriction • C-spine control should be considered on all traumatic and some medical calls • Evaluate the patient • Mechanism of injury • Signs and symptoms • Reliability • Document equipment used to restrict spinal motion if this is care provided • Document findings if the need for spinal control/motion restriction is not required

15. In-field Spinal Clearance • Risky mechanisms of injury • High velocity MVC > 40mph • Unrestrained occupant in MVC • Passenger compartment intrusion >12″ • Ejection from vehicle • Rollover MVC • Motorcycle collision >20 mph • Death in same vehicle • Pedestrian struck by vehicle • Falls > 2 time patient height • Diving injury

16. In-field Spinal Clearance • Signs and/or symptoms • Pain in neck or spine • Tenderness/deformity of neck or spine upon palpation • Paralysis or abnormal motor exam • Abnormal response to painful stimuli • Any little complaint of numbness or tingling to distal extremities or a single digit is included as an abnormal response • Remember dermatomes from May 2011 CE?

17. In-field Spinal Clearance • Patient reliability • Signs of intoxication • Abnormal mental status • Communication difficulty • Includes non-English speaking patients • Abnormal stress reaction • Being added to revised SOP’s • Distracting injuries • Amazing how the mind can focus on one thing and ignore other problems

18. When in doubt, immobilize • When appropriate and supported with assessment, immobilization not necessary Either way... • DOCUMENT DOCUMENT DOCUMENT

19. Patient Circulation • What is the perfusion status of the patient? • Is their circulation sufficient to support perfusion to the brain (mental status) and generate a blood pressure (can you feel a radial pulse)? • Altered mental status first sign of altered perfusion • Hypotension a late sign of altered perfusion

20. Circulation • Does the patient have a pulse? • Rate? • Only 3 options: normal, too slow, or too fast • Quality? • Palpated distally? • Takes higher blood pressure to generate a distal pulse (ie: radial) • Does the patient have signs of shock? • Does the patient have life threatening bleeding?

21. First Patient Contact • Can learn a lot from “hello” • Walk up to patient and say hello and introduce yourself • As you do this, take their hand (feeling their pulse) • Do their eyes focus? • Are their eyes glazed over? • Do you have a pulse? • What’s the general information of the pulse– • Rate? Regularity? Quality?

22. Circulation Status • The eyes are very sensitive to blood flow • Eyes will reflect when circulation is decreased • Need adequate perfusion to the brain to maintain normal mentation • Need a blood pressure of at least 60 systolic to feel the distal radial pulse

23. Relatively Stable Patient • If the patient can talk (make sense)… • If the patient has a radial pulse… • They are considered relatively stable even though they may have signs and symptoms • Hence the phrase “relatively” stable

24. Assessing the Skin • Reflects patient circulation • Color • Temperature • Condition • Skin not a priority organ and a decrease in circulation noted with reflexive vasoconstriction and therefore paleness during times of poorer circulation

25. Skin Color • Areas to assess in the adult • Nail beds • Inside of cheek • Inside of lower lids • Capillaries are close to the surface of the skin in these areas so quickly reflect changes in circulation • Accurate even in dark complexions • Normal color is pink

26. Skin Color • Areas to assess in pediatrics • Palms of the hands • Soles of the feet • In darker complexions evaluate lips and nail beds • Normal color is pink

27. Skin Color

28. Assessing Temperature • Body constantly generating and losing heat • Body functions in a narrow temperature range • EMS most concerned with cases of the extreme • Hypothermia • Hyperthermia

29. Measuring Temperature • Palpating the skin measures surface temperature • Usually evaluated in subjective terms • Normal/Hot/Warm/Cool/Cold • Core temperature reflects level of heat inside trunk around organs • Normal oral temperature around 98.60F • Normal rectal temperature 1 degree higher • Normal axillary temperature 1 degree lower • Tympanic thermometers very common • Beware: wide margin of error

30. Assessing Skin Condition • Subjective evaluation • Normal • Dry • Moist • Diaphoretic • Can reflect recent activity level of patient • Can reflect under/over dressing

31. Skin Condition

32. What’s Important??? • Watching the trends!!! • What is staying the same? • What is changing? • What does it mean when there is a change?

33. Physical Examination • Used to evaluate/investigate areas that are/may be involved in the patient’s complaint • Practice and experience dictate your comfort and capability when performing a physical exam • Learn to pick up on intuitive information as well as objective information

34. Steps of Physical Assessment • Inspection – visual process always done first • Palpation • Palpate painful areas last • Use light touch with finger tips and warmed hands • Auscultation • Most commonly of breath sounds • Warm stethoscope first • Listen directly over skin; not over clothing • Percussion • Rarely done in the field; needs a quiet environment • Requires practice to be a benefit

35. History of Present Illness/Injury • O – onset (what were you doing)? • P – what makes it better/worse? • Palliation/provocation • Q – describe it in your own words • R – does it radiate/spread anywhere? • S – what is the discomfort on a scale of 0-10? • T – what time did this start?

36. On-going Physical Assessment • The most important aspect is watching for changes/trends • One set of vital signs, one time for palpation, one time for anything related to the patient and you have nothing for comparison • On-going means to repeat what has already been done • If abnormalities are found, be same person doing the reassessing

37. Patient Assessment Discussion • Divide the participants up into smaller groups • Assign each group a scenario • The groups should decide on an approach for assessing their patient • Discuss general impression • Discuss treatment • Discuss what to document • Answer the “Critical Thinking” questions • Smaller group to report their discussion to the larger group You may use your SOP’s as reference tool

38. Case Scenario #1 • Dispatched for a 67 year-old male with complaints of difficulty breathing • Sudden onset after smoking a cigarette • Awake, oriented, obeys commands • Tripod position; pursed lip breathing • Radial pulse rapid and regular • Skin cool, dusky, diaphoretic • Hx: Emphysema, hypertension, “water in the lungs” • On home O2 last 5 years

39. Case Scenario #1 cont’d • Allergies: environmental • Meds: Lasix, digoxin, Aldactone, theophylline, Alupent inhaler • VS: 158/88; P – 120; R – 20; SpO2 85% • Breath sounds: • Bilateral wheezing • Talking in 1-2 word sentences • Using accessory muscles • JVD and pedal edema present and chronic

40. Case Scenario #1 • What is the rhythm strip? • Sinus tachycardia with PVC’s • ST elevation noted so needs 12 lead • Check if there are 2 or more contiguous leads with ST elevation present (there is none) • Note: PVC’s fairly common in the COPD population

41. Case Scenario #1Small Group Discussion • What is your impression? • What is your treatment? • How do you monitor effectiveness of treatment?

42. Case Scenario #1 • Impression • Exacerbation of COPD • Possible left heart failure • Treatment • Increase oxygen delivery • Administer Albuterol nebulizer treatment for wheezing • Obtain 12 lead EKG • Note ST segment elevation on Lead II – is there more? (only present in Lead II) • Reassessment • Respiratory status • EKG monitor (unchanged)

43. Case Scenario #1Critical Thinking Questions 1. What is the significance of the tripod position, speaking in 1-2 word sentences, and use of accessory muscles? 2. What is the relationship with emphysema and “water in the lungs”? 3. What action can be taken regarding the home oxygen tank? 4. Based on the patient’s medications, what electrolyte may be a factor? 5. How do you assess the degree of respiratory distress?

44. Case Scenario #2 • Dispatched for a 76 year-old male due to a fall at home • Upon arrival your patient is sitting upright on the couch, watching you approach • Awake, verbally responsive, oriented x3 • Radial pulse irregular • Skin normal, dry • Hx: After a nap patient tried to get up but fell; Pt states “I can’t get up right”

45. Case Scenario #2 • Hx: Relatively healthy; total hip replacement 2 years ago, hypertension • Allergies: none • Meds: Hydrodiuril, digoxin, Coumadin • VS: 146/82; P – 78; R – 16; SpO2 98% • Does not move left leg on command, left arm moves weakly and no grasp on left • Blood glucose 89 • Abrasion to left elbow and knee from fall • Denies hitting his head

46. Case Scenario #2 • What is the rhythm? • Atrial fibrillation

47. Case Scenario #2Small Group Discussion • What is your impression? • What is your treatment? • How do you monitor effectiveness of treatment?

48. Case Scenario #2 • Impression • Acute stroke • Most likely ischemic (a clot) due to risk factor of atrial fibrillation • Need to also assess for injuries from the fall • Treatment • IV-O2-monitor • Assess with Cincinnati Stroke Scale • Expedited transport; Activating “Stroke Alert” at receiving hospital • Reassessment • Monitor B/P, watch for mental status changes

49. Case Scenario #2Critical Thinking Questions • What is the significance of atrial fibrillation related to strokes? • What side of the brain has the stroke affected? • Why isn’t the patient’s speech affected? • How does hypertension predispose to stroke? • What is the most important questions to ask?

50. Case Scenario #3 • Dispatched for a 3 year-old for possible allergic reaction • Upon arrival you hear fussy crying • Patient on mother’s lap squirming, trying to scratch self • Watching your approach • Patient is covered with hives • Itching started 1 hour ago and 30 minutes ago broke out in hives