Paramedic Care: Principles & Practice Volume 3: Patient Assessment CHAPTER Fourth Edition...

Paramedic Care: Principles & Paramedic Care: Principles & PracticePractice

Volume 3: Patient AssessmentVolume 3: Patient Assessment

CHAPTER

Fourth EditionFourth Edition

Patient Assessmentin the Field

Standard

• Assessment

Competency

• Integrate scene and patient assessment findings with knowledge of epidemiology and pathophysiology to form a field impression.

• This includes developing a list of differential diagnoses through clinical reasoning to modify the assessment and formulate a treatment plan.

Introduction

• Patient assessment: problem-oriented evaluation of patient; establishing priorities of care.

• Patient's condition determines components you use; how to use them.

Introduction

• Proficiency in performing patient assessment will determine your ability to deliver highest quality of prehospital advanced life support (ALS).

Scene Size-Up

• First stage of every emergency call.

• Ensure safe environment.• Take necessary precautions for personal protection.

• Determine what resources needed.• Locate all patients.• Assess mechanism of injury (MOI) or nature of medical illness.

Primary Assessment

• Determine whether patient “looks dead or doesn't look dead.”

• If patient looks dead, quickly assess responsiveness and breathing.

• If pulse absent, begin chest compressions immediately.

• If patient shows signs of life, conduct primary assessment (ABC).

Primary Assessment

• Steps of Primary Assessment– Form general impression– Stabilize cervical spine as needed– Assess baseline mental status– Assess airway– Assess breathing– Assess circulation– Assign priority

Manually stabilize the head and neck on first patient contact.

Primary Assessment

• Should take less than 1 minute, unless you intervene with lifesaving measures.

• Do not delay transport for detailed assessments and procedures.

Secondary Assessment

• Vital signs, followed by focused history and physical exam.

• Based on primary assessment and patient's chief complaint.

• Includes monitoring technology.

• Types of Patients– Major trauma patient with significant injury or altered mental status

– Minor trauma patient with isolated injury

– Responsive medical patient– Unresponsive medical patient

• The Major Trauma Patient– Primary assessment.– Rapid secondary assessment.– Package patient.– Rapid transport to emergency department.

– Perform reassessment and treatments en route.

– MOI could be life-threatening.

• Predictors of Serious Internal Injury– Fall from more than 20 feet– Automobile crash with intrusion– Ejection from vehicle– Death in same passenger compartment– Automobile–pedestrian collision– Automobile–bicycle collision– Motorcycle crash

• MOIs can result from seat belts, air bags, child safety seats.

• Look for hidden internal injuries.• Physical signs of trauma confirm index of suspicion.

• If in doubt, transport patient to medical facility without delay; always best to err on side of precaution.

• Rapid Secondary Assessment– To identify all other life-threatening conditions.

– Assess patient systematically; avoid tunnel vision.

– Maintain spinal immobilization throughout rapid trauma exam.

– Reconsider decision to transport; things can change unexpectedly.

• Rapid Secondary Assessment– Assess mental status using AVPU mnemonic.

– Compare findings with baseline mental status from initial assessment.

– Pay special attention to head, neck, chest, abdomen, pelvis.

– Major concern: internal injuries beneath superficial wounds.

• Rapid Secondary Assessment– Deformities, contusions, abrasions, penetrations, burns, tenderness, lacerations, swelling.

– Assess head for injuries and crepitus.– Simple scalp laceration can cause life-threatening hemorrhage.

– Altered mental status and abnormality in structure of skull: serious emergency.

• Rapid Secondary Assessment– Inspect and palpate neck for injuries and crepitus; significant blood loss quickly.

– Examine jugular veins for abnormal distention.

– Inspect and palpate trachea.– Inspect and palpate neck for subcutaneous emphysema.

• Rapid Secondary Assessment– Palpate posterior neck for evidence of spinal trauma.

Procedure 7–1Rapid Secondary Assessment—

The Head and Neck

Procedure 7–1 Rapid Secondary Assessment—The Head and Neck7-1a The first step in the rapid secondary assessment is to palpate the head.

Procedure 7–1 Rapid Secondary Assessment—The Head and Neck7-1b Periodically examine your gloves for blood.

Procedure 7–1 Rapid Secondary Assessment—The Head and Neck7-1c Inspect and palpate the anterior neck. Pay particular attention to tracheal deviation and subcutaneous emphysema.

Procedure 7–1 Rapid Secondary Assessment—The Head and Neck7-1d Inspect and palpate the posterior neck. Note any tenderness, irregularity, or edema.

• Rapid Secondary Assessment– Look for signs of acute respiratory distress.

– Quickly inspect and then palpate chest.

• Rapid Secondary Assessment– Be careful when palpating ribs; look for erythema caused by impact to ribs.

– Suspect major damage to underlying organs, especially vascular structures, when ribs broken.

– Observe for equal, symmetrical, effortless chest rise.

• Rapid Secondary Assessment– Flail chest greatly reduces air movement.

– Inspect patient's chest and back for open wounds.

– Seal any open wounds with occlusive dressing; tape dressing on three sides.

– Auscultate both lungs quickly at midaxillary line for air movement.

Procedure 7–2 Rapid Secondary Assessment—The Chest7-2c Seal any sucking chest wound with tape on three sides.

• Rapid Secondary Assessment– Tension pneumothorax: life-threatening condition.

– Inspect and palpate abdomen for injuries and crepitus.

– Note areas of bruising and guarding.

Procedure 7–2Rapid Secondary Assessment—

The Chest

Procedure 7–2 Rapid Secondary Assessment—The Chest7-2a Palpate the clavicles.

Procedure 7–2 Rapid Secondary Assessment—The Chest7-2b Stabilize a flail chest.

Procedure 7–2 Rapid Secondary Assessment—The Chest7-2c Seal any sucking chest wound with tape on three sides.

Procedure 7–2 Rapid Secondary Assessment—The Chest7-2d Perform needle decompression to relieve tension pneumothorax if authorized.

• Rapid Secondary Assessment– Inspect and palpate abdomen for injuries and crepitus.

– Note areas of bruising and guarding.

• Rapid Secondary Assessment– Bruising over umbilicus (Cullen's sign).

– Bruising over flanks (Grey Turner's sign).

– Both signs indicate intraabdominal hemorrhage; immediate transport to medical facility for surgery.

– Test for rebound tenderness.

• Rapid Secondary Assessment– Examine pelvis for injuries and crepitus; stable pelvic ring.

– Evaluate pelvic ring at iliac crests and symphysis pubis.

– Immobilize pelvis before transport to prevent movement and possible circulatory catastrophe.

Procedure 7–3 Rapid Secondary Assessment—The Chest7-3a Assess the integrity of the pelvis by gently pressing medially on the pelvic ring.

• Rapid Secondary Assessment– Inspect and palpate all four extremities for injuries and crepitus.

– Splint fractures en route to hospital.– Evaluate distal neurovascular function.

– Inability to feel and move both legs indicates complete spinal cord disruption.

Procedure 7–3 Rapid Secondary Assessment—The Chest7-3f Assess distal sensation and motor function.

• Rapid Secondary Assessment– Diminished sensation, paresthesias, or diminished motor ability indicates partial disruption.

– Weakness or disability on only one side of body suggests brain injury due to stroke or head injury.

Procedure 7–3Rapid Secondary Assessment—The Pelvis and Extremities

Procedure 7–3 Rapid Secondary Assessment—The Chest7-3a Assess the integrity of the pelvis by gently pressing medially on the pelvic ring.

Procedure 7–3 Rapid Secondary Assessment—The Chest7-3b Compress the pelvis posteriorly.

Procedure 7–3 Rapid Secondary Assessment—The Chest7-3c Palpate the legs.

Procedure 7–3 Rapid Secondary Assessment—The Chest7-3d Palpate the arms.

Procedure 7–3 Rapid Secondary Assessment—The Chest7-3e Palpate the dorsalis pedis pulse to evaluate distal circulation in the leg.

Procedure 7–3 Rapid Secondary Assessment—The Chest7-3f Assess distal sensation and motor function.

• Rapid Secondary Assessment– Check for MedicAlert tags.– Log-roll patient onto side to inspect posterior body; note tenderness in spinal area.

– History: chief complaint, history of present illness, past history, current health status.

Inspect and palpate the posterior body.

• SAMPLE History– Symptoms– Allergies– Medications– Pertinent past medical history– Last oral intake– Events leading up to the incident

• The Minor Trauma Patient– Isolated injury; no significant MOI; no signs of systemic involvement.

– Does not require extensive history or comprehensive physical exam.

– Ensure hemodynamic status via primary assessment.

– Secondary assessment on specific isolated injury.

• The Responsive Medical Patient– History takes precedence over physical exam.

– Physical exam: identifies signs of medical complications rather than injury.

– Conscious, alert patients can tell you about their illness.

– Chief complaint: pain, discomfort, or dysfunction; patient requested help.

Begin treatment while you assess your responsive medical patient.

• The Responsive Medical Patient– Present problem: circumstances surrounding chief complaint.

– Follow acronym OPQRST–ASPN.– Past medical history: insights into chief complaint and field diagnosis.

– Family/social history: history of serious disease may be “red flag” in the case.

• OPQRST–ASPN– Onset– Provocation/Palliation– Quality– Region/Radiation– Severity– Time– Associated Symptoms– Pertinent Negatives

• The Responsive Medical Patient– Review of systems: system-by-system list of questions more specific than those asked during basic history.

– Begin focused physical exam based on information elicited from patient.

– Cardiac chest pain/respiratory distress, altered mental status, acute abdomen.

• The Unresponsive Medical Patient– Begin with primary assessment.– Rapid head-to-toe exam.– Brief history from family or friends.

– Airway protected.– Assess head, neck, chest, abdomen, pelvis, extremities, posterior aspect of body.

• The Unresponsive Medical Patient– Assess baseline vital signs.– Perform additional tests.– Consider unresponsive patient unstable.

– Expedite transport to hospital.

Reassessment

• Patient condition can change suddenly.

• Reassess mental status, airway patency, breathing adequacy, circulation, any deterioration.

• Every 15 minutes for stable patients.

• Every 5 minutes for unstable patients.

Procedure 7–4Reassessment

Procedure 7–4 Reassessment7-4a Reevaluate the ABCs.

Procedure 7–4 Reassessment7-4b Take all vital signs again.

Procedure 7–4 Reassessment7-4c Perform your focused assessment again.

Procedure 7–4 Reassessment7-4d Evaluate your interventions' effects.

Reassessment

• Mental Status– Recheck mental status by performing AVPU exam frequently during transport.

– Falling level of response indicates direct or indirect brain pathology.

Reassessment

• Airway Patency– Can change instantly.– Endotracheal intubation best way to secure airway in patients with no gag reflex.

– Be prepared for the worst.

Reassessment

• Breathing Rate and Quality– Sudden increase in rate or respiratory effort suggests deterioration.

– Subtle increases in respiratory rate can suggest developing problem.

– Decrease in rate and effort could mean treatments are effective.

– Requires constant reevaluation.

Reassessment

• Pulse Rate and Quality– Rising pulse rate: shock, hypoxia, cardiac dysrhythmia.

– Falling rate: terminal stage of shock or rise in intracranial pressure.

– Sudden change in rate or regularity: cardiac dysrhythmia.

– Loss of peripheral pulses: decompensating shock.

Reassessment

• Skin Condition– Reflects body's hemodynamic status.

– Reevaluate skin color, temperature, condition.

• Transport Priorities– Depending upon patient status, you may need to either upgrade or downgrade transport decision.

Reassessment

• Vital Signs– Reassessing vital signs reveals trends.

– Reevaluate critical patients every 5 minutes.

• Secondary Assessment– Repeat focused assessment as chief complaint dictates.

Reassessment

• Effects of Interventions– Know expected therapeutic benefits of interventions; evaluate whether they worked.

• Management Plans– Evaluate whether care is working. – If not, consider another management plan.

– Be flexible to change course of action.

Clinical Decision Making

• Critical Thinking– Form concept– Interpret data– Apply principles– Evaluate results– Reflect on incident

• Form a Concept– Assess general environment and immediate surroundings.

– Conduct initial assessment.– Chief complaint, history of present illness, past history, current health status.

– Conduct focused physical exam.

• Interpret the Data– Consider all data.– Determine most common and statistically probable conditions that fit patient's initial presentation.

– Differential field diagnosis.

• Apply the Principles– Devise management plan that covers all contingencies.

• Evaluate the Results– Reassess patient's condition and effects of protocol interventions.

– Determine whether treatment improving patient's condition and status.

• Reflect on the Case– Discuss field diagnosis and care with emergency physician.

– Compare field diagnosis with physician's diagnosis.

– Conduct run critique with your crew.

– With every patient contact, your experience grows and clinical judgment improves.

Summary

• Patient assessment is key to providing effective prehospital emergency medical care.

• Primary assessment, secondary assessment, vital signs, reassessment.

• Primary assessment: identify and treat life-threatening airway, breathing, circulation problems.

Summary

• Secondary assessment: identify signs and symptoms surrounding chief complaint.

• Problem-oriented approach; easily modified to match patient's clinical situation.

• Reassessment: reevaluate patient for changes in status en route to hospital.

Summary

• Trauma patient with significant MOI: primary assessment, rapid secondary assessment, rapid transport.

• Patient with isolated, minor trauma: physical exam focused on particular problem or area.

• Responsive medical patient: primary and secondary assessment; focused on chief complaint, vital signs.

Summary

• Unresponsive medical patient: primary assessment; rapid secondary assessment and rapid transport.

• You will be expected to use clinical judgment when deciding which assessment tools to use.

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