8: Patient Assessment

8: Patient Assessment

Cognitive3-1.1 Recognize hazards/potential hazards.3-1.2 Describe common hazards found at the scene of

a trauma and a medical patient.3-1.3 Determine if the scene is safe to enter.3-1.4 Discuss common mechanisms of injury/nature of

illness.3-1.5 Discuss the reason for identifying the total number

of patients at the scene.3-1.6 Explain the reason for identifying the need for

additional help or assistance.

Scene Size-up Objectives (1 of 2)

Scene Size-up Objectives (2 of 2)

Affective

3-1.7 Explain the rationale for crew members to evaluate scene safety prior to entering.

3-1.8 Serve as a model for others explaining how patient situations affect your evaluation of mechanism of injury or illness.

Psychomotor

3-1.9 Observe various scenarios and identify potential hazards.

Cognitive3-2.1 Summarize the reasons for forming a general impression of

the patient.3-2.2 Discuss methods of assessing altered mental status.3-2.3 Differentiate between assessing the altered mental status in

the adult, child, and infant patient. 3-2.4 Discuss methods of assessing the airway in the adult, child,

and infant patient. 3-2.5 State reasons for management of the cervical spine once the

patient has been determined to be a trauma patient.

Initial AssessmentObjectives (1 of 7)


3-2.6 Describe methods used for assessing if a patient is breathing.

3-2.7 State what care should be provided to the adult, child, and infant patient with adequate breathing.

3-2.8 State what care should be provided to the adult, child, and infant patient without adequate breathing.

3-2.9 Differentiate between a patient with adequate and inadequate breathing.

3-2.10 Distinguish between methods of assessing breathing in the adult, child, and infant patient.


3-2.11 Compare the methods of providing airway care to the adult, child, and infant patient.

3-2.12 Describe the methods used to obtain a pulse.3-2.13 Differentiate between obtaining a pulse in

an adult, child, and infant patient.3-2.14 Discuss the need for assessing the patient

for external bleeding.3-2.15 Describe normal and abnormal findings

when assessing skin color.3-2.16 Describe normal and abnormal findings

when assessing skin temperature.


3-2.17 Describe normal and abnormal findings when assessing skin condition.

3-2.18 Describe normal and abnormal findings when assessing skin capillary refill in the infant and child patient.

3-2.19 Explain the reason for prioritizing a patient for care and transport.


Affective 3-2.20 Explain the importance of forming a general

impression of the patient.3-2.21 Explain the value of performing an initial

assessment.


Psychomotor3-2.22 Demonstrate the techniques for assessing

mental status.3-2.23 Demonstrate the techniques for assessing the

airway.3-2.24 Demonstrate the techniques for assessing if

the patient is breathing.3-2.25 Demonstrate the techniques for assessing if

the patient has a pulse.


3-2.26 Demonstrate the techniques for assessing the patient for external bleeding.

3-2.27 Demonstrate the techniques for assessing the patient's skin color, temperature, condition, and capillary refill (infants and children only).

3-2.28 Demonstrate the ability to prioritize patients.

Cognitive

3-3.1 Discuss the reasons for reconsideration concerning the mechanism of injury.

3-3.2 State the reasons for performing a rapid trauma assessment.

3-3.3 Recite examples and explain why patients should receive a rapid trauma assessment.

3-3.4 Describe the areas included in the rapid trauma assessment and discuss what should be evaluated.

Focused History and Physical Exam: Trauma Objectives (1 of 3)

3-3.5 Differentiate when the rapid assessment may be altered in order to provide patient care.

3-3.6 Discuss the reason for performing a focused history and physical exam.

Affective

3-3.7 Recognize and respect the feelings that patients might experience during assessment.


Psychomotor

3-3.8 Demonstrate the rapid trauma assessment that should be used to assess a patient based on mechanism of injury.


Cognitive3-4.1 Describe the unique needs for assessing an

individual with a specific chief complaint with no known prior history.

3-4.2 Differentiate between the history and physical exam that are performed for responsive patients with no known prior history and responsive patients with a known prior history.

3-4.3 Describe the needs for assessing an individual who is unresponsive.

Focused History and Physical Exam: Medical Patients

Objectives (1 of 3)

3-4.4 Differentiate between the assessment that is performed for a patient who is unresponsive or has an altered mental status and other medical patients requiring assessment.

Affective

3-4.5 Attend to the feelings that these patients might be experiencing.


Objectives (2 of 3)

Psychomotor

3-4.6 Demonstrate the patient care skills that should be used to assist a patient who is responsive with no known history.

3-4.7 Demonstrate the patient care skills that should be used to assist a patient who is unresponsive or has an altered mental status.


Objectives (3 of 3)

Cognitive

3-5.1 Discuss the components of the detailed physical exam.

3-5.2 State the areas of the body that are evaluated during the detailed physical exam.

3-5.3 Explain what additional care should be provided while performing the detailed physical exam.

3-5.4 Distinguish between the detailed physical exam that is performed on a trauma patient and that of the medical patient.

Detailed Physical ExamObjectives (1 of 2)

Affective

3-5.5 Explain the rationale for the feelings that these patients might be experiencing.

Psychomotor

3-5.6 Demonstrate the skills involved in performing the detailed physical exam.

Detailed Physical ExamObjectives (2 of 2)

Cognitive

3-6.1 Discuss the reason for repeating the initial assessment as part of the ongoing assessment.

3-6.2 Describe the components of the ongoing assessment.

3-6.3 Describe trending of assessment components.

Affective

3-6.4 Explain the value of performing an ongoing assessment.

Ongoing AssessmentObjectives (1 of 2)

Ongoing AssessmentObjectives (2 of 2)

3-6.5 Recognize and respect the feelings that patients might experience during assessment.

3-6.6 Explain the value of trending assessment components to other health professionals who assume care of the patient.

Psychomotor

3-6.7 Demonstrate the skills involved in performing the ongoing assessment.

Patient Assessment

• Scene size-up• Initial assessment• Focused history and physical exam

– Vital signs– History

• Detailed physical exam• Ongoing assessment

Patient Assessment Process

Scene Size-up

• Dispatch information• Inspection of scene• Scene hazards• Safety concerns• Mechanism of injury• Nature of illness/chief complaint• Number of patients• Additional resources needed

Body Substance Isolation

• Assumes all body fluids present a possible risk for infection

• Protective equipment– Latex or vinyl gloves should always be

worn– Eye protection– Mask – Gown – Turnout gear

Scene Safety: Potential Hazards

• Oncoming traffic• Unstable surfaces• Leaking gasoline• Downed electrical lines• Potential for violence• Fire or smoke

• Hazardous materials

• Other dangers at crash or rescue scenes

• Crime scenes

Scene Safety

• Park in a safe area.• Speak with law

enforcement first if present.

• The safety of you and your partner comes first!

• Next concern is the safety of patient(s) and bystanders.

• Request additional resources if needed to make scene safe.

Mechanism of Injury

• Helps determine the possible extent of injuries on trauma patients

• Evaluate:

– Amount of force applied to body

– Length of time force was applied

– Area of the body involved

Nature of Illness

• Search for clues to determine the nature of illness.

• Often described by the patient’s chief complaint

• Gather information from the patient and people on scene.

• Observe the scene.

The Importance of MOI/NOI

• Guides preparation for care to patient

• Suggests equipment that will be needed

• Prepares for further assessment

• Fundamentals of assessment are same whether emergency appears to be related to trauma or medical cause.

Number of Patients

• Determine the number of patients and their condition.

• Assess what additional resources will be needed.

• Triage to identify severity of each patient’s condition.

Additional Resources

• Medical resources– Additional units– Advanced life support

• Nonmedical resources– Fire suppression– Rescue– Law enforcement

C-Spine Immobilization

• Consider early during assessment.

• Do not move without immobilization.

• Err on the side of caution.


Initial Assessment

• Develop a general impression.

• Assess mental status.• Assess airway.• Assess the adequacy of

breathing.• Assess circulation.• Identify patient priority.

Develop a General Impression

• Occurs as you approach the scene and the patient

– Assessment of the environment

– Patient’s chief complaint

– Presenting signs and symptoms of patient

Obtaining Consent

• Introduce self.• Ask patient’s name.• Obtain consent.

Chief Complaint

• Most serious problem voiced by the patient

• May not be the most significant problem present

Assessing Mental Status

• Responsiveness– How the patient

responds to external stimuli

• Orientation– Mental status and

thinking ability

Testing Responsiveness

• A Alert• V Responsive to Verbal stimulus• P Responsive to Pain• U Unresponsive

Testing Orientation

• Person • Place• Time• Event

Caring for Abnormal Mental Status

• Complete initial assessment.• Provide high-flow oxygen.• Consider spinal immobilization.• Initiate transport.• Support ABCs.• Reassess.

Assessing the Airway

• Look for signs of airway compromise:– Two- to three-word dyspnea– Use of accessory muscles– Nasal flaring and use of accessory muscles

in children– Labored breathing

Signs of Airway Obstruction in the Unconscious Patient

• Obvious trauma, blood, or other obstruction

• Noisy breathing such as bubbling, gurgling, crowing, or other abnormal sounds

• Extremely shallow or absent breathing

Assessing Breathing

• Choking

• Rate

• Depth

• Cyanosis

• Lung sounds

• Air movement

Assessing Breath Sounds

High-Flow Oxygen Administration

• Breathing faster than 20 breaths/min• Breathing slower than 12 breaths/min• Breathing too shallow• Decreased level of consciousness• Respiratory distress• Poor skin color

Positioning the Patient

• Position of comfort– Sitting up with feet dangling– High Fowler’s position

• Spinal precautions if possible spinal injury

Assessing the Pulse

• Presence• Rate• Rhythm• Strength

Age Range (beats/min)

Infant: 1 month to 1 year 100 to 160

Toddler: 1 to 3 years 90 to 150

Preschool-age: 3 to 6 years 80 to 140

School-age: 6 to 12 years 70 to 120

Adolescent: 12 to 18 years 60 to 100

Normal Pulse Rates in Infants and Children

Assessing and Controlling External Bleeding

• Assess after clearing the airway and stabilizing breathing.

• Look for blood flow or blood on floor/clothes.• Controlling bleeding

– Direct pressure– Elevation– Pressure points

Assessing Perfusion

• Color• Temperature• Skin condition• Capillary refill

Priority Patients

• Difficulty breathing• Poor general

impression• Unresponsive with no

gag reflex• Severe chest pain• Signs of poor perfusion

• Complicated childbirth• Uncontrolled bleeding• Responsive but unable

to follow commands• Severe pain• Inability to move any

part of the body

Transport Decision

• Patient condition• Availability of advanced care• Distance to transport• Local protocols


Goals of the Focused History and Physical Exam

• Understand the circumstances surrounding the chief complaint.

• Obtain objective measurements.• Perform physical exam.

Components of Focused History and Physical Exam

• Medical history• Baseline vital signs• Physical exam

Rapid Physical Exam

• 60-90 second head-to-toe exam

• Performed on:– Significant trauma

patients– Unresponsive

medical patients• Identifies undiscovered

conditions

DCAP-BTLS

• D Deformities

• C Contusions

• A Abrasions

• P Punctures/ Penetrations

• B Burns

• T Tenderness

• L Lacerations

• S Swelling

Components of a Rapid Physical Exam (1 of 3)

• Maintain spinal immobilization while checking patient’s ABCs.

• Assess the head.• Assess the neck.• Apply a cervical spine immobilization collar.


• Assess the chest.

• Assess the abdomen.

• Assess the pelvis.


• Assess all four extremities.

• Roll the patient with spinal precautions.

Focused Physical Exam

• Used to evaluate patient’s chief complaint• Performed on:

– Trauma patients without significant MOI– Responsive medical patients

Head, Neck, and Cervical Spine• Feel head and neck for deformity,

tenderness, or crepitation.• Check for bleeding.• Ask about pain or tenderness.

Chest

• Watch chest rise and fall with breathing.

• Feel for grating bones as patient breathes.

• Listen to breath sounds.

Abdomen

• Look for obvious injury, bruises, or bleeding.

• Evaluate for tenderness and any bleeding.

• Do not palpate too hard.

Pelvis

• Look for any signs of obvious injury, bleeding, or deformity.

• Press gently inward and downward on pelvic bones.

Extremities

• Look for obvious injuries.• Feel for deformities.• Assess

– Pulse– Motor function– Sensory function

Posterior Body

• Feel for tenderness, deformity, and open wounds.

• Carefully palpate from neck to pelvis.• Look for obvious injuries.

Specific Chief Complaints

• Chest pain• Shortness of breath• Abdominal pain• Pain associated with

bones or joints• Dizziness

Significant Mechanism of Injury

• Ejection from vehicle• Death in passenger

compartment• Fall greater than 15'-20'• Vehicle rollover• High-speed collision

• Vehicle-pedestrian collision

• Motorcycle crash• Unresponsiveness or

altered mental status• Penetrating trauma to the

head, chest, or abdomen

Assessment Steps forSignificant MOI

• Rapid trauma assessment• Baseline vital signs• SAMPLE history• Reevaluate transport decision

Assessment Steps for Trauma Patients Without Significant MOI

• Focused assessment• Baseline vital signs• SAMPLE history• Reevaluate transport decision

Responsive Medical Patients

• History of illness• SAMPLE history• Focused assessment• Vital signs• Reevaluate transport decision

Unresponsive Medical Patients

• Rapid medical assessment• Baseline vital signs• SAMPLE history• Reevaluate transport decision


Detailed Physical Exam

• More in-depth exam based on focused physical exam

• Should only be performed if time and patient’s condition allows

• Usually performed en route to the hospital

Performing the DetailedPhysical Exam (1 of 10)

• Visualize and palpate using DCAP-BTLS.• Look at the face.• Inspect the area around the eyes and eyelids.• Examine the eyes.


• Pull the patient’s ear forward to assess for bruising.

• Use the penlight to look for drainage or blood in the ears.


• Look for bruising and lacerations about the head.

• Palpate the zygomas.


• Palpate the maxillae.

• Palpate the mandible.


• Assess the mouth and nose for obstructions and cyanosis.

• Check for unusual odors.


• Look at the neck.

• Palpate the front and the back of the neck.

• Look for distended jugular veins.


• Look at the chest.

• Gently palpate over the ribs.


• Listen for breath sounds.• Listen also at the bases and

apices of the lungs.


• Look at the abdomen and pelvis.

• Gently palpate the abdomen.

• Gently compress the pelvis.


• Gently press the iliac crests.

• Inspect all four extremities.

• Assess the back for tenderness or deformities.


Ongoing Assessment

• Is treatment improving the patient’s condition?

• Has an already identified problem gotten better? Worse?

• What is the nature of any newly identified problems?

Steps of the Ongoing Assessment

• Repeat the initial assessment.

• Reassess and record vital signs.

• Repeat focused assessment.

• Check interventions.

Review

1. Assessment of an unconscious patient's breathing begins by:

A. inserting an oral airway.

B. manually positioning the head.

C. assessing respiratory rate and depth.

D. clearing the mouth with suction as needed.

Review

Answer: B

Rationale: You cannot assess or treat an unconscious patient’s breathing until the airway is patent—that is, open and free of obstructions. Manually open the patient’s airway (eg, head tilt-chin lift, jaw-thrust), use suction as needed to clear the airway of blood or other liquids, insert an airway adjunct to assist in maintaining airway patency, and then assess the patient’s respiratory effort.

Review1. Assessment of an unconscious patient's breathing begins

by:

A. inserting an oral airway.Rationale: You insert an airway adjunct to assist in maintaining

airway patency after the head-tilt-chin-lift.B. manually positioning the head.Rationale: Correct answerC. assessing respiratory rate and depth.Rationale: After the airway is opened and suctioned, then

determine the patient’s respiratory effort by assessing the respiratory rate and depth.

D. clearing the mouth with suction as needed. Rationale: This is done after attempting to open the airway with

proper positioning.

Review

2. You arrive at the scene of an “injured person.” As you exit the ambulance, you see a man lying on the front porch of his house. He appears to have been shot in the head and is lying in a pool of blood. You should:

A. immediately assess the patient.B. proceed to the patient with caution.C. quickly assess the scene for a gun.D. Retreat to a safe place and wait for law

enforcement to arrive.

Review

Answer: D

Rationale: Your primary responsibility as an EMT-B is to protect yourself. Prior to entering any scene, you must assess for potential dangers. In cases where violence has occurred, you must retreat to a safe place and wait for law enforcement personnel to arrive.

Review2. You arrive at the scene of an “injured person.” As you exit the

ambulance, you see a man lying on the front porch of his house. He appears to have been shot in the head and is lying in a pool of blood. You should:

A. immediately assess the patient.Rationale: You must wait until the scene is safe.B. proceed to the patient with caution.Rationale: You must wait until the scene is safe.C. quickly assess the scene for a gun.Rationale: This is the responsibility of law enforcement.D. Retreat to a safe place and wait for law enforcement to

arrive.Rationale: Correct answer

Review

3. During the scene size-up, you should routinely determine all of the following, EXCEPT:

A. the mechanism of injury or nature of illness.

B. the ratio of pediatric patients to adult patients.

C. whether or not additional resources are needed.

D. if there are any hazards that will jeopardize safety.

Review

Answer: B

Rationale: Components of the scene size-up—after taking BSI precautions—include determining if the scene is safe for entry, determining the mechanism of injury or nature of illness, determining the number of patients, and determining if additional resources are needed at the scene.

Review

3. During the scene size-up, you should routinely determine all of the following, EXCEPT:

A. the mechanism of injury or nature of illness.

Rationale: This is part of the scene size-up.

B. the ratio of pediatric patients to adult patients.

Rationale: Correct answer

C. whether or not additional resources are needed.


D. if there are any hazards that will jeopardize safety.


Review

4. Findings such as inadequate breathing or an altered level of consciousness should be identified in the:

A. initial assessment.

B. focused physical exam.

C. ongoing assessment.

D. detailed physical exam.

Review

Answer: A

Rationale: The purpose of the initial assessment is to identify and manage any life threats to the patient, such as inadequate breathing, an altered level of consciousness, or severe hemorrhage.

Review

4. Findings such as inadequate breathing or an altered level of consciousness should be identified in the:

A. initial assessment.


B. focused physical exam.

Rationale: The focused physical exam will help EMS to identify specific problems, based upon the patient’s chief complaint.

C. ongoing assessment.

Rationale: This is performed during transport and will provide information on other clues on how the current care plan is working.

D. detailed physical exam.

Rationale: This will provide EMS with more information about the nature of the patient’s problem.

Review

5. A semiconscious patient pushes your hand away when you pinch his earlobe. You should describe his level of consciousness as:

A. alert.

B. unresponsive.

C. responsive to painful stimuli.

D. responsive to verbal stimuli.

Review

Answer: C

Rationale: Semiconscious patients are not alert, nor or they unresponsive. The fact that the patient pushes your hand away when you pinch his earlobe indicates that he is responsive to painful stimuli. If he opens his eyes or responds when you speak to him, he would be described as being responsive to verbal stimuli.

Review

5. A semiconscious patient pushes your hand away when you pinch his earlobe. You should describe his level of consciousness as:

A. alert.

Rationale: This is when the patient’s eyes open spontaneously as you approach.

B. unresponsive.

Rationale: This is when the patient does not respond to any stimulus.

C. responsive to painful stimuli.


D. responsive to verbal stimuli.

Rationale: This is when the patient’s eyes open with verbal stimuli and tries to respond.

Review

6. Which of the following is considered a significant mechanism of injury for a child?

A. Bicycle collision

B. Fall from higher than 5'

C. Slow-speed vehicle collision

D. Abrasion injury of the abdomen

Review

Answer: A

Rationale: Significant mechanisms of injury for a child include falls from greater than 10’, bicycle collisions, and medium-speed vehicle collisions, among others.

Review

6. Which of the following is considered a significant mechanism of injury for a child?

A. Bicycle collision


B. Fall from higher than 5‘

Rationale: A significant mechanism of injury is a fall greater than 10 feet or 2 to 3 times the child’s height.

C. Slow-speed vehicle collision

Rationale: A significant mechanism of injury occurs with speeds greater than 20 miles per hour.

D. Abrasion injury of the abdomen

Rationale: An abrasion is the result of an injury.

Review

7. An unresponsive patient with a possible spinal injury and inadequate breathing should be placed:

A. on a backboard and given assisted ventilations.

B. in a PASG and given oxygen via nonrebreathing mask.

C. in a semisitting position and given assisted ventilations.

D. in the recovery position and given oxygen via nonrebreathing mask.

Review

Answer: A

Rationale: Use spinal motion restriction precautions (eg, backboard, cervical collar, lateral immobilization of the head) on any patient with a possible spinal injury. If the patient is breathing inadequately (eg, shallow [reduced tidal volume] breathing, fast or slow rate), assist ventilations with a bag-mask device and 100% oxygen.

Review7. An unresponsive patient with a possible spinal injury and

inadequate breathing should be placed:

A. on a backboard and given assisted ventilations.Rationale: Correct answerB. in a PASG and given oxygen via nonrebreathing mask.Rationale: Inadequate breathing is always managed with

assisted ventilations via a bag-mask device.C. in a semisitting position and given assisted ventilations.Rationale: Spinal injuries are secured to a long backboard.D. in the recovery position and given oxygen via nonrebreathing

mask.Rationale: Spinal injuries are not placed on the side but supine

on a long backboard and breathing is assisted in this scenario.

Review

8. Which of the following would you NOT detect during your general assessment of a patient?

A. Cyanosis

B. Gurgling respirations

C. Severe bleeding

D. Rapid heart rate

Review

Answer: D

Rationale: The general impression is what you first notice as you approach the patient, but before physical contact with the patient is made. It is what you see, hear, or smell. A rapid heart rate (tachycardia) would not be detected until you actually perform the initial assessment; you cannot see, hear, or smell tachycardia.

Review

8. Which of the following would you NOT detect during your general assessment of a patient?

A. Cyanosis

Rationale: You can see cyanosis during the general assessment.

B. Gurgling respirations

Rationale: You can hear gurgling during the general assessment.

C. Severe bleeding

Rationale: You can see bleeding during your general assessment.

D. Rapid heart rate


Review

9. You should call for additional help before you begin to care for patients at a multiple-casualty incident because:

A. a hazardous material may exist.

B. the incident may be the result of terrorism.

C. the patients will die if more help does not arrive quickly.

D. you might get preoccupied with patient care and forget to call.

Review

Answer: D

Rationale: If the call for additional resources is delayed, it is very easy to become involved with patient care. The tendency then is to complete the assessment and treatment before turning to other matters, such as re-evaluating the situation and calling for help. This just delays the needed resources that much longer.

Review

9. You should call for additional help before you begin to care for patients at a multiple-casualty incident because:

A. a hazardous material may exist.

Rationale: This is also part of the scene size-up and scene safety.

B. the incident may be the result of terrorism.

Rationale: This is part of scene size-up and calling for help before providing medical treatment.

C. the patients will die if more help does not arrive quickly.

Rationale: Patients may die during a multiple-casualty incident, but help must be called in before treatment begins.

D. you might get preoccupied with patient care and forget to call.


Review

10. Your initial assessment of an elderly woman who fell reveals an altered level of consciousness and a large hematoma to her forehead. After protecting her spine and administering oxygen, you should:

A. obtain baseline vital signs.B. perform a rapid trauma assessment.C. transport the patient immediately.D. perform a focused exam of her head.

Review

Answer: B

Rationale: If any life-threatening problems are discovered in the initial assessment, they should be addressed immediately. The EMT-B should then perform a rapid trauma assessment (or rapid medical assessment in unresponsive medical patients) to look for other potentially life-threatening injuries or conditions.

Review10. Your initial assessment of an elderly woman who fell reveals

an altered level of consciousness and a large hematoma to her forehead. After protecting her spine and administering oxygen, you should:

A. obtain baseline vital signs.Rationale: This is part of the initial assessment.B. perform a rapid trauma assessment.Rationale: Correct answerC. transport the patient immediately.Rationale: This is determined after the completion of a rapid

trauma assessment.D. perform a focused exam of her head.Rationale: This is completed not only on the head but on the

entire body.

Documents

8: Patient Assessment