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01/09/2013
1
Chapter 13
Patient Assessment
Copyright ©2010 by Pearson Education, Inc.
All rights reserved.
Prehospital Emergency Care, Ninth Edition
Joseph J. Mistovich • Keith J. Karren
Objectives
1. Define key terms introduced in this chapter.
2. Explain the importance of developing a systematic
patient assessment routine and list the four main
components of the patient assessment (slides 26, 28,
85, 209).
3. List the steps of the scene size-up (slides 26-27).
4. State the main purpose of the primary assessment and
list the steps of the primary assessment (slides 28-30).
5. Explain how forming and revising a general impression
of the patient spans the entire patient assessment
process (slides 31-32).
6. Determine if a patient is injured or ill and obtain the
chief complaint (slides 33-36).
Objectives
7. Identify immediate life threats during the general
impression (slides 37-38).
8. Given a variety of patient scenarios, differentiate those
who do and do not need spinal stabilization,
demonstrate how to establish in-line stabilization, and
demonstrate patient positioning for assessment (slides
39-42).
9. Using the AVPU method, assess and document the
level of responsiveness (slides 43-56).
10. Determine airway status in responsive patients and
those with an altered mental status, demonstrate
methods of establishing and maintaining an open
airway, and recognize indications of partial airway
occlusion (slides 57-65).
01/09/2013
2
Objectives
11. Assess the rate and quality of breathing; determine if
the patient has absent, inadequate or adequate
breathing; provide positive pressure ventilation in the
patient with absent or inadequate breathing; and
provide oxygenation as determined by the SpO2 level
in the patient who is breathing adequately (slides 66-
74).
12. Assess the circulation to include assessing the pulse,
identifying and controlling major bleeding, and
assessing perfusion through skin color, temperature,
and condition and capillary refill, and recognize and
begin treatment for shock (slides 75-81).
Objectives
13. Discuss establishing patient priorities by evaluating
critical findings to the airway, breathing, or circulation to
determine if a patient is unstable and a candidate for
rapid secondary assessment and immediate transport
to the hospital (slides 82-83).
Objectives
14. Describe performing the secondary assessment using
an anatomical approach, including steps for assessing
the following (slides 89-105): a. Head
b. Neck
c. Chest
d. Abdomen
e. Pelvis
f. Lower extremities
g. Upper extremities
h. Posterior body
15. Describe performing the secondary assessment using
a body systems approach (slides 106-107).
01/09/2013
3
Objectives
16. Summarize assessment of the vital signs during the
secondary assessment (slides 108-109).
17. Discuss obtaining a history during the secondary
assessment, including use of the SAMPLE and
OPQRST mnemonics (slides 110-112).
18. List the sequence in which the steps of the secondary
assessment are generally performed for a trauma
patient and define the following types of physical exam
that can be chosen for a trauma patient (slides 113-
114): a. Rapid secondary assessment for a trauma patient
b. Modified secondary assessment for a trauma patient
Objectives
19. List the mechanisms of injury that have a high
incidence of producing critical trauma and the special
considerations for infants and children (slides 115-118).
20. For the trauma patient with a significant mechanism of
injury, discuss how to continue spinal stabilization,
reasons to consider requesting advanced life support,
and reasons to reconsider transport decisions (slides
120-125).
21. Explain how to use the Glasgow Coma Scale (GCS) to
rank the patient’s level of consciousness and how to
interpret the resulting GCS score (slides 126-127).
Objectives
22. Discuss how to conduct a rapid secondary assessment
for a trauma patient with significant mechanism of
injury, altered mental status, multiple injuries, or critical
finding (unstable patient) (slides 128-151).
23. Discuss critical (unstable) findings, possibilities, and
emergency care for the trauma patient associated with
assessment of the head, neck, chest, abdomen, pelvis,
extremities, posterior body, or baseline vital signs
(slides 152-155).
24. Explain the purpose and elements of the trauma score
(slides 156-157).
01/09/2013
4
Objectives
25. Discuss how to conduct a modified secondary
assessment for a trauma patient with no significant
mechanism of injury, altered mental status, multiple
injuries, or critical finding (stable patient) (slides 158-
162).
26. Explain circumstances when you should perform a
complete, rather than a modified, secondary
assessment on a trauma patient with no significant
mechanism of injury (slides 163-164).
Objectives
27. Name the key differences in the secondary
assessment for the responsive medical patient versus
the unresponsive medical patient with regard to (slides
165-166): a. Sequence of steps
b. Appropriate type of physical exam (modified or rapid)
28. Explain how to conduct a secondary assessment for a
medical patient who is not alert or is disoriented, is
responding only to verbal or painful stimuli, or is
unresponsive (slides 167-192).
Objectives
29. Discuss critical (unstable) findings, possibilities, and
emergency care for the medical patient with an altered
mental status associated with assessment of the head,
neck, chest, or pelvic region (slides 193-194).
30. Explain how to conduct a secondary assessment for a
medical patient who is alert and oriented (slides 195-
207).
31. Explain the purposes of reassessment (slides 208-
210).
32. Explain how to conduct and to complete the
reassessment (slides 211-235).
01/09/2013
5
Multimedia Directory
Slide 30 Initial Assessment Video
Slide 88 Detailed Physical Exam Video
Slide 97 Abdominal Assessment Techniques Video
Slide 112 Assessment of Pain Video
Slide 217 Reassessment Video
Topics
Section 1 – Scene Size-Up
Section 2 – Primary Assessment
Form a General Impression of the Patient
Assess Level of Consciousness (Mental Status)
Assess the Airway
Assess Breathing
Assess Circulation
Establish Patient Priorities
Topics
Section 3 – Secondary Assessment
Overview of Secondary Assessment: Anatomic
and Body Systems Approaches, Baseline Vital
Signs, and History
Secondary Assessment: Trauma Patient
Reevaluate the Mechanism of Injury
Rapid Secondary Assessment: Trauma Patient
with Significant Mechanism of Injury, Altered
Mental Status, Multiple Injuries, or Critical
Finding (Unstable)
01/09/2013
6
Topics
Modified Secondary Assessment: Trauma
Patient with NO Significant Mechanism of Injury,
Altered Mental Status, Multiple Injuries, or
Critical Finding (Stable)
Secondary Assessment: Medical Patient
Medical Patient Who Is Not Alert or Is
Disoriented, Is Responding Only to Verbal or
Painful Stimuli, or Is Unresponsive
Responsive Medical Patient Who Is Alert and
Oriented
Topics
Section 4 – Reassessment
Purposes of the Reassessment
Repeat the Primary Assessment
Complete the Reassessment
CASE STUDY
#1
Trauma Patient
Dispatch
01/09/2013
7
EMS Unit 74
Respond to Newton Drive, Greenway Apartments, Building 24 for an unresponsive
patient with an unknown problem. Police are at the scene.
Time out 1512
Upon Arrival
• Adult male lying supine below a two-story fire-
escape ladder
• Police on scene advise they were called for a
domestic incident
• Neighbors heard fighting and gunfire
How would you proceed with the assessment of this patient?
01/09/2013
8
CASE STUDY
#2
Medical Patient
Dispatch
EMS Unit 74
Respond to 33 East Sassafras Street for a
patient with an unknown problem. Daughter
made the call.
Time out 1623
• Arrive at a well-kept home in a quiet neighborhood
• A middle-aged woman hurries out to meet you
• “It’s my mother,” she says. “She can’t seem to
catch her breath.”
Upon Arrival
01/09/2013
9
How would you proceed with the assessment of this patient?
Back to Topics
Section 1 – Scene
Size-Up
Steps of the
Scene Size-Up • Standard
Precautions
• Scene safety
• Mechanism of
injury or nature
of illness
• Number of
patients
• Need for
additional
resources Back to Objectives
01/09/2013
10
Section 2– Primary
Assessment
Back to Topics
Steps of the
Primary
Assessment
• Form general impression of the patient
• Assess level of consciousness
• Assess the airway • Assess breathing • Assess circulation • Establish patient
priorities Back to Objectives
Return to Directory
Click here to view a video on the topic of initial assessment.
Initial Assessment
01/09/2013
11
Form a General
Impression of the
Patient
Back to Topics
• First impression
• Stable or unstable
• Chief complaint
(© Mark C. Ide) Back to Objectives
Determine If the Patient Is
Injured or Ill
Back to Objectives
01/09/2013
12
• Injured versus ill
• Blunt trauma
• Penetrating trauma
• Clues in environment
Obtain the Chief Complaint
• Chief complaint
• Original complaint may not be chief complaint
• People on scene may help for unresponsive patients
01/09/2013
13
Identify Immediate Life
Threats during the General
Impression
Back to Objectives
Those that you identify as you
approach
Treat obvious life threats.
Establish In-Line
Stabilization
Back to Objectives
01/09/2013
14
• For suspected spine injury
• Neutral in-line position
• Maintain until you immobilize patient on backboard
Position the Patient for
Assessment
• If the patient is prone, roll him to supine for better assessment
• Establish in-line stabilization first if spine injury is suspected
01/09/2013
15
Assess Level of
Consciousness
(Mental Status)
Back to Topics
Assess the Level of
Responsiveness
Back to Objectives
• A – Alert
• V – Verbal
• P – Pain
• U – Unresponsive
01/09/2013
16
Assess the Level of Responsiveness
Alertness and Orientation
Alert
Eyes open and able to speak to you as you approach
Assess the Level of Responsiveness
Responsiveness to
Verbal Stimulus
01/09/2013
17
Verbal
Makes an attempt to respond only
when you speak to him
Assess the Level of Responsiveness
Responsiveness to
Painful Stimulus
• Types of stimuli
• Responses to stimuli Pain
01/09/2013
18
Extension posturing
Flexion posturing
Assess the Level of Responsiveness
Unresponsiveness
• Not responsive to verbal or painful stimuli
• Can lead to airway compromise
Unresponsive
01/09/2013
19
Assess the Level of Responsiveness
Document the Level of
Responsiveness
• Be specific
• Should take a few
seconds to assess
Document
Assess the Airway
Back to Topics
01/09/2013
20
Determine Airway Status
In the Responsive Patient
Back to Objectives
If the patient is alert and talking without difficulty, assume the airway is patent.
Determine Airway Status
In the Unresponsive or
Severely Altered Mental
Status Patient
01/09/2013
21
• High risk of airway occlusion
• EMS must manage
Open the Airway
• Manual maneuvers
• Suction
• Airway adjuncts
• Manual thrusts
• Positioning of patient
01/09/2013
22
Indications of Partial Airway
Occlusion
• Snoring
• Gurgling
• Crowing
• Stridor
Assess Breathing
Back to Topics
01/09/2013
23
Assess Rate and Quality of
Breathing
Look
Back to Objectives
• Inadequate tidal volume
• Abnormal respiratory rate
• Signs of respiratory distress
Look
Assess Rate and Quality of
Breathing
Listen and Feel
01/09/2013
24
• Absent or inadequate breathing
• Adequate breathing
Listen and Feel
Assess Rate and Quality of
Breathing
Oxygen Therapy in the
Patient with Adequate
Breathing
• Based on
patient’s
condition
• NEVER
withhold
oxygen
01/09/2013
25
Assess Rate and Quality of Breathing
Adequate Oxygenation Based
on the SpO2 Reading
• SpO2 greater than 95 percent on room air is indicative of adequate oxygenation
• After stabilizing airway and breathing, move to circulation
Assess Circulation
Back to Topics
01/09/2013
26
Assess the Pulse
Back to Objectives
Determine
• Presence
• Approximate rate
• Strength and regularity
Identify Major Bleeding
01/09/2013
27
• Control major
bleeding only
• Expose
blood-soaked
areas
Assess Perfusion
Assess skin
• Color
• Temperature
• Condition
• Signs of shock
01/09/2013
28
Establish Patient
Priorities
Back to Topics
• Unstable versus
stable
• Rapid transport
versus secondary
assessment on
the scene
Back to Objectives
Back to Topics
Section 3 – Secondary
Assessment
01/09/2013
29
• Physical assessment
• Baseline vital signs
• Patient history
Back to Objectives
Overview of
Secondary
Assessment:
Anatomic and Body
Systems Approaches,
Baseline Vital Signs,
and History
Back to Topics
• Inspection, palpation,
and auscultation
• Life threats should be
managed as found
01/09/2013
30
Return to Directory
Click here to view a video on the topic of a detailed physical exam.
Detailed Physical Exam
Performing the Secondary
Assessment: An Anatomic Approach
Assess the Head
Back to Objectives
• Scalp
• Face
• Ears
• Eyes
• Nose
• Mouth
Head
01/09/2013
31
Performing the Secondary
Assessment: An Anatomic Approach
Assess the Neck
• Cover large lacerations with
occlusive dressings
• Jugular vein distention (JVD)
• Tracheal deviation
Neck
Performing the Secondary
Assessment: An Anatomic Approach
Assess the Chest
01/09/2013
32
• Inspect for
trauma
• Inspect
chest rise
• Palpate
• Auscultate
Chest
Performing the Secondary
Assessment: An Anatomic Approach
Assess the Abdomen
• Inspect
• Palpate
Abdomen
01/09/2013
33
Return to Directory
Click here to view a video on abdominal assessment techniques.
Abdominal Assessment Techniques
Performing the Secondary
Assessment: An Anatomic Approach
Assess the Pelvis
• Bleeding
• Priapism
• Palpation of
pelvic wings
Pelvis
01/09/2013
34
Performing the Secondary
Assessment: An Anatomic Approach
Assess the Lower
Extremities
• Pulses
• Motor function
• Sensation
• Deformity
Lower
Extremities
Performing the Secondary
Assessment: An Anatomic Approach
Assess the Upper
Extremities
01/09/2013
35
• Deformities
• Pulses
• Motor function
• Sensation
Upper
Extremities
Performing the Secondary
Assessment: An Anatomic Approach
Assess the Posterior Body
• If not already
secured to a
backboard, roll the
patient to the side
• Inspect the thorax,
lumbar area,
buttocks and lower
extremities
• Palpate
• Check for deformity
or pain
Assess the
Posterior
Body
01/09/2013
36
Performing the Secondary
Assessment: A Body
Systems Approach
Back to Objectives
• Respiratory
• Cardiovascular
• Neurologic
• Musculoskeletal
Assess Baseline Vital Signs
Back to Objectives
01/09/2013
37
• Breathing
• Pulse
• Skin
• Capillary refill
• Blood pressure
• Pupils
• SpO2
Obtain a History
Back to Objectives
• SAMPLE
• OPQRST
01/09/2013
38
Return to Directory
Click here to view a video on the topic of the assessment of pain.
Assessment of Pain
Secondary
Assessment:
Trauma Patient
Back to Topics
• Rapid secondary assessment
• Modified secondary assessment
Back to Objectives
01/09/2013
39
Reevaluate the
Mechanism of Injury
Back to Topics
Significant Mechanisms
of Injury
Back to Objectives
High Incidence of
Critical Trauma
• Ejection
• Death of an occupant in the same vehicle
• Fall greater than 20 feet
• High speed collision
• Intrusion greater than 12 inches into patient compartment
• Blast injuries
• Deformed steering wheel
01/09/2013
40
Other Significant
Mechanisms for Children
• Fall greater than ten feet or two to three times the height of the child
• Bicycle versus motor vehicle
• Pedestrian versus motor vehicle at medium speed
• Unrestrained child during a MVC
Rapid Secondary
Assessment: Trauma
Patient with
Significant Mechanism
of Injury, Altered
Mental Status, Multiple
Injuries, or Critical
Finding (Unstable)
Back to Topics
Continue Spine Stabilization
Back to Objectives
01/09/2013
41
Until head and body are secured on a backboard
Consider an Advanced Life
Support Request
• Consider ALS but do
not delay transport
• Follow local protocols
01/09/2013
42
Reconsider the Transport
Decision
Don’t be afraid to
upgrade the
transport decision as
the patient’s status
changes.
Reassess Mental Status
Back to Objectives
01/09/2013
43
• Causes of decreased mental status
• Level of orientation
Perform a Rapid Secondary
Assessment
Back to Objectives
• Inspect
• Palpate
• Auscultate
• Listen
• Smell
01/09/2013
44
Perform a Rapid Secondary
Assessment
Assess the Head
Head
• Scalp and
skull
• Face
• Ears
• Pupils
• Nose
• Mouth
Perform a Rapid Secondary
Assessment
Assess the Neck
01/09/2013
45
Neck
• Trauma
• Midline trachea
• Jugular vein distention
Perform a Rapid Secondary
Assessment
Apply a Cervical Spine
Immobilization Collar
Apply a
Cervical Spine
Immobilization
Collar
• Place after assessment of the neck
• Maintain in-line spine immobilization
01/09/2013
46
Perform a Rapid Secondary
Assessment
Assess the Chest
Chest • Expose
• Inspect
• Palpate
• Auscultate
Perform a Rapid Secondary
Assessment
Assess the Abdomen
01/09/2013
47
Abdomen
• Inspect
• Palpate
• Markle test
Perform a Rapid Secondary
Assessment
Assess the Pelvis
Pelvis
• Inspect
• Palpate
01/09/2013
48
Perform a Rapid Secondary
Assessment
Assess the Extremities
Extremities
• Inspect
• Palpate
• Pulses
• Motor
function
• Sensation
Perform a Rapid Secondary
Assessment
Assess the Posterior Body
01/09/2013
49
Posterior Body • Inspect
• Palpate
Assess Baseline Vital Signs
• Breathing
• Pulse
• Skin
• Pupils
• Blood pressure
• Pulse oximetry
01/09/2013
50
Assess Baseline Vital Signs
Blood Glucose Test
Rule out a hypoglycemic episode.
Obtain a SAMPLE History
01/09/2013
51
• Signs/symptoms
• Allergies
• Medication
• Past pertinent history
• Last oral intake
• Events leading to
injury
Prepare the Patient for
Transport
Back to Objectives
• Once immobilized, do
not delay transport
• Limit scene time to ten
minutes or less for
critical trauma
01/09/2013
52
Provide Emergency Care
Life-threatening problems must be
managed prior to transport.
Trauma Score
Back to Objectives
01/09/2013
53
• Respiratory
rate
• Systolic
blood
pressure
• GCS
Back to Topics
Modified Secondary
Assessment: Trauma
Patient with NO
Significant Mechanism
of Injury, Altered
Mental Status, Multiple
Injuries, or Critical
Finding (Stable)
Perform a Modified Secondary
Assessment
Back to Objectives
01/09/2013
54
Focuses on injury site and
surrounding areas only
Obtain Baseline Vital Signs
and SAMPLE History
• Baseline vital signs
• SAMPLE
01/09/2013
55
Perform a Rapid Secondary
Assessment If Indicated
Back to Objectives
If in doubt, conduct a
complete secondary
assessment.
Secondary
Assessment:
Medical Patient
Back to Topics
01/09/2013
56
Signs and symptoms related to a
disease process
Back to Objectives
Medical Patient Who Is
Not Alert or Is
Disoriented, Is
Responding Only to
Verbal or Painful
Stimuli, or Is
Unresponsive
Back to Topics
• Considered critical
• Rapid secondary
assessment
• Prompt transport
• Look for
environmental clues
Back to Objectives
01/09/2013
57
Perform a Rapid Secondary
Assessment for the Medical Patient
Assess the Head
Head • Inspect
• Palpate
• Check pupils
Perform a Rapid Secondary
Assessment for the Medical Patient
Assess the Neck
01/09/2013
58
Neck
• Inspect
• JVD
• Accessory
muscle use (© David Effron, MD)
Perform a Rapid Secondary
Assessment for the Medical Patient
Assess the Chest
Chest • Inspect
• Auscultate
–Crackles
–Wheezing
01/09/2013
59
Perform a Rapid Secondary
Assessment for the Medical Patient
Assess the Abdomen
Abdomen
• Inspect
• Palpate
• Markle test
Perform a Rapid Secondary
Assessment for the Medical Patient
Assess the Pelvic
Region
01/09/2013
60
• Inspect
• Palpate
Pelvis
Perform a Rapid Secondary
Assessment for the Medical Patient
Assess the Extremities
Extremities • Inspect
• CMS
• Palpate
01/09/2013
61
Perform a Rapid Secondary
Assessment for the Medical Patient
Assess the Posterior Body
• Inspect and
palpate for
discoloration,
edema and
tenderness
• Sacral edema
may indicate
congestive heart
failure
Assess the
Posterior
Body
Assess Baseline Vital Signs
01/09/2013
62
• Breathing
• Pulse
• Skin
• Pupils
• Blood pressure
• Pulse oximetry
Assess Baseline Vital Signs
Blood Glucose Test
Rule out a hypoglycemic episode.
01/09/2013
63
Position the Patient
• Place in recovery position
• Have suction available
Obtain a SAMPLE History
01/09/2013
64
Obtain a SAMPLE history from
those available.
Provide Emergency Care
Oxygen via nonrebreather mask or
bag-valve mask if needed
01/09/2013
65
Make a Transport Decision
Back to Objectives
• Manage life threats
• Expedite transport
• Reassess en route
Responsive Medical
Patient Who Is Alert
and Oriented
Back to Topics
01/09/2013
66
Assess Patient Complaints:
OPQRST
Back to Objectives
• Onset
• Provocation
• Quality
• Radiation
• Severity
• Time
Complete the SAMPLE
History
01/09/2013
67
• Complete SAMPLE
history
• Obtain additional
information for
continuance of care
Perform a Modified
Secondary Assessment
• Focused or
complete
• If complaint is
nonspecific, do a
complete
assessment
01/09/2013
68
Assess Baseline Vital Signs
• Assess baseline
vital signs
• Watch for
changes
Provide Emergency Care
01/09/2013
69
• Contact medical direction if necessary
• Maintain a patent airway and ventilation
Make a Transport Decision
• Vital signs every
– Five minutes in
critical
– 15 minutes in
noncritical
• Assess, intervene,
and reassess
01/09/2013
70
Back to Topics
Section 4 –
Reassessment
Purposes of the
Reassessment
Back to Topics
• Detect changes
• Identify missed
injuries
• Adjust care
Back to Objectives
01/09/2013
71
Detect Any Change in
Condition
Back to Objectives
Detect changes
in the patient’s
condition.
Identify Any Missed Injuries
or Conditions
01/09/2013
72
• Possibly find
injuries missed
on scene
• Patient may
complain of new
symptoms
Adjust the Emergency Care
Steps of Reassessment
• Repeat primary assessment
• Reassess and record vital signs
• Repeat secondary assessment
• Check interventions
• Note trends in patient’s condition
01/09/2013
73
Return to Directory
Click here to view a video on the topic of Reassessment.
Reassessment
Repeat the Primary
Assessment
Back to Topics
Reassess Mental Status
01/09/2013
74
• Check speech
patterns
• Assess ability to
obey commands
• Repeat GCS
Reassess the Airway and
Reassess Breathing
• Airway patency
• Adequate breathing
01/09/2013
75
Reassess Circulation
• Pulse
• Bleeding
• Skin
Reestablish Patient
Priorities
01/09/2013
76
Readjust the transport
decision as the patient’s
condition changes.
Complete the
Reassessment
Back to Topics
Reassess and Record Vital
Signs
01/09/2013
77
Record vital signs and the time
they were taken.
Repeat Components of the
Secondary Assessment for
Other Complaints
• Investigate any
new complaints
by the patient
• Readjust
assessment to
include new areas
01/09/2013
78
Check Interventions
• Determine that
interventions
are producing
wanted results
• If not, adjust
treatments
Note Trends in Patient
Condition
01/09/2013
79
Document changes in
the patient’s condition:
better or worse.
CASE STUDY
Follow-Up
CASE STUDY
#1
Trauma Patient
Follow-Up
Primary Assessment
• Shirt front, left pants leg soaked in
blood
• Skin is pale, cool, and clammy
• Right lower leg severely deformed
• Responds to painful stimuli only
• Chest is barely rising and falling
CASE STUDY
01/09/2013
80
Primary Assessment
• Insert OPA and BVM
• Gunshot wound to left anterior chest
CASE STUDY
Secondary Assessment
• Apply cervical collar; in-line stabilization
• Decreased breath sounds on the left side
of chest
• Log rolled onto backboard
• BP: 70/50 mmHg; PERRL; HR: 136 per
minute; RR: six (now ten per minute with
BVM)
CASE STUDY
Reassessment
• Reassess interventions and patient’s vital
signs every five minutes
• Radio hospital
• No change in patient’s condition
• Upon arrival, give oral report, complete
written report, and prep ambulance for
next call
CASE STUDY CASE STUDY
01/09/2013
81
CASE STUDY
#2
Medical Patient
Follow-Up
CASE STUDY
#2
Primary Assessment
• Mrs. Ortega is a 72-year-old female
• Speaking in short sentences
• Seated in tripod position
• Apply nonrebreather mask at 15 lpm
• Skin pink, warm, and dry
• Rapid radial pulse
CASE STUDY
Secondary Assessment
• Symptoms started this morning and
worsened
• No allergies
• Medications relate to history of
emphysema
• Last oral intake was lunch
CASE STUDY
01/09/2013
82
Secondary Assessment
• No unusual events
• BP: 120/90 mmHg; P: 100; RR: 28;
SpO2: 88 percent
• Hear wheezing without a
stethoscope
CASE STUDY
Reassessment
• Reassess vital signs every 15
minutes
• Call hospital
• Note no changes en route
• Give oral report to staff
• Finish care report
• Clean ambulance
CASE STUDY
• 23-year-old male who fell ~ 20 feet from a
balcony at a concert
• Bystanders state he was talking and
moaning right after fall; now won’t respond
Physical exam:
• Patient is not alert
• Blood is coming from his mouth and ears
• Left arm is angulated, obviously fractured
Critical Thinking Scenario 1
01/09/2013
83
1. What would be your first immediate
action when you arrive at the patient?
2. What assessment should you conduct
first?
3. What are the components of that
assessment and in what order would you
perform them?
4. What life threats would you assess for
and how would you manage them?
Critical Thinking Questions
5. What injuries should you suspect in this
patient?
6. What baseline vital signs would you
assess?
7. Would you perform a rapid secondary
assessment or a modified secondary
assessment?
8. What does the change in his mental
status indicate?
Critical Thinking Questions
9. When would you transport?
10.How would you prepare the patient for
transport?
11.What would you do while en route to the
medical facility?
Critical Thinking Questions
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84
• 78-year-old female with difficulty breathing
• Daughter states patient has a heart
condition and hasn’t been feeling well for
two days
• She thought her mother was napping, went
to wake her, and she did not respond
• Patient is supine on the couch, extremely
pale and cyanotic
• Patient presents with snoring respirations
Critical Thinking Scenario 2
1. Do you suspect she is a trauma or
medical patient?
2. What would be your first immediate
action when you arrive at the patient?
3. What assessment should you conduct
first?
4. What are the components of that
assessment and in what order would you
perform them?
Critical Thinking Questions
5. What life threats are you assessing for
and how would you manage them?
6. Would you collect a SAMPLE history first
or do a medical assessment?
7. Would you perform a rapid secondary
assessment or a modified secondary
assessment?
8. How would you collect a SAMPLE
history?
Critical Thinking Questions
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85
9. What does the mental status possibly
indicate?
10.What would you expect the SpO2 reading
to be?
11.When would you transport?
12.How would you prepare the patient for
transport?
13.What would you do while en route to the
medical facility?
Critical Thinking Questions
Reinforce and Review
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