Download Principles of Assessment for EMS by: Bob & Kirsten Elling

Principles of Patient Assessment
in EMS
By:
Bob Elling, MPA, EMT-P
&
Kirsten Elling, BS, EMT-P
Chapter 12 – Focused History &
Physical Exam of the Respiratory
Patient
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Objectives
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Describe how and when the FH and PE of
a patient with a respiratory complaint are
integrated into the patient assessment
algorithm.
List some of the common respiratory chief
complaints.
Discuss the importance of quickly
obtaining pertinent medical information
about the patient with respiratory distress.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Objectives
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(continued)
List examples of relevant information the
EMS provider needs to obtain in the
focused history of the patient with
respiratory distress.
Describe physical findings about the
patient’s ability to speak that would
indicate signs of mild, moderate and
severe respiratory distress.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Objectives
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(continued)
Describe findings that indicate an
immediate life threat in a patient with
respiratory distress including: the
patient’s mental status, breathing effort,
position of comfort, and skin CTC.
Describe the technique for listening to
lung sounds.
Describe the physical examination of the
chest using visualization, auscultation,
palpation and percussion.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Objectives (continued)
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List the additional diagnostic tools that
may be used and describe how these tools
may or may not be helpful in the
assessment of a patient with respiratory
distress.
List and describe both normal and
abnormal lung sounds.
List and describe both normal and
abnormal breathing patterns.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Objectives (continued)
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List abnormal physical findings associated
with the patient diagnosed with a
pulmonary disorder and describe the
significance of each.
List some of the most common acute
respiratory conditions.
Describe the signs and symptoms
associated with the most common acute
respiratory conditions.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Introduction
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Respiratory problems are either acute
such as obstruction, bronchospasm,
or APE or chronic such as COPD or
CHF.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Respiratory Chief Complaints
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Dyspnea
Chest pain
Cough
Wheezing
Signs of infection
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Focused History
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For the patient with respiratory distress
obtain the most pertinent information first.
When a patient is severely distressed
modify questions to yes or no answers.
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Utilize family/caretakers, etc
Obtain OPQRST and SAMPLE information
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Focused History
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O – onset
P – provocation
Q – quality
R – region/referral/radiation
S – severity
T – time
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Focused History
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S – signs/symptoms
A – allergies
M – medications
P – pertinent past medical history
L – last oral intake
E – events leading up to
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Physical Exam
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Determine patient’s mental status and
level of distress.
A patient with moderate to severe distress
will have difficulty speaking in full
sentences.
The inability to speak in full sentences
indicates an immediate life threat.

A limited number of words spoken between
breaths is described as “one, two, or three
word dyspnea.”
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Physical Exam (continued)
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Other findings that indicate an immediate
life-threat in a patient with respiratory
distress include:
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Altered MS, anxiety or confusion/hypoxia
Signs of poor perfusion such as cyanosis,
pallor, or diaphoresis
Absent or abnormal breath sounds
Use of accessory muscles
Tachycardia or bradycardia (sustained)
Hypotension
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Visual Inspection
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Assess skin color, temp, and condition
(CTC) for poor perfusion
Assess neck and chest for symmetry,
deformity and accessory muscle use
Assess respiratory rate, pattern, and depth
Note the presence of JVD, which may be
associated with heart failure, COPD,
massive pulmonary embolism, and
cardiogenic shock
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Auscultate
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Listen for normal, abnormal (adventitious)
and absence of breath sounds
Begin in the apecies and work down to the
bases
Always compare side-to-side and listen on
both the anterior chest and posterior chest
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Palpate and Percuss
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Assess for:
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Tenderness
Symmetrical expansion
Tactile fremitus (shaking vibration of the chest
wall while breathing)
Masses or lumps
Note the size, location and density of
consolidation or underlying organs
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Further Examination
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Note the following:
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Presence and degree of peripheral edema
Ascites
Use of transdermal patches
Scars
Implanted devices (AICD)
Intra-catheters
Medic Alert tags
General hygiene
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Diagnostic Tools
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Trending the findings of the exam, VS and
diagnostics is more important than
isolated readings
SpO2 – non-invasive, not always reliable
(normal reading > 95%)
ECG – can alert you to presence of cardiac
dysrhythmia
Temperature – an important VS in children
and the elderly
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Diagnostic Tools
EtCO2 – non-invasive and reliable.
Normal reading is 36-44 mm Hg
 Peak flow meter – easy to use,
inexpensive, establish a baseline for
therapy. A reading of < 150 L/min in
an adult indicates a need for
treatment

© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Abnormal Findings Associated with
Respiratory Distress
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One or two word dyspnea = severe
distress
Purses-lip breathing – creates airway
pressure to help keep the alveoli from
collasping
Retractions – accessory muscle use, most
notable during inspection (ribs, clavicles,
sternum)
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Abnormal Findings Associated
with Respiratory Distress
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Nasal flaring – widening of the nostrils
indicates partial airway obstruction, most
notable in children
Carpopedal spasms – spasmotic
contractions of the hands, wrists, feet, and
ankles from prolonged hyperventilation or
any condition that leads to respiratory
alkalosis
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Abnormal Findings (continued)
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Abnormal or adventitious breath sounds
using numerous terms and definitions with
few agreeing on the same words
When assessing breath sounds:
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Listen to skin not the shirt!
Apex to base comparing side-to-side
Use simple terms to describe your findings
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Abnormal Findings (continued)
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Abnormal lung sounds include:
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Wheezing – continuous whistling sound
caused by narrowing of the lower airways
Stridor – is a disturbing high-pitched sound
associated with upper airway obstruction
Grunting – is a sound that occurs primarily in
infants/small children when the child breathes
out against a partially closed epiglottis
(usually a sign of distress)
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Abnormal Findings (continued)
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Wet or dry lungs – simple, yet effective terms
to describe the presence or absence of fluid in
the lungs
Crackles – are sounds similar to the crumpling
up of a candy wrapper, sometimes describe as
rales
Rhonchi – is a rattling noise in the upper
airways caused by mucous or other secretions
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Abnormal Findings (continued)
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Absent sounds – no sounds heard in the lungs
may be due to consolidation of edema or
pneumonia, complete FBAO, and severe
asthma
Absent unilateral sounds may be due to
pneumothorax, pneumoectomy, increased
consolidation (pneumonia) decompensated
COPD or partial FBAO
Pleural friction rub – is not a lung sound but is
heard in the chest as a grating sound over the
area that is painful
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Abnormal Breathing Patterns
(continued)
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Eupnea – normal breathing
Tachypnea – rapid shallow breathing and
the rate is age related
Hyperventilation – a rate greater than that
required for normal body function; it is the
result of increased respiratory rate, depth
or both
Bradypnea – slow breathing
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Abnormal Breathing Patterns
(continued)
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Hypoventilation – an irregular and shallow
pattern that may occur at any respiratory
rate
Biots respirations – an irregular, but cyclic
pattern of an increased and decreased
rate and depth, with periods of apnea; it is
associated with brain injury or heat stroke
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Abnormal Breathing Patterns
(continued)
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Cheyne-Stokes respirations – a rhythmic
pattern of gradually increasing and
decreasing rate and depth with periods of
apnea (associated with severe CHF, ICP,
drug OD and meningitis)
Kussmaul’s respirations or “air hunger” - a
distressing dysnea occuring in paroxysms
and is associated with diabetic acidosis,
coma and other causes of excess acid in
the blood
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Abnormal Breathing Patterns
(continued)
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Agonal respirations – “dying breaths,”
characterized by irregular and
progressively slowing gasps of air
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Abnormal Physical Findings
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Poor perfusion.
Edema – including peripheral, central
and/or pulmonary.
Clubbing – enlarged finger tips or toes
(associated with a history of heavy
smoking, COPD, lung CA, fibrosis, chronic
heart disease and other conditions).
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Abnormal Physical Findings
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Pulsus paradoxus – a marked decrease
(10-20mm Hg or more) in systolic BP
coinciding with inspiration (associated with
asthma, pulmonary embolism, tension
pneumothorax, cardiac tamponade,
hypovolemic shock.)
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Abnormal Anterior Chest
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Barrel chest – enlarged and rounded
cross section to chest associated with
COPD and sometimes asthma
Funnel chest – compression of the lower
part of sternum
Pigeon chest – characterized by a
protruding sternum
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Abnormal Posterior Chest
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Kyphosis – hunchback, associated with
congenital disorders and diseases; may
impeded movement of respiratory muscles
Scoliosis – a lateral curvature of the spine
Lordosis – a forward curvature of the
lumbar spine associated with Kyphosis,
muscular dystrophy and rickets
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Dyspnea Features
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Causes of dyspnea with exertion are either
pulmonary or cardiac
Dyspnea from pulmonary causes tend to
resolve quicker with cessation of exertion
than cardiac causes
Causes of dyspnea without exertion
include: anemia, chest trauma, acute MI,
pulmonary embolism, spontaneous
pneumothorax
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Dyspnea Features
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Acute dyspnea in children most often
occurs due to asthma, bronchiolitis, croup,
or upper airway FBAO
Acute dyspnea in the elderly is often
caused by exacerbation of COPD or heart
failure
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Dyspnea Features
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Common factors that can trigger
respiratory conditions include:
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Exercise or stress
Infection
Allergies
Tobacco smoke
Chemicals or other irritants
Medications may worsen COPD (ie: betablockers)
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Common Acute Respiratory Conditions
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Pathophysiology relates to abnormalities
affecting ventilation, diffusion, perfusion
or any combination.
Most common causes are:
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Asthma
COPD
CHF
Anxiety
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Common Acute Respiratory
Conditions
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Additional causes include:
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Allergies
Anaphylaxis
Pneumonia
Spontaneous pneumothorax or embolism
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Conclusion
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The management of a patient with a
respiratory problem includes a prompt and
accurate assessment with recognition of
immediate life-threatening conditions,
followed by prompt intervention and
resuscitation as appropriate.
When the patient’s condition is unstable or
critical these steps take priority over a
detailed assessment.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Conclusion (continued)
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The FH & PE are always a high priority, as
the information obtained guides the
course of treatment.
Ask the most pertinent questions first.
Be alert for signs of rapid deterioration
and quickly formulate a plan to intervene.
Many patients with dyspnea are having a
cardiac problem.
The assessment process is dynamic and
the EMS provider must modify the FH &
PE to include more than one body system.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.