Download Unit 2 Patient Assessment

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Occupational First Aid. Fetac Level 5
Unit 2 Patient Assessment
Learners should be able to:
2.1 Describe a primary and secondary survey
Reference: D Limmer, M O’Keefe, E Dickinson; Emergency Care 10th Edition; Pearson,
Prentice Hall 2005
Reference: AAOS 2009: Chapter 2
The assessment steps to discover and treat any life-threatening problems are called the initial
assessment or primary survey. It is always the first element in the total assessment of the
patient:
1. Forming a general impression (immediate assessment of the environment and the
patient’s chief complaint and appearance)
2. Assessing mental status – Alert, Verbal Response, Painful Response, Unresponsive
(and manually stabilizing the patient’s head and neck, when appropriate)
3. Assessing Airway
4. Assessing Breathing
5. Assessing Circulation- pulse, skin, bleeding: If the patient is light-skinned, you can
check pulse and skin at the same time. As you take the radial pulse, note whether the
skin at the wrist is warm, pink, and dry-indicating good circulation-or pale and
clammy (cool and moist) - indicating poor circulation. If your patient is dark-skinned,
you can check the colour of the lips or nail beds, which should be pink.
Know what to look for when injury or sudden illness strikes,
i.
Scene safe
ii.
Shake and shout- check the victim for responsiveness
iii.
For an unresponsive victim have someone call 999
iv.
Open the airway (by head tilt, chin lift)
v.
Look for chest to rise and fall, listen carefully for breathing sounds and feel for air
coming from mouth
If unresponsive and breathing- roll the victim into the recovery position
If unresponsive and not breathing- give 2 normal breaths each lasting one second- if
no response to breaths start CPR
(Correct any immediately life-threatening problems as soon as they are found)
The Secondary Survey
Following the initial assessment and control of any immediate life threats, you will begin a
more thorough assessment of your patient. Two essential elements of this assessment will be
measuring vital signs and taking a medical history. Vital signs are measurable things like
pulse, blood pressure, and respirations. Because they reflect the patient’s condition-and
changes in the patient’s condition- you will take them early and repeat them often.
The medical history includes information about the present medical problem and facts about
the patient that existed before the patient needed first aid. It is called a SAMPLE history
(Signs and Symptoms; Allergies; Medications; Past Medical History; Last oral intake; Events
leading up to the injury or illness). If the victim can speak s/he is responsive and may be able
to tell you what’s wrong. Ask questions about each item to gather important information.
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If the victim is injured do a quick physical exam, using the mneumonics DOTS to help
identify signs and symptoms of injury
Deformity
Open wounds
Tenderness
Swelling
Most victims will be able to tell you where they are injured.
Focus your attention there.
For a victim with multiple injuries such as a pedestrian struck by a car quickly examine the
entire body for DOTS starting at the head and working your way down.
Only apply pressure to areas without pain.
Check:
 Head- check for blood /fluid in ears or nose
 Mouth-is the airway clear?
 Skin- colour, temperature and moisture
 Examine the neck and chest for abnormalities
 Gently squeeze and push down on the abdomen
 Squeeze and push down on the pelvis
 Check each leg and foot
 Ask the victim to move each foot and push against your hand
 Repeat this sequence for each foot and hand
 If you do not suspect spinal injury check the back
2.2 State the normal respiration rates for an adult at rest
Reference: D Limmer, M O’Keefe, E Dickinson; Emergency Care 10th Edition; Pearson,
Prentice Hall 2005
The act of breathing is called respiration. A single breath is considered to be the complete
process of breathing in (called inhalation or inspiration) followed by breathing out (called
exhalation or expiration). For the determination of vital signs, you are concerned with two
factors: rate and quality.
The respiratory rate is the number of breaths a patient takes in one minute. The rate of
respiration is classified as normal, rapid, or slow. The normal respiration rate for an adult at
rest is between 12 and 20 breaths per minute. Keep in mind that age, sex, size, physical
conditioning and emotional state can influence breathing rates. Fear and other emotions
experienced during an emergency can cause an increase in respiratory rate.
Normal Respiratory Rates (Breaths per minute, At rest)
Adult
12 to 20
Above 24:Serious
Below 10:Serious
Respiratory quality: the normal or abnormal (shallow, laboured, or noisy) character of
breathing
Respiratory rhythm: the regular or irregular spacing of breaths
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2.3 List the methods to obtain a breathing rate
Reference: D Limmer, M O’Keefe, E Dickinson; Emergency Care 10th Edition; Pearson,
Prentice Hall 2005
Start counting respirations as soon as you have determined the pulse rate. Many individuals
change their breathing rate if they know someone is watching them breathe. For this reason,
do not move your hand from the patient’s wrist or tell the patient you are counting the
respiratory rate. After you have counted pulse beats, immediately begin to watch the patient’s
chest and abdomen for breathing movements. Count the number of breaths taken by the
patient during 30 seconds and multiply by 2 to obtain the breaths per minute. While counting,
note the rate, quality and rhythm of respiration. Record your results. For example,
“Respirations are 16, normal, and regular”. Record the time of the assessment.
2.4 State the normal pulse rates for an adult at rest
Pulse
The pumping action of the heart is normally rhythmic, causing blood to move through the
arteries in waves, not smoothly and continuously at the same pressure like water flowing
through a pipe. A fingertip held over an artery where it lies close to the body’s surface and
crosses over a bone can easily feel the characteristic “beats” as the surging blood causes the
artery to expand. What you feel is called the pulse. When taking a patient’s pulse, you are
concerned with two factors: rate and quality.
It is essential that you record all vital signs as you obtain them, along with the time at which
you took them.
The pulse rate is the number of beats per minute. The number you get will allow you to
decide if the patient’s pulse rate is normal, rapid, or slow.
Pulse rates vary among individuals. Factors such as age, physical condition, degree of
exercise just completed, medications or other substances being taken, blood loss, stress, and
body temperature all have an influence on the rate. The normal rate for an adult at rest is
between 60 and 100 beats per minute. Any pulse rate above 100 beats per minute is rapid,
while a rate below 60 beats per minute is slow. An athlete may have a normal at-rest pulse
rate between 40 and 50 beats per minute. This is a slow pulse rate, but it is not an indication
of poor health. The same pulse rate in a non-athletic or elderly person may indicate a serious
condition. You should be concerned about the typical adult whose pulse rate stays above 100
or below 60 beats per minute.
Pulse Quality
Two factors determine pulse quality: rhythm and force. Pulse rhythm reflects regularity. A
pulse is said to be regular when intervals between beats are constant. When the intervals are
not constant, the pulse is irregular.
Pulse force refers to the pressure of the pulse wave as it expands the artery. Normally, the
pulse should feel as if a strong wave has passed under your fingertips. This is a strong or full
pulse. When the pulse feels weak and thin, the patient has a thready pulse.
2.5 List the methods to obtain a pulse rate.
During the determination of vital signs, you should initially find a radial pulse in patients
1year of age and older. This is the wrist pulse, named for the radial artery found on the lateral
(thumb) side of the forearm. In an infant 1 year old or less, find the brachial pulse in the
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upper arm rather than the radial pulse. If you cannot measure the pulse on one arm, try the
pulse of the other arm. When you cannot measure the radial or brachial pulse, use the carotid
pulse, felt along the large carotid artery on either side of the neck. Excessive pressure on the
carotid artery can result in slowing of the heart, especially in older patients. If you have
difficulty finding the carotid pulse on one side, try the other side, but do not assess the carotid
pulses on both sides at the same time.
In order to measure a radial pulse, find the pulse site by placing your first three fingers on the
thumb side of the patient’s wrist just above the crease (toward the shoulder). Do not use your
thumb. It has its own pulse that may cause you to measure your own pulse rate. Slide your
fingertips toward the thumb side of the patient’s wrist, keeping one finger over the crease.
Apply moderate pressure to feel the pulse beats. A weak pulse may require applying greater
pressure. But take care- if you press too hard you may press the artery shut. If you experience
difficulty, try the patient’s other arm.
2.6 Outline the methods to assess the skin colour, temperature, condition
The colour, temperature and condition of the skin can provide valuable information about
your patient’s circulation. There are many blood vessels in the skin. Since the skin is not as
important to survival as some of the other organs (like the heart and brain) the blood vessels
of the skin will receive less blood when a patient has lost a significant amount of blood or the
ability to adequately circulate blood. Constriction (growing smaller) of the blood vessels
causes the skin to become pale. For this reason, the skin can provide clues to blood loss as
well as a variety of other conditions.
The best places to assess skin colour in adults are the nail beds, the inside of the cheek and
the inside of the lower eyelids. Tiny blood vessels called capillaries are very close to the
surface of the skin in all of these places, so changes in the blood are quickly reflected at these
sites. They are also more accurate indicators than other sites in adults with dark complexions.
In infants and children, the best places to look are the palms of the hands and the soles of the
feet. In patients with dark skin you can check the lips and nail beds.
Ordinarily, the colour you see in any of these places is pink. Abnormal colours include pale,
cyanotic (blue-grey), flushed (red) and jaundiced (yellow). Pale skin frequently indicates
poor circulation of blood. A common cause of this in the field is loss of blood. Cyanotic skin
is usually a result of not enough oxygen getting to the red blood cells. Flushed skin may be
caused by exposure to heat. Jaundice is a yellowish tint to the skin from liver abnormalities.
An uncommon skin coloration is mottling, a blotchy appearance that sometimes occurs in
patients, especially children, in shock.
2.7 Differentiate between hot, cool and cold skin temperature
To determine skin temperature, feel the patient’s skin with the back of your hand. A good
place to do this is the patient’s forehead. Note if the skin feels normal (warm), hot, cool, or
cold. If the patient’s skin seems cold, then further assess by placing the back of your hand on
the abdomen beneath the clothing. At the same time, notice condition- is the skin dry
(normal), moist, or clammy (both cool and moist)? Look for goose pimples which are often
associated with chills. Many patient problems are exhibited by changes in skin temperature
and condition. Continue to be alert for major temperature differences on various parts of the
body. For example, you may note that the patient’s trunk is warm but his left arm feels cold.
Such a finding can reveal a problem with circulation.
Skin Temperature/Condition
Cool, clammy
Cold, moist
Significance/Possible Causes
Sign of shock, anxiety
Body is losing heat
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Cold, dry
Hot, dry
Hot, moist
Goose pimples accompanied by shivering,
chattering teeth, blue lips, and pale skin
Exposure to cold
High fever, heat exposure
High fever, heat exposure
Chills, communicable disease, exposure to
cold, pain, or fear
2.8 Differentiate between a sign and symptom
Sign: An indication of a patient’s condition that is objective or can be observed by another
person, an indication that can be seen, heard, smelled or felt by the first aider or others.
Symptom: An indication of a patient’s condition that cannot be observed by another person
but rather is subjective, or felt and reported by the patient
2.9 Explain the need to search for additional medical identification
When obtaining he SAMPLE history the search for a medical identification tag is important
to ascertain allergies and pertinent past history and what medications are currently being
taken.
2.10 Outline the reason for forming a general impression of the patient
Forming a general impression helps you to determine how serious the patient’s condition is
and to set priorities for care and transport. It is based on your immediate assessment of the
environment and the patient’s chief complaint and appearance.
The environment can provide a great deal of information about the patient. It frequently gives
clues- to the first aider who looks for them-about the patient’s condition and history. One of
the most important things it can sometimes tell you is what happened. Is there an overturned
ladder, indicating that the patient may have fallen? Has the patient been exposed to a cold
outdoor environment for a long time? Or is there no apparent mechanism of injury, leading
you to presume that the patient has a medical problem rather than trauma (an injury)?
Although one cannot rely completely on the patient’s environment to rule out trauma, when
combined with the chief complaint (eg the patient complaining of symptoms that sound more
like a medical problem than an injury) environmental clues become extremely useful.
The chief complaint is how the patient him/herself would describe (if possible) why aid is
needed.
You form a general impression by looking, listening and smelling. You look for the patient’s
age and sex. You look at the patient’s position to see if it indicates an injury, pain or
difficulty in breathing. You listen for sounds like moaning, snoring, or gurgling respirations.
You sniff the air to detect any smells like hazardous fumes, urine, faeces, vomitus or decay.
2.11 Assess levels of consciousness including using the alert, verbal,pain, unresponsive
(AVPU) scale
Determining the mental status, or level of responsiveness, will usually be easy, since most
patients are alert and responsive, that is, they are awake and will talk and answer questions
sensibly. Some are not awake but will respond to verbal stimuli, such as talking or shouting.
At a more depressed level, the patient will respond only to painful stimuli, such as pinching a
toe or rubbing the sternum briskly. The lowest and most serious status is unresponsiveness,
when the patient will not respond even to a painful stimulus. An easy way to keep these
levels of responsiveness in mind is by remembering the letters AVPU, for alert, verbal
response, painful response and unresponsive.
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2.12 Assess the patient for external bleeding
Check for severe bleeding by quickly scanning for blood up and down the body, for bloodsoaked clothing, or for blood collecting on the ground or floor. If you see severe bleeding,
control it with pressure.
2.13 Outline the airway, cervical spine, breathing and circulation (AcBC) approach to a
trauma victim
1. Form a general impression of patient and patient’s environment
2. Assess patient’s mental status (Intervention : spinal stabilization?)
3. Assess airway (Intervention Perform appropriate manoeuvres to open and maintain
airway- head tilt-chin lift or jaw-thrust)
4. Assess Breathing (Look Listen Feel)
5. Assess for any life-threatening injury
6. Evaluate circulation by taking the patient’s pulse and evaluating skin temperature,
colour and condition
7. In infants and young children also assess circulation by testing capillary refill.
(Interventions: For indications of poor circulation, treat for shock. If no pulse,
perform CPR)
8. Assess for Bleeding (Intervention: Control severe bleeding)
AcBC
Opening the Airway
The airway is the passageway by which air enters or leaves the body. The structures of the
airway are the nose, mouth, pharynx, larynx, trachea, bronchi and lungs.
The procedures for airway evaluation and opening the airway are best carried out with the
patient lying supine (flat on his back). Often you will find a patient already supine in bed.
You can perform airway procedures with the patient in this position. Patients who are found
in positions others than supine or on the ground should be moved to a supine position on the
floor for evaluation.
AcBC
Immobilizing Cervical Spine
Any movement of a trauma (injured) patient before immobilization of the head and spine can
produce serious injury to the spinal cord. If injury is suspected, protect the head and neck as
you position the patient. Airway and breathing, however, have priority over protection of the
spine and must be assured as quickly as possible. If the trauma patient must be moved in
order to open the airway or to provide ventilations, you will probably not have time or access
to a cervical collar or head immobilization device on a stretcher but, instead, will have to
provide as much manual stabilization as possible.
Use the following as indications that head, neck, or spinal injury may have occurred,
especially when the patient is unconscious and cannot tell you what happened:
 Mechanism of injury is one that can cause head, neck or spine injury. For example, a
patient who is found on the ground near a ladder or stairs may have such injuries.
Motor-vehicle collisions are another common cause of head, neck and spine injuries
 Any injury at or above the level of the shoulders indicates that head, neck or spine
injuries may also be present
 Family or bystanders may tell you that an injury to the head, neck or spine has
occurred, or they may give you information that leads you to suspect it.
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Positioning the patient for basic life support
Patients who are found in positions other than supine must be repositioned for evaluation and
treatment and the rescuer must act alone.
1.
2.
3.
4.
Straighten the legs and position the closer arm above the patient’s head
Then grasp under the distant armpit
Cradle the head and neck, and move the patient as a unit onto his side.
Move the patient onto his back and reposition the extended arm.
AcBC
Assess Breathing
You must open and maintain the airway in the patient who cannot do so for himself. There
are two procedures commonly recommended for opening the airway: the head-tilt, chin-lift
maneuver and the jaw-thrust maneuver, the latter being recommended when head, neck or
spine injury is suspected.
If any indication of head, neck or spine injury is present, DO NOT USE THE HEADTILT, CHIN-LIFT MANOEUVRE. (USE THE JAW-THRUST MANOEUVRE
INSTEAD.) Remember that any unconscious and many conscious trauma patients may
be suspected of having an injury to the head, neck or spine.
Head-Tilt, Chin-Lift Manoeuvre
The head-tilt, chin-lift manoeuvre provides for the maximum opening of the airway. It is
useful on patients who are in need of assistance in maintaining an airway or breathing. It is
one of the best methods for correcting obstructions caused by the tongue.
To perform the head-tilt, chin-lift manoeuvre, follow the steps listed below:
i.
Once the patient is supine, place one hand on the forehead and place the fingertips
of the other hand under the bony area at the centre of the patient’s lower jaw
ii.
Tilt the head by applying gentle pressure to the patient’s forehead
iii.
Use your fingertips to lift the chin and to support the lower jaw. Move the jaw
forward to a point where the lower teeth are almost touching the upper teeth. Do
not compress the soft tissues under the lower jaw, which can obstruct the airway.
iv.
Do not allow the patient’s mouth to be closed. To provide an adequate opening at
the mouth, you may need to use the thumb of the hand supporting the chin to pull
back the patient’s lower lip. Do not insert your thumb into the patient’s mouth (to
avoid being bitten).
Jaw-Thrust Manoeuvre
The jaw-thrust manoeuvre is most commonly used to open the airway of an unconscious
patient with suspected head, neck or spine injury or unknown mechanism of injury.
1. Carefully keep the patient’s head, neck and spine aligned, moving him as a unit as you
place him in the supine position.
2. Kneel at the top of the patient’s head. For long-term comfort it may be helpful to rest your
elbows on the same surface as the patient’s head.
3. Carefully reach forward and gently place one hand on each side of the patient’s lower jaw,
at the angles of the jaw below the ears.
4. Stabilize the patient’s head with your forearms.
5. Using your index fingers, push the angles of the patient’s lower jaw forward.
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6. You may need to retract the patient’s lower lip with your thumb to keep the mouth open
7. Do not tilt or rotate the patient’s head.
The purpose of the Jaw-Thrust Manoeuvre is to open the airway without moving the head or
neck.
Breathing: Patient with Suspected Spine injury:
 Position yourself directly above (at the top of) the patient’s head
 Apply the mask to the patient. Use the bridge of the nose as a guide for correct
position
 Place the thumb sides of your hands along the mask to hold it firmly on the face
 Use your remaining fingers to lift the angle of the jaw. Do not tilt the head
backward.
 While lifting the jaw squeeze the mask with your thumbs and fingers to achieve a
seal.
 Give slow full breaths into the one way valve on the mask.
AcBC
Circulation
Adult: Assess skin, radial pulse (normal 60-100), bleeding. If cardiac arrest, perform CPR.
Treat appropriately for bleeding (PEEPS) and shock.
Children: Assess skin, radial pulse, bleeding, capillary refill. Remember normal pulse rates
vary for children (11-14years: 60-105; 6-10years:70-110; 3-5years:80-120; 1-3years:80-130)
If cardiac arrest, perform CPR using child techniques. Treat appropriately for bleeding
(PEEPS) and shock.
Infants to one year: Assess skin, brachial pulse (6-12months 80-140; infant 0-5months: 90140; newborn:120-160), bleeding, capillary refill. If cardiac arrest, perform CPR using
particular infant techniques. Treat appropriately for bleeding (PEEPS) and shock.
2.14 Explain how the mechanism of injury may lead to a risk of spinal injury
AAOS 2009: Chapter 9
Road traffic incidents, direct blows, falls from heights, physical assaults and sports injuries
are common causes of spinal injury. Suspect spine injuries in casualties with significant head
injuries, since the two are often associated.
Recognising Spinal Injuries
 The signs of spinal injuries include the following:
 Inability to move arms and/or legs
 Numbness, tingling, weakness, or burning sensation in the arms/or legs
 Deformity (odd-looking angle of the casualty’s head and neck)
 Neck or back pain
2.15 Describe the requirements for an explicit handover between occupational first aiders and
other health care practitioners including documentation as appropriate
CFR Training Manual; PHECC: page 41
The Handover
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Explicit handover between responders/practitioners is essential and will eliminate confusion
regarding the responsibility for care. When practitioners arrive on-scene it is important that
responders do not stop resuscitation efforts, particularly CPR, until requested to do so. A
brief handover report should be given to assist decision making.
Important initial information to include:
 Was the arrest witnessed or unwitnessed?
 How long is CPR being performed?
 Has the patient been defibrilated and if so how many shocks were delivered?
 Is there any known medical condition, particularly heart disease?
Clinical Practice Guidelines (CPGs) are designed to set and maintain standards of prehospital emergency care for practitioners and responders in Ireland. The CPGs are algorithms
or flow charts for specific illness and injuries and often interlink with other CPGs to facilitate
a consistent comprehensive approach for medical and trauma emergencies.
2.16 Demonstrate a primary and secondary survey
Primary: ABC
Secondary: Vital Signs; Head-Toe survey checking DOTS; SAMPLE Assessment
2.17 demonstrate assessment of breathing
Head-Tilt, Chin Lift or Jaw-thrust, Look/Listen/Feel Method
2.18 demonstrate assessment of a pulse
 Radial (wrist) pulse:patients one year of age and older
 Brachial (upper arm) pulse: infant one year or less
 Carotid (large carotid artery on either side of the neck) pulse: if cannot locate first
two. Be careful when palpating a carotid pulse in a patient, excessive pressure on the
carotid artery can result in slowing of the heart, especially in older patients.
In order to measure a radial pulse, find the pulse site by placing your first three fingers on the
thumb side of the patient’s wrist just above the crease (toward the shoulder). Do not use your
thumb. It has its own pulse that may cause you to measure your own pulse rate. Slide your
fingertips toward the thumb side of the patient’s wrist, keeping one finger over the crease.
Apply moderate pressure to feel the pulse beats. A weak pulse may require applying greater
pressure. But take care- if you press too hard you may press the artery shut. If you experience
difficulty, try the patient’s other arm.
2.19 Demonstrate manual in-line stabilisation of the head in a suspected spinal injury
You should apply manual stabilization on first contact with any patient who you suspect may
have an injury to the spine based on mechanism of injury, or history, or signs and symptomsthat is, to virtually any trauma patient.
When you apply manual stabilization, your object is to hold the patient’s head still in a
neutral, in-line position. That is, the head should be facing forward and not turned to either
side nor tilted forward or backward. You must be careful not to pull or twist the patient’s
head but rather to hold it perfectly still and to remind the patient not to try to move it.
If your patient is in another position, for example crumpled on his side adapt the technique as
practical to hold the head in a steady position in line with the spine.
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1. When your patient is sitting up, position yourself just behind the patient and hold the
head by spreading your fingers over the sides of the head and placing your thumbs
behind the ears.
2. When your patient is supine, kneel behind the patient and spread your fingers and
thumbs around the sides of the head to hold it steady.