2013 BAA - Patient Assessment

Module 6 Patient Assessment

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Patient Assessment

Mechanism of Injury (MOI) ‐ trauma

In order for ECP to be able to provide best possible treatment, you need to have understanding of injuries are sustained by look at MOI. You are required to “search for clues” and be vigilant E.g. MVA’s

Steering wheel that is buckled or bent o Thoracic trauma / fractures, neck, spinal, head trauma / fractures / injuries

Front windshield damaged with a target looking shatter / crack / broken where windshield is damaged o Head, neck, spinal, thoracic trauma / fractures

Dashboard is damaged or crumbled o Leg and pelvic fractures

Kinetic force: When a car is driving at 120 km/p/h and has a head on collision with a brick wall, the car collides with the wall at approximately 240km/p/h

Nature of illness (NOI) ‐ medical

You are required to “search for clues” and be vigilant for clues on how the incident happened / occurred. Pt. home – general appearance of living quarters can provide many clues. Run‐down messy apartment with liquor bottles scattered everywhere could give an indication of the type of pt. you are about to treat.

1 Primary Survey Primary survey consists of

o BSI and then o HHH ABC (conscious pt.) alternatively o HHH CAB (unconscious pt.)

Primary survey – most important starting point in pre‐hospital pt. assessment in emergency care

Even as you walking towards pt. and scene – critical assessment of ABC / CAB will determine pt. outcome

Before primary survey – there are vital steps to be taken before pt. can be touched or treated o That is Body Substance Isolation

1.1 Body Substance Isolation (BSI)

Practice regarding ALL bodily fluids as being potentially infectious

Always use BSI to protect yourself & partner from exposure to infectious disease/s

Various ways to protect yourself from exposure to infectious disease/s o Masks o Gloves and eye protection o Hand washing o Disposal of used supplies

NEVER leave medical equipment / dressing / bandages or anything used while treating the pt. behind!!!!!!

Once BSI taken care of – primary survey can begin Primary survey includes rapid assessment of pt. level of consciousness


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In almost every situation – following steps are excellent guidelines to follow:

H Hazards Is the scene safe to approach the pt.

H Help Send for help if needed – e.g. fire brigade

H Hello

A Airway Is pt. airway clear and free of debris?

B Breathing Is pt. breathing?

C Circulation Does pt. have pulse? And or obvious bleeding?

After primary survey is complete and all life‐threatening injuries taken care of o Proceed to finding out pt. history

Primary survey must be continuously assessed on same pt. o If ABC not re‐assessed continuously – pt. condition may deteriorate without you being aware of it.

SPEAK to your pt. NON‐STOP o GSC can easily be completed if pt. is speaking o If pt. stops speaking you are immediately aware that the pt. has deteriorated.

2 Secondary survey Integral part of the pt. overall approach Secondary survey has sequence and manner – follow this

GENERAL APPEARANCE My provide clue in providing a diagnoses e.g. cold and clammy

PT. POSITIONING Foetal position could mean they are guarding an acute abdomen

Trauma patients may lie in various positions depending on injuries sustained

BEHAVIOUR Pt. in pain may be crying or have various facial expressions

Anxious pt. may look scared and wary of surroundings

Be prepared for signs of restlessness o May indicate pt. becoming hypoxic or has internal bleeding o Restlessness in pt. must never be overlooked – can often indicate serious / potentially serious

condition.

OBVIOUS WOUNDS AND DEFORMITIES Look for areas of blood soaked clothing

Or deformed / unnatural positioned extremities

SKIN Always observe the colour, temperature and abnormalities

This will give you a good idea of the pt. perfusion

Bright red skin – could be indication of: o carbon monoxide poisoning – (gas heater, attempted suicide by exhaust fumes) o allergic rash o dilation of blood vessels

Pale skin o often associated with pt. in shock or normally pt. as being cold and clammy

Bluish tinged skin o can be indication of hypoxia / hypothermia

Yellow skin o Usually indication of jaundice – best seen in “whites” of eyes o Jaundice most often due to liver disease – e.g. hepatitis

Hives and urticarial – indication of allergic reaction


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2.1 Pt. History

S A M P L E

Signs and Symptoms Signs is something you seeSymptoms is what the pt. tells you

Allergies Ask – are you allergic to anything like medication like aspirin or food like peanuts

Medication Are you on chronic medication or taking medication for anything like flu or heart problems

Past medical history This question needs to include the pt. as well as the pt. family (pt. may not have past heart problems but pt. parents or family may have heart problems)

Last meal When was the last time the pt. ate or had something to eat

Events leading up to the event

What was the pt. doing before the pain started

2.2 Chief Complaint

This is main symptom that causes pt. to call for assistance e.g. difficulty breathing

Always be alert to more serious underlying conditions even though

Pt. might be complaining about specific wound e.g. pedestrian involved in MVA may complain of injured arm

Physically examination may reveal internal abdominal bleed – possible ruptured spleen

2.2.1 History of Chief Complaint

Obtain full as possible history from pt.

Ask the flowing questions: O P Q R S T

Onset When did the pain start / begin?

Provokes What provokes the pain?E.g. was the pt. exercising?

Quality What is the quality of pain?Crushing / stabling / feels like someone is sitting on their chest

Radiation / Radiating Is the pain radiating?i.e. to the jaw, arms, abdomen, back

Severity How sever is the pain?Scale of 1 – 10? 10 being the worse the pt. has ever felt

Time How long has the pain lasted?1 hour And is the pain constant or does it come and go and for how long

VITAL SIGNS

At this point vitals MUST be taken Signs – something you can see, hear, feel Pt. may not be aware of them e.g. rate / rhythm / strength of pulse

Pulse

Respiration

Air entry

Haemoglucose test (HGT)

Blood pressure

Pupils

Glasgow coma scale

Revised trauma score

Skin colour and temperature

Capillary refill


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2.3 Pulse

Palpated where an artery lies – close to surface skin – e.g. radial artery When evaluating pulse: (things to consider)

Rate Number of beats per minute

Rhythm Regularity of beats

Volume / strength Force / amplitude of each beat

Normal pulse rates per minute:

Adults 60 – 100 bpm

Children 80 – 100 bpm

Toddlers 100 – 120 bpm

New‐borns 120 – 140 bpm

Extremely fit adult can have pulse rate as low as 40 – 60 bpm (unfit person has faster pulse) Pulse rate only tell us little Pulse rate with rhythm and strength could tell us lots E.g. pt. pulse rate 120 bpm – regular but weak Could indicate pt. that is in shock E.g. pt. pulse rate 120bpm – regular but strong Could indicate health pt. after exercising When describing pulse – ALWAYS include rhythm, rate and strength / volume Pulse can be located in many areas of the body:


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2.4 Respiration

When describing respiration rate – ALWAYS include rhythm, rate and depth and ANY abnormal sounds / smells if present Normal respiration rate:

Adult 12 – 20 bpm

Child 15 – 30 bpm

Infant 25 – 50 bpm

Groups of children Ages Normal respiratory rates

New‐borns and infants Up to 6 months old 30‐60 breaths/min

Infants 6 to 12 months old 24‐30 breaths/min

Toddlers and children 1 to 5 years old 20‐30 breaths/min

Children 6 to 12 years 12‐20 breaths/min

Cheyne stokes respiration o Usually a sign of severe brain injury o Breathing gets deeper and deeper then stops for some time and the cycle then repeats

Depths of breaths may be affected by many factors o Pt. rib fractures – pt. will find it difficult to breath and therefore decrease breathing in order to lessen

pain o Overdose of narcotic drugs (respiration depressants) – may have shallow breathing

Abnormal breathing sounds o Snoring – obstructed airway o Stridor – high pitched squeaking noise heard on IN‐halation – caused by narrowing of airway

Usually around larynx o Gurgling – indicated collection of fluids in upper airway

Total lung capacity o 6000ml: Forced deep breathe ‐ Volume of air in lung after a forceful inspiration

Tidal volume o 500ml: Normal breathing – volume of air inspire / expire during each respiratory cycle o Normal breathing 12‐20 breathes per minute)

Dead air space o 150ml: Air remaining in passages

Minute volume o Amount of air that moves in and out of the lungs per minute o Tidal Volume x respiratory rate (12‐20 bpm) = minute volume

o VT or tidal volume is the amount of air the lungs breathe in one breath, o VE or minute volume is the number of breaths o RR (respiratory rate or f=frequency) breathed in one minute times the tidal volume. o Thus VT x RR = VE.

350ml x 12 breaths per minute = 4,2 L/min.


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2.4.1.1 Signs of abnormal breathing

Slower the 8 breaths/min OR faster than 24 breaths/min

Muscles retractions

Pale / cyanotic skin (bluish coloured skin)

Cool, damp (clammy) skin

Shallow / irregular respirations

Pursed lips

Nasal flaring

2.5 Air entry

Air entry is determined by auscultating both the left and right sides of the thoracic cavity

Auscultating the thorax with a stethoscope

It is used to determine equality of breath sounds on both sides of the chest o Unequal air entry may suggest pneumothorax


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Auscultation:

Normal Abnormal

Sound Present & equal Diminished / unequal / absent

Expansion Adequate & equal Inadequate / unequal

Effort Unlaboured / normal Laboured / increased effort / uses accessory muscles / flail rib fractures / subcutaneous emphysema

2.6 Blood Pressure

Two components to blood pressure measurements:

Systolic (contraction of the heart)

Diastolic (relaxation of the heart) Blood Pressure = Cardiac Output x Peripheral resistance Cardiac output = Stroke volume x Heart rate Blood pressure is recorded: systolic over diastolic e.g. 120/80 Normal blood pressures: Systolic: 100 – 140mmHG Diastolic: 65 – 90mmHG Male pt. Adult

Age + 100 = Systolic BP 40 + 100 = 140

Diastolic BP = 2/3 of systolic BP 90 ‐ 100

Female pt. Adult

Age + 90 = Systolic BP 30 + 90 = 120

Diastolic BP = 2/3 of systolic BP 80

Blood pressure can be estimated by finding different pulses: Pedal pulse: 90mmHG Radial pulse: 80mmHG Femoral pulse: 70mmHG Carotid pulse: 60mmHG RMB:

BP only of many vital signs and must not be used in isolation

e.g. pt. that has lost lots of blood may have normal BP o this due to response of vasoconstriction by vessels and increase in heart rate and output to maintain

pressure o By the time the pt. BP falls – pt. is already in sever hypovolaemic shock

2.7 Pupils

Remember: PEARL Pupils equal and reactive to light +‐ Normal size pupil 4mm State of pupils may be indicator of cerebral perfusion and oxygenation of brain Two main parameters:

Size of pupils

Reaction of pupils to light In normal healthy person – pupils are equal size and shape


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Size of pupil is usually determined by amount of light entering the eye

Bright light causes pupil to constrict

Darkness causes pupils to dilate When brain deprived of oxygen – pupils dilate Use of drugs may affect pupils Pt. who have dilated pupils but are alert and responsive – DON’T have problem with oxygenation to brain Drug may have caused papillary response Rate of reaction to light may give clues to states of brain

Pupils slow to react – usually mean the brain or portion of the brain is hypoxic

2.8 Glasgow coma scale (value out of 15)

Derived from various responses to stimuli:

Responses are: o Opening of eyes o Use of speech o Ability to move

/15 Visual Response Verbal Ability Motor Skills

1 Eyes don’t open None No movement

2 Pain causes eyes to open Incomprehensible words / sounds Abnormal extension to pain

3 Voices cause eyes to open Inappropriate words Abnormal flexion to pain

4 Spontaneous Minimal / confused Withdraws from pain

5 ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Orientated Localizes pain

6 ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Moves on command

Lowest score is 3

2.9 Revised Trauma Score

/12 GCS Systolic BP Resp. Rate

4 13 – 15 >90 10‐29

3 9 – 12 76 – 89 >29

2 6 – 8 50 – 75 6 – 9

1 4 – 5 1 – 49 1 ‐ 5

0 3 0 0

Lowest score is 3

2.10 Capillary refill

2 seconds to refill Press nail bed – release and determine time it takes for nail bed to return to initial colour.

2.11 Haemoglucose test (HGT)

Haemoglucose test – done by assessing blood sugar level of pt. Normal blood sugar level – 3.5 – 6.7 (or 7.4) mmol/L


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2.12 Head – to ‐ Toe

Head Slide hands from neck upwards – to feel posterior scalp. Be extremely careful in trauma pt. NOT to move head DO NOT press hard on deformities – may push fragments of broken bone into brain Feel for deformities, swelling and blood

Ears Look for ear damage Blood and CSF (cerebra‐spinal fluid) – may be oozing from ears ‐ May be indication of skull fracture Battle signs (bruising over mastoid process ‐ May be indication of skull fracture

Nose Look for swelling, deformity or bruisingBlood and CSF (cerebra‐spinal fluid) draining from nose ‐ May be indication of skull fracture

Eyes Check external trauma – eyes and eyelidsRaccoon eyes (bruising around the eyes) – May sometimes be indication of skull fracture

Mouth 1st feel jaw for signs of fractures Open mouth – check there is no foreign matter within e.g. broken teeth/dentures, vomits, blood etc.

Neck DO NOT move neck in trauma pt. Gently examine neck for wounds, bruises, palpate for subcutaneous emphysema Examine trachea – deviated or midline Examine posterior and anterior aspects of neck for swelling and deformities. Completion of neck examination – immobilize neck with neck brace

Chest Fully expose pt. chest when necessary. – be respectful and allow pt. to keep their dignity Examine chest for stability, unity, bruising and wounds Auscultate chest for unequal breath sounds or any abnormal breath sounds e.g. wheezing, rales Lookout for medic‐alert bracelet

Abdomen Ensure abdomen is exposed Look for bruising, lacerations, bowel eviscerations Palpate abdomen for tenderness, rigidity or guarding

Pelvis Locate crests of ilium (hips) and gently exert pressureInstability or pain from this compression may indicated fracture of the pelvis

Genitalia Should not normally be done – unless obvious signs of injury i.e. blood soaking through clothing, impalement of object Always be sensitive and cautious when exposing genitalia – allow pt. maintain dignity – provide privacy Very legal problems may be caused by this type of examination

Extremities Expose legs and arms if injury is expectedExamine for bleeding, deformity, bruising, abnormalities or abnormal positioning of limbs Test pt. sensation – response to touch – BADINSKI REFLEX – normal movement toes curl – abnormal movement toes pull up and away for touch. Medical pt. look for swelling – sacral oedema and pericardial oedema and poor circulation (pulse) Lookout for medic‐alert bracelet Completion of examining legs – examine arms in the same manor.


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3 Triage Triage is a French word – meaning sorting

Defined as categorizing and sorting of pt. according to degree / severity of injuries / illness

Assessment of injuries is conducted briefly – establishing o Type of injuries sustained o How severe injuries are o Who is to receive priority in primary care o And transportation to medical facility

During this assessment ABC principle is applied o Screaming, hysterical pt. usually NOT highest priority

Pt. is conscious and has open airway o Silent pt. usually have depressed level of consciousness

Possible airway obstruction Possible breathing difficulty Possible haemorrhage – resulting in shock

ECP responsible for triage MUST overcome desire to stop and treat individual pt. – ECP must complete ABC

ECP should continue categorizing each pt.

To enable arriving team to quickly identify pt. needs of immediate treatment

3.1.1 Prioritization of pts.

ECP responsible for triage must ensure all pt. are closely monitored – triaging pt. may change

Attention must be directed to priority 1 (/ highest priority) before treatment is administered to priority two pt. (/ lower priority pt.)

Call centre must be updated of ALL events on continuous basis and any further assistance required

Triage MUST be performed repeatedly (does not consist of one assessment)

3.1.1.1 Priority 1

Highest priority Life threatening emergencies Pt. in danger of asphyxia / hypoxia

Obstructed airway

Apnea

Sucking chest wounds

Tension pneumothorax

Pt. in shock / impending shock

Major external / internal bleeding

Burns over more than 20% of body surface

Cardiac tamponade

3.1.1.2 Priority 2

Second priority Pt. seriously injured

Visceral injuries WITHOUT shock

Burns – less than 20% o Including face / hands / feet / genitalia

Spinal cord injuries

Compound fractures / dislocations


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3.1.1.3 Priority 3

Third priority Pt. with moderate to light injuries

Soft tissue injuries WITHOUT shock

Musculoskeletal injuries WITHOUT shock / WITHOUT loss of pulse / WITHOUT loss in sensation

Minor injuries of the eyes

Burns of other locations – less than 20%

3.1.1.4 Priority 4

These are dead pt. Priority 4 pt. should be left where they are found and covered SAPS will take over responsibility for removal of these victims

4 Pt. Effective interaction / communication

4.1 Effective interaction with patients

Make and keep eye contact

Use pt. proper name (if you forget pt. name – use sir/ma’am)

Tell pt. truth

Use language pt. can understand

Be careful of what you say about pt. to others

Be aware of own body language

Speak slowly, clearly, distinctly (always)

If pt. hearing impaired, speak clearly and face pt. when speaking

Allow time for pt. to answer questions

Act in calm, confident manner

4.2 Communicating with elderly pt.

Determine pt. function age

DO NOT assume elderly pt. senile / confused

Allow pt. ample time to respond

Watch for confusion, anxiety, impaired hearing / vision

ALWAYS explain what is being done

4.3 Communicating with children

Children are aware of what’s going on

Allow people / objects that provide comfort to remain close

Explain procedures to children truthfully

Position yourself on their level

4.4 Communicating with hearing impaired pt.

Always assume pt. has NORMAL intelligence

Make sure you have paper and pen

Face pt. and speak slowly, clearly and distinctly

NEVER shout

Learn simple phrases used in sign language

4.5 Communicating with visually impaired pt.

Ask pt. if they can see at all

Explain all procedures truthfully as being performed

If guide dog present – transport guide dog also.


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4.6 Language barriers

Use short, simple questions and answers

Points to specific parts of body as you ask questions

Learn common words and phrases – non‐English language areas

4.7 Mentally disturbed pt.

Interaction with mentally disturbed can be difficult at best of times

Should be kept in mind – abnormal behaviour may be part and parcel of medical diseases, reaction to severe stress, drug abuse

NOT every pt. has specific mental (psychiatric) disorder.

Pt. with hypoglycaemia or alcohol ingestion may appear mentally disturbed

5 Disruptive behaviour and drug abuse Overview

Drug defined as substance – can produce physical / mental effect on the body

Every drug can have undesirable side effect or reaction

Some reactions are life threatening and require emergency treatment

Sometimes drugs misused and cause serious reactions

Most drugs abused are done for mood altering effects

Includes alcohol

General misuse of drugs is termed as “substance abuse”

5.1 Drugs

Drug defined as substance – can produce physical / mental effect on the body

Drug abuse is worldwide

Varies from

Simple minor overdoses of medically prescribed drugs o Inhalation of intoxicating chemicals o To major narcotic usage

Cocaine powerful CNS stimulant

Heroin CNS depressant – does have mood elevating effects

LSD ‐ One of most important and dangerous hallucinogenic drug o Alters pt. awareness of themselves – can cause fatal situations when pt. believes they can leap off

buildings and fly.

5.2 Alcohol

Alcohol – powerful CNS depressant

Chronic alcoholics may be suicidal

Drunken pt. may show aggression, inappropriate behaviour, fall easily / be combative

Pt. who abuses alcohol and drugs usually have underlying personality disorder o Pt. should always be approached in caring and understanding manner

If pt. becomes too aggressive – call for assistance ‐ SAPS

6 Death and terminal illness

6.1 SIDS (Sudden Infants Death Syndrome)

Thousands of babies die from SIDS every year

Usually occurs during sleep – in apparently healthy baby: 2 – 4 month old

Also known as cot death

Almost certainly encounter anguished, severely distressed pts.

Always make effort to revive baby with basic life support – unless baby is cold and stiff


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Transport to hospital – even if baby seems dead to you o Be sure to examine baby o Signs of child abuse – DO NOT make this obvious to the parents

Evidence of child abuse MUST be reported to doctor at receiving hospital

6.2 Sudden death

Often pt. will not have been previously ill / in danger – death will be a great shock to everyone

Any doubts if the pt. is dead – full resuscitation should be carried out. o When person obviously dead – support should be given to the family and friends

Keep family informed of what you are doing

Close relatives and friends should be allowed to see the body if desired o BUT any mutilated areas should be covered

NEVER raise false hopes – possible response to resuscitation if death is inevitable

If possible, do not resuscitate pt. when family around; ask family to leave the room

6.3 Terminal illness

Terminally ill pt. usually know / strongly suspect they are about to die

May be little to do for terminally ill pt. – other than to make them comfortable

Determine if pt. and family are aware that death is approaching

Pt. should NOT die alone!!

7 Abuse

7.1 Child abuse

Child abuse may take many forms o Beatings o Burns o Rape o Even attempted murder

Anyone may be a victim of abuse – seen most often among family members

Victims / pts. Of abuse may demonstrate anger / rage / withdrawal

Victim may say little, appear not to care, may not want anyone near them

If child abuse it suspected – make every effort to get child to hospital for doctors examination o RMB to express your feelings to doctor – avoid confronting parents with suspiciouns

7.2 Adult abuse

Commonly known as “wife beating” / “husband beating” (abuse of husbands also recognised)

May be possible at times to quietly discuss problem with victim alone – who will often refuse help

However – issue must NOT be forced – best course of action o Attempt to persuade pt. to be taken to hospital

Documents

2013 BAA - Patient Assessment