Download File - Dan Shaw

Patient Assessment
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Outline
• Scene Size-Up
• Patient History
• Initial
Assessment
• Ongoing
Assessment
• Physical
Examination
• Hand-Off Report
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Patient Assessment
• Determining the
problems a
patient is
experiencing
• Goal is to identify
and treat critical
problems
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Scene Size-Up
• First step of patient assessment
– Personal safety
– Safety of scene
– Assessment of Mechanism of Injury (MOI)
or Nature of Illness (NOI)
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Size up this scene
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Personal Safety
• First concern is PPE
– BSI
– Protective clothing
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Size up this scene
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Common hazards
• Unstable vehicles
• Undeployed airbags
• Leaking fluids
• Traffic
• Agitated or violent patient or
bystanders
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Hazardous Materials
• Tractor-trailer crashes, train
derailments, industrial sites, farm
incidents
• Notify HAZMAT team
• Do not approach scene until directed
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Crimes Scenes
and Environment
• Crime Scenes
– Violent crime
– Domestic violence
• Environment
– Slopes, ice, water, etc.
– Weather conditions
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Bystanders
• Often not aware of hazards and may
put themselves at risk
• May also put others at risk
– Smoking in presence of oxygen or spilled
fuel
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Safety First
• If the scene is not safe, and you
cannot make it safe, do not enter
STOP!
• Wait for specially trained rescue
personnel to make scene safe or
bring patient to you
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MOI
• An evaluation of forces that caused
an injury
• May help anticipate injuries
• Systematically survey scene and
question bystanders
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What would you ask or look for?
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items
and derived
Determine
• If patient
assaulted (shot,
beaten, stabbed)
• Weapon used
• Height of fall
• Surface patient
landed on
• Position patient
landed
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Nature of Illness
• What are some
clues to illness?
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Nature of Illness
• Why did patient
call for help?
• What is the
patient’s
complaint?
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Rights
Reserved
Clues to Illness
• Patient confined to bed
• Patient uses walker or cane
• Patient lacks adequate food/shelter
• Patient takes medications
• Other clues?
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Number of Patients
• Incident may involve more than 1 patient
• Must be determined before patient care
• Call for additional resources if needed
• If more than 1 patient, perform triage
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The initial assessment is
performed to identify any
immediate threats to the
patient’s life
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Initial Assessment
• GILT
– General impression / life threatening
• Level of responsiveness
• Checking ABCDEs
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GILT
• Gather information about patient and
patient’s environment
– What is the patient’s position?
– What is the patient’s appearance?
– Any sights/sounds/smells?
– Does it appear to be medical or trauma?
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LOC
• Evaluate level of
consciousness
using the AVPU
– Alert
– Verbal
– Pain
– Unconscious
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Caution!
If trauma,
begin by
stabilizing
patient’s
cervical spine
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Unconscious Patient
• Speak to patient
• If no response
– Shake patient’s
shoulder
– Pinch earlobe or
shoulder
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Infants & Children
• AVPU not a good scale
• Note if interaction
with parents and
actions normal
for age
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A - Airway
• Responsive Patient
– Can patient speak without difficulty?
• Unresponsive Patient
– Perform head-tilt chin-lift/jaw-thrust
– Inspect airway
– Clear airway as needed
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Assess & Treat
If patient’s airway
is not open ….
OPEN IT!
Before moving on
to B - Breathing
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B - Breathing
• Responsive Patient
– Ability to speak without stopping to catch
breath
– Noisy breathing
– Patient position
– Use of accessory muscles
– Rate and depth of ventilations
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B - Breathing
Unresponsive
patient
• Look
• Listen
• Feel
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Assess & Treat
If breathing is absent, too fast, too
slow, too shallow,
Immediately begin ventilations
before moving to C - Circulation
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C - Circulation
• Evaluation of
circulation of
patient’s blood
– Look for major
blood loss
– Assess pulse
– Assess skin
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Check for Blood Loss
• Major external bleeding
– Actively bleeding?
– Pool of blood anywhere?
– Collection of blood in patient clothes/hair?
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Assess & Treat
Control major bleeding
Often times this goes
hand-in-hand with A - Airway
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Assess Pulse - Where?
• Responsive adult
– Radial pulse
• Unresponsive adult
– Carotid pulse
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Assess Pulse - Where?
• Responsive child
– Radial or brachial pulse
• Unresponsive child
– Carotid or femoral pulse
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Assess Pulse - Where?
• Infant
– Brachial pulse
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Assess Pulse
Determine
• Presence or
absence
• Rate
• Strength
• Regularity
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Assess & Treat
If no pulse,
Immediately begin
chest compressions
before moving to D - Disability
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Assess Skin
• Color
• Temperature
• Moisture
• Inadequate circulation causes pale,
cool, clammy skin
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D - Disability
• Assessment of brain function
• Use Glasgow Coma Scale (GCS)
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Glasgow Coma Scale
Eye Opening
Spontaneous
To Voice
To Pain
None
4
3
2
1
Verbal Response
Oriented
Confused
Inappropriate Words
Incomprehensible Words
None
5
4
3
2
1
Motor Response
Obeys Command
Localizes Pain
Withdraw (pain)
Flexion (pain)
Extension (pain)
None
6
5
4
3
2
1
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E – Expose / Environment
• Expose the patient’s body as needed
or appropriate to assess for injury or
illness
• Consider the environment and keep
the patient warm
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Make a decision!
• Is the patient critical?
• Is the patient non-critical?
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What is critical?
• Any life-threatening problems
identified in the ABCDEs!
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Communicate
and Ask Questions
• Helps determine
– Patient’s age and sex
– Chief complaint
– Level of responsiveness
– Status of airway and breathing
– Status of circulation and disability
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Vital Signs
• Respiratory Rate
– Note depth, regularity, and effort
• Heart Rate
– Note location, regularity, and strength
• Blood Pressure
– Auscultated vs. palpated
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Physical Examination (PE)
• Begins once life-threatening
problems addressed
• Purpose is locating and beginning
management for signs and
symptoms of injury and illness
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Take Note!
• May not perform
detailed PE if
life-saving care
still required
• Not all patients
will require all
steps of a
detailed PE
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Physical Examination
• Inspection
– Look for signs
of illness or
injury
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Physical Examination
• Palpation
– Feel for signs
of illness or
injury
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Systematic and Orderly
• Often done “head to toe”
• Assess all body areas for DOTS
– D = Deformities
– O = Open injuries
– T = Tenderness
– S = Swelling
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Physical Examination
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• Listen to lung
sounds
Physical Examination
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• Look for medical
alert tags
Patient History
• Take patient history either before,
after, or during physical examination
– Depends on situation
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• Begin with
patient
• If patient can’t
answer
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– Ask family
members
– Ask bystanders
SAMPLE History
S – Signs and symptoms
– May also ask S – Social drugs
A – Allergies
M – Medications
P – Past history (medical / surgical)
L – Last oral intake
E – Events leading to injury or illness
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Signs and Symptoms
A sign is a finding you can hear, see,
feel or measure
A symptom is something a patient
describes
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Ask Questions …
• Can you describe the problem?
• What kind of symptoms?
• What makes the symptoms
better/worse?
• When did the symptoms start?
• How long have you had problem?
• Anything like this happen before?
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A - Allergies
• Medications
• Foods
• Substances in
environment
• Any medical
alert tags?
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M - Medications
• Prescription
medications
• Over-the-counter
medications
• Another person’s
medications
• Has patient recently
stopped taking any
medications
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P – Past History
• Are you seeing physician for
anything?
• Ever been hospitalized?
• Any medical problems?
• Any pertinent surgeries?
• Any significant injuries?
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L – Last Oral Intake
• When did you last eat or drink?
• What was it?
• How much?
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E – Events leading up to
injury or illness
• What were you doing when the
problem started?
• Were there any other symptoms at
that time?
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Ongoing Assessment
• Assessment doesn’t end after
physical examination and patient
history
• Continue to reassess patient until
additional help arrives
– Frequency depends on patient’s condition
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What do I Reassess?
•
•
•
•
Airway
Breathing
Circulation
Disability (mental status)
– GCS
• Reassure the patient while waiting
for help
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When EMS Unit Arrives
Provide:
• Patient age and
sex
• Chief complaint
• Assessment and
history findings
• Summary of care
provided
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Summary
• Initial assessment provides a general
impression of the patient’s condition
– Correct life-threats during the initial
assessment
• Other assessment activities help
provide clues to the nature of illness
or injury
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Questions?
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