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Chapter 13 Patient Assessment National EMS Education Standard Competencies Assessment Integrate scene and patient assessment findings with knowledge of epidemiology and pathophysiology to form a field impression. This includes developing a list of differential diagnoses through clinical reasoning to modify the assessment and formulate a treatment plan. National EMS Education Standard Competencies Scene Size-up • Scene safety • Scene management − − − − − − Impact of the environment on patient care Addressing hazards Violence Need for additional or specialized resources Standard precautions Multiple patient situations National EMS Education Standard Competencies Primary Assessment • Primary assessment for all patient situations − Initial general impression − Level of consciousness − ABCs − Identifying life threats − Assessment of vital functions National EMS Education Standard Competencies Primary Assessment (cont’d) • Begin interventions needed to preserve life. • Integration of treatment/procedures needed to preserve life National EMS Education Standard Competencies History Taking • Determining the chief complaint • Investigation of the chief complaint • Mechanism of injury/nature of illness • Past medical history • Associated signs and symptoms • Pertinent negatives National EMS Education Standard Competencies History Taking (cont’d) • Components of the patient history • Interviewing techniques • How to integrate therapeutic communication techniques and adapt the line of inquiry based on findings and presentation National EMS Education Standard Competencies Secondary Assessment • Performing a rapid full-body exam • Focused assessment of pain • Assessment of vital signs • Techniques of physical examination • Respiratory system − Presence of breath sounds National EMS Education Standard Competencies Secondary Assessment (cont’d) • Cardiovascular system • Neurologic system • Musculoskeletal system National EMS Education Standard Competencies Secondary Assessment (cont’d) • Techniques of physical examination for all major − Body systems − Anatomic regions • Assessment of − Lung sounds National EMS Education Standard Competencies Monitoring Devices • Obtaining and using information from patient monitoring devices including (but not limited to): − − − − − − − Pulse oximetry Noninvasive blood pressure Blood glucose determination Continuous ECG monitoring 12-lead ECG interpretation Carbon dioxide monitoring Basic blood chemistry National EMS Education Standard Competencies Reassessment • How an when to reassess patients • How and when to perform a reassessment for all patient situations National EMS Education Standard Competencies Medicine Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression and implement a comprehensive treatment/disposition plan for a patient with a medical complaint. National EMS Education Standard Competencies Medical Overview • Assessment and management of a − Medical complaint • Pathophysiology, assessment, and management of medical complaints to include: − Transport mode − Destination decisions Introduction • One of the most important skills you will develop is the ability to assess a patient. − Identify your patient’s problem(s). − Set your care priorities. − Develop a patient care plan. − Execute your plan. Sick Versus Not Sick • Determine whether the patient is sick or not sick. − If the patient is sick, determine how sick. • Every time you assess a patient: − Qualify whether your patient is sick or not sick − Quantify how sick the patient is Establishing the Field Impression • A determination of what you think is the patient’s current problem − You must be able to communicate and ask the right questions. • Be a “detective.” Establishing the Field Impression • The process must be organized and systematic but still flexible. − Know when to expand your questioning. − Know when to focus your questioning. Medical Versus Trauma • Medical patients − Identify chief complaint and sift through medical history. • Trauma patients − Medical history may have less impact − Requires a modified approach Scene Size-Up • Involves evaluating the overall safety and stability of the scene − Safe and secure access into the scene − Ready egress out of the scene − Specialty resources needed Scene Safety • Ensure the safety and well-being of your EMS team and any other responders. − If the scene is not safe, do what is necessary to make it safe. − Requires constant reassessment Scene Safety Courtesy of Anthony Caliguire, NREMT-P − Wear a highvisibility public safety vest. − Consider specialty reflective gloves, coats, and boots. © Adam Alberti, NJFirePictures.com • Crash-and-rescue scenes often include multiple risks. Scene Safety • Ensure that your team can safely gain access to the scene and the patient. − Consider a snatch and grab. • Establish a safe perimeter to keep bystanders out of harm’s way. Scene Safety • Be wary of toxic substances and toxic environments. − Proper body and respiratory protection is a must. Courtesy of Tempe Fire Department Scene Safety • Potential crime scenes − Law enforcement should enter first. − Formulate an escape plan. − Be aware of violence from bystanders. − Patients who abuse methamphetamines can be a large threat. © Paul Chiasson, CP/AP Photos Scene Safety • Risks related to the environment include: − Unstable surfaces − Snow and ice − Rain • Consider the stability of the structures around you. Courtesy of James Tourtellotte/U.S. Customs & Border Control Scene Safety • Ensure safety of the patient and bystanders next. • When the environment is unfriendly perform assessment, address threats, and move the patient as quickly as possible. Mechanism of Injury or Nature of Illness • Mechanism of injury (MOI) − Forces that act on the body to cause damage • Nature of illness (NOI) − General type of illness a patient is experiencing Mechanism of Injury or Nature of Illness • Multiple patients or obese patient may warrant additional resources. − Multiple patients must be triaged. − Be familiar with specialized resources. − Assess the need for spinal motion restriction. Standard Precautions • Your first priority is your own safety and the safety of other EMS team members. Standard Precautions • Treat all patients as potentially infectious. − Wear properly sized gloves. − Wear eye protection. − Wear a HEPA or N95 mask. − Wear a gown. − Wash your hands after removing gloves. Standard Precautions • Personal protective equipment (PPE) − Clothing or equipment that provides protection from substances that pose a health/safety risk • Steel-toe boots • Helmets • Heat-resistant outerwear • Self-contained breathing apparatus • Leather gloves Primary Assessment: Form a General Impression • Based on initial presentation and chief complaint • Make conscious, objective, and systematic observations − Is the patient in stable or unstable condition? − Is the patient sick or not sick? Primary Assessment: Form a General Impression • Observe level of consciousness. • Decide whether to implement spinal motion restriction procedures. • Determine your priorities of care. • Identify age and sex of the patient. Primary Assessment: Form a General Impression • Treat life threats as you find them − What additional care is needed? − What needs to be done on scene? − When to initiate transport? − Which facility is most appropriate? • Assess mental status by using AVPU process Assess the Airway • Is airway open and patent? • Listen for noisy breathing. • Move from simple to complex: − Position − Obstruction Assess the Airway • For all unresponsive patients: − Establish responsiveness. − Assess breathing. • If ineffective or absent, open the airway. • Mechanical means requires an airway adjunct Assess Breathing • Is the patient breathing? − If not, you must breathe for him or her. − If so, is he or she breathing adequately? • Consider minute volume. − Respiratory rate multiplied by the tidal volume inspired with each breath Assess Breathing • Assess breathing rate. − Too fast: greater than 24 breaths/min − Too slow: 8–20 breaths/min • Assess for chest rise and fall. • Assess for breath sounds. • Assess for air movement. Assess Circulation • Palpate the pulse. − Count the number of beats in 15 seconds and multiply times four. • Normal pulse rate for adults is 60–100 beats/min. • Bradycardia — rate less than 60 beats/min. • Tachycardia — rate higher than 100 beats/min. Assess Circulation • Force: Normal pulse feels “full.” • Rhythm: Normal rhythm is regular. • Report your findings: − Rate − Force − Rhythm • Inspect skin for obvious signs of bleeding. • Capillary refill evaluates ability to restore blood − To test: • Place thumb on patient’s finger and compress. • Remove pressure. • Adequate perfusion: color restored within two seconds. © Jones and Bartlett Publishers. Courtesy of MIEMSS. © Jones and Bartlett Publishers. Courtesy of MIEMSS. Assess Circulation Assess Circulation • Assess the skin to evaluate perfusion. − Color − Temperature − Moisture Assess Circulation Restoring Circulation • If a patient has inadequate circulation: − Restore or improve circulation. − Control severe bleeding. − Improve oxygen delivery to the tissues. Restoring Circulation • If you cannot feel a pulse, begin CPR until an AED or manual defibrillator is available. − Follow standard precautions. − Evaluate cardiac rhythm of any patient in cardiac arrest. − Oxygen delivery is improved through the administration of 100% supplemental oxygen. Assess and Control External Bleeding • Perform a rapid exam. − Venous bleeding: steady blood flow − Arterial bleeding: spurting flow of blood • Evaluate unresponsive patients by running your gloved hands from head to toe. Identify and Treat Life Threats • Determine if a life threat is present and, if so, immediately address it. − A patient who is dying will: • Become less aware of surroundings • Stop making attempts to communicate • Lose consciousness • Become unresponsive to external stimuli • Muscles of the jaw will become slack Identify and Treat Life Threats • Conditions that cause sudden death: − Airway obstruction − Respiratory arrest − Severe bleeding Assess the Patient for Disability • Perform a neurologic evaluation. − Have the patient move all extremities. • Assess for motor strength and weakness. • Assess grip strength. • Assess for loss of sensation. • Be mindful of exposure concerns. Perform a Rapid Exam • Observe for asymmetry/obvious defects. • Palpate the entire surface of the skull, then down to C7 of the spine. • Squeeze and roll the shoulder girdles. • Palate the abdomen and rock the pelvis. Perform a Rapid Exam • Grasp each arm at the shoulder girdle and slide your hands down to the wrist. • Palpate the legs. • Ask the patient to wiggle fingers and toes. • Ask the patient if they are bleeding. Perform a Rapid Exam • Guidelines: − − − − Inspect. Palpate. Auscultate. See Skill Drill 13-1. • DCAP-BTLS: − − − − − − − − Deformities Contusions Abrasions Punctures/penetration/ paradoxical movement Burns Tenderness Lacerations Swelling Make a Transport Decision • Identify priority patients. − Do only what is necessary at the scene and handle everything else en route. Priority Patients • Hypoperfusion or shock • Poor general impression • Complicated childbirth • Unresponsive patients • Chest pain w/systolic BP < 100 mm Hg • Uncontrolled bleeding • Severe pain anywhere • Multiple injuries • Responsive but does not or cannot follow commands • Difficulty breathing History Taking • Gain information about the patient and the events surrounding the incident. • Ask open-ended questions. • Avoid leading questions. • Ask age-appropriate questions. • Be patient. Patient Information • Name and chief complaint • Data required by local EMS system • Who called 911 and why • Medical ID jewelry • Information from medical responders Techniques for History Taking • Appearance and demeanor − Clean, neat, and professional − Good attitude − Identify your service and certification level. − Try to interview in a private setting. Techniques for History Taking • Confidentiality − Be familiar with relevant laws. • How to address the patient − Ask how he or she would like to be addressed. − Err on the side of formality. − Be familiar with the cultural groups in area. Techniques for History Taking • Note taking − Let the patient know that you will be writing information down. © Glen E. Ellman − Position yourself at eye level. − Maintain good eye contact. Techniques for History Taking • Reviewing medical history and information reliability − Document the source of all information. − During routine transfers, look over paperwork. − Evaluate your sources for reliability. Responsive Medical Patients • Chief complaint − Should be recorded in patient’s own words − Should include: • What is wrong • Why treatment is being sought Responsive Medical Patients • History of illness − OPQRST • Onset • Provocation • Quality • Region/radiation/ referral • Severity • Time − SAMPLE • Signs and symptoms • Allergies • Medications • Pertinent past history • Last oral intake • Events that led to injury or illness Responsive Medical Patients • “What made you call 9-1-1?” • Patient may have multiple complaints. • Flesh out history of chief complaint • Signs and symptoms: what happened and when • Look for medical ID tags or cards. Responsive Medical Patients • Past medical history − Should include: • Current medications and dosages • Allergies • Childhood illnesses • Adult illnesses • Past surgeries • Past hospitalizations and disabilities Responsive Medical Patients • Past medical history (cont’d) − Patient’s emotional affect provides insight into overall mental health. − Determine whether the patient has ever experienced the problem. • A new problem or condition is best considered serious until proven otherwise. Responsive Medical Patients • Current health status − Made up of unrelated pieces of information − Ties together past history with history of current event − Decide which items you want to explore and which you do not Responsive Medical Patients • Family history − Helps establish patterned and risk factors for potential diseases − Information should be related to the patient’s current medical condition. Responsive Medical Patients • Social history − Smoking habits − Alcohol consumption and drug use − Sexual habits − − − − Diet Occupation Environment Travel history Unresponsive Patients • Rely on: − Head-to-toe physical examination − Normal diagnostic tools − Family and friends • Look for clues. − Pill containers − Medical jewelry Trauma Patients • Life-threatening MOIs − Ejection from a vehicle − Death of another patient in same vehicle − Falls of greater than 15′ to 20′ or three times patient’s height − Vehicle rollover − High-speed vehicle crash − Vehicle-pedestrian collision − Motorcycle crash − Penetrating wounds to head, chest, or abdomen Trauma Patients © Mark C. Ide © Jack Dagley Photography/ShutterStock, Inc. © Corbis © Larry St. Pierre/ShutterStock, Inc., © Jones & Bartlett Learning. Photographed by Kimberly Potvin © micheal ledray/ShutterStock, Inc. © Dan Myers, Figure Trauma Patients • High-priority infant or child MOIs: − Falls from more than 10′ or two to three times the child’s height − Fall of less than 10′ with loss of consciousness − Medium- to highspeed vehicle crash − Bicycle collision Trauma Patients • Two or more serious MOIs increase the chance of a serious or fatal injury. • In an MVC, determine whether seat belts and/or air bags were involved. − Improperly installed child seats can be useless. © Thinkstock/Getty Images Patients with Minor Injuries or No Significant MOI • If a patient shows signs of systemic involvement, continue with assessment. Review of Body Systems • General symptoms − Ask questions regarding: • Fever • Chills • Malaise • Fatigue • Night sweats • Weight variations Review of Body Systems • Skin, hair, and nails − Rash, itching, hives, or sweating • Musculoskeletal − Joint pain, loss of range of motion, swelling, redness, erythema, and localized heat or deformity Review of Body Systems • Head and neck − Severe headache or loss of consciousness − Eyes • Visual acuity, blurred vision, diplopia, photophobia, pain, changes in vision, and flashes of light Review of Body Systems • Head and neck (cont’d) − Nose • Sense of smell, rhinorrhea, obstruction, epistaxis, postnasal discharge, and sinus pain − Throat and mouth • Sore throat, bleeding, pain, dental issues, ulcers, and changes to taste sensation Review of Body Systems • Endocrine − Enlargement of the thyroid gland − Temperature intolerance − Skin changes − − − − Swelling of hands and feet Weight changes Polyuria, polydipsia, polyphagia Changes in body and facial hair Review of Body Systems • Chest and lungs − Dyspnea and chest pain − Coughing, wheezing, hemoptysis, and tuberculosis status − Previous cardiac events − Pain or discomfort − Orthopnea, edema, and past cardiac testing Review of Body Systems • Hematology − History of anemia, bruising, and fatigue • Lymph nodes − Tender and enlarged lymph nodes Review of Body Systems • Gastrointestinal − Appetite and general digestion − Food allergies and intolerances − Heartburn, nausea and vomiting, diarrhea − − − − Hematemesis Bowel regularity, changes in stool, flatulence, Jaundice Past GI evaluations and tests Review of Body Systems • Genitourinary − Dysuria − Increased frequency of urination, urgency − Nocturia − Hematuria − Polyuria − Pain to the flank and suprapubic region Review of Body Systems • Genitourinary (cont’d) − Men • Erectile dysfunction, fluid discharge, and testicular pain − Females • Menstrual regularity, last menstrual period, dysmenorrhea, vaginal discharge, abnormal bleeding, pregnancies, and contraception use Review of Body Systems • Neurologic − Seizures or syncope, loss of sensation, weakness in extremities, paralysis, loss of coordination or memory, and muscle twitches − Facial asymmetry − If you suspect stroke or TIA, use Cincinnati Stroke Scale. Review of Body Systems • Psychiatric − Depression, mood changes − Difficulty concentrating − Anxiety, irritability − Sleep disturbances, fatigue − Suicidal or homicidal tendencies Clinical Reasoning • Combines knowledge of anatomy, physiology, pathophysiology, and patient’s complaints • Pay attention to signs or symptoms that are inconsistent with working diagnosis. − Differential diagnosis – a working hypothesis of the nature of the problem Communication Techniques • Encourage dialogue. − Use layperson terminology. Communication Techniques Communication Techniques • Empathetic response − Put yourself in the patient’s shoes. − Do not hesitate to communicate your feelings. Communication Techniques • Ask about feelings. − Tired, depressed, etc. − Validate the patient’s feelings. − Be empathetic but effective. Communication Techniques • Getting more information − Question region or location of pain. − Question quality of abdominal pain. − Add, delete, and modify questions. − Avoid close-ended and leading questions. − Try to be orderly and systematic. Communication Techniques • Asking direct questions − If you need a date, time, etc., ask for it. • Applying clinical reasoning − Critical thinking consists of: • Concept formation • Data interpretation • Application of principles • Reflection in action • Reflection on action Communication Techniques • Applying clinical reasoning (cont’d) − Think and perform well under pressure. − Be a patient listener. − Communicate with patients. − Look for nonverbal communication. Getting a History on Sensitive Topics • Alcohol and drug abuse − Patients may give an unreliable history. − Alcohol can mask signs and symptoms. − Keep a professional attitude. © Jack Dagley Photography/ShutterStock, Inc. Getting a History on Sensitive Topics • Physical abuse, domestic abuse, and sexual assault − Required to report − Look for clues. − Always call law enforcement. − Maintain evidence per protocol. Getting a History on Sensitive Topics • Sexual history − Talk to the patient in private. − Keep your questions focused. − Do not interject opinions or biases. − Treat with compassion and respect. Cultural Competence • Common barriers to communication: − Race − Ethnicity − Age − Gender − Language − Education − Religion − Geography − Economic status Cultural Competence • Respect ideas and beliefs. • Consider dietary practices. • Obtain consent. • Provide best possible care for all patients. • Research prevalent groups in your area. • Remember the importance of manners. Special Challenges in History Taking • Silence • Intoxication • Overly talkative patients • Crying • Patients with multiple symptoms • Anxious patients • Reassurance • Anger and hostility • Depression • Sexually attractive patients • Confusing behaviors or histories Special Challenges in History Taking • Limited education or intelligence • Language barriers • Hearing problems • Visual impairment/ blindness • Family and friends Age-Related Considerations • Pediatric patients − Include child in the history-taking process. − Be sensitive to the fears of the parents. − Pay attention to the parent-child relationship. Age-Related Considerations • Pediatric patients (cont’d) − Tailor your questions to the age of the child. • Neonates/infants: maternal history and birth history • 3 to 5 years: performance in school • Adolescent: risk-taking behaviors, self-esteem issues, rebelliousness, drug and alcohol use, and sexual activity − Gather an accurate family history. Age-Related Considerations • Geriatric patients − Accommodate sensory losses. − Patients tend to have multiple problems. • May have multiple chief complaints • May take a multitude of medications Age-Related Considerations • Geriatric patients (cont’d) − Symptoms may be less dramatic. − Consider including a functional assessment. • Assessment of mobility • Upper extremity function • Activities of daily living Secondary Assessment • Process by which quantifiable, objective information is obtained from a patient about his or her overall state of health − Consists of two elements: • Obtaining vital signs • Performing a head-to-toe survey Secondary Assessment • Not every aspect will be completed in every patient. − Factors to consider: • Location • Positioning of the patient • The patient’s point of view • Maintaining professionalism Assessment Techniques Inspection − Looking at the patient − Touching to obtain information • Pulses: use finger • Skull: use palms • Skin: use back of hand © Jones & Bartlett Learning. Courtesy of MIEMSS. • Palpation Assessment Techniques • Percussion − Striking surface of the body, typically where it overlies various body cavities − Detects changes in the densities of the underlying structures − See Skill Drill 13-2. Assessment Techniques • Auscultation − Listening with a stethoscope − Requires: • Keen attention • Understanding of what “normal” sounds like • Lots of practice Vital Signs • Pulse − Assess rate, presence, location, quality, regularity − To palpate, gently compress an artery against a bony prominence. • Count for 15 minutes and multiply by four. • Check for central pulse in unresponsive patients. Vital Signs Vital Signs • Respiration − Assess rate by inspecting the patient’s chest − Quality • Pathologic respiratory patterns or rhythms • Tripod positioning, accessory muscle use, retractions − Rate should be measured for 30 seconds and multiplied by two for pediatric patients. Vital Signs • Blood pressure − Product of cardiac output and peripheral vascular resistance • Systolic pressure • Diastolic pressure − Measured using a cuff − Ideally should be auscultated Vital Signs • Temperature − When measuring the tympanic membrane temperature: • External auditory canal must be free of cerumen. • Position the probe so the infrared beam is aimed at the tympanic membrane. • Wait 2-3 seconds until temperature appears. Vital Signs • Pulse oximetry − Should never be used as an absolute indicator of the need for oxygen − Measures percentage of hemoglobin saturation Equipment Used in the Secondary Assessment • Stethoscope • Otoscope • Blood pressure cuff (sphygmomanometer) • Scissors • Capnography • Glucometry • Ophthalmoscope • Reliable light source • Gloves • Sheet or blanket Equipment Used in the Secondary Assessment • Stethoscope − Acoustic: blocks out ambient sounds − Electronic: converts sound waves into electronic signal and amplifies them © Denis Pepin/ShutterStock, Inc. Equipment Used in the Secondary Assessment • Blood pressure cuff − Measurement of blood pressure − Consists of inflatable cuff and manometer (pressure meter) − Use the appropriate size! © WizData, Inc./ShutterStock, Inc. Equipment Used in the Secondary Assessment • Ophthalmoscope − Allows you to look into patient’s eyes − Consists of concave mirror and battery-powered light − Requires dilation of pupils and diagnostic expertise © Kenneth Chelette/ShutterStock, Inc. Equipment Used in the Secondary Assessment • Otoscope − Evaluates ears of a patient − Consists of head and handle Physical Examination • Look for signs of significant distress • Other aspects: − Dress − Hygiene − Expression − Overall size − Posture − Untoward odors − Overall state of health © Jones & Bartlett Learning. Courtesy of MIEMSS. Physical Examination • Terms to describe the degree of distress: − − − − − No apparent distress Mild Moderate Acute Severe • Terms to describe the general state of a patient’s health: − − − − − Chronically ill Frail Feeble Robust Vigorous Full-Body Scan • A systematic head-to-toe examination • Patients who should receive: − Sustained a significant MOI − Unresponsive − Critical condition • See Skill Drill 13-3. Focused Assessment • Performed on patients who have sustained nonsignificant MOIs and are responsive • Focus on the immediate problem. Mental Status • For any patient with a “head” problem, assess and palpate for signs of trauma. − Assess the patient in four areas: • Person • Place • Day of week • The event Mental Status • Use the Glasgow Coma Scale − Assigns point value for eye opening, verbal response, and motor response Mental Status • Mental status examination − General appearance − Speech and language patterns − Mood − − − − Thoughts and perceptions Information relevant to thought content Insight and judgment Cognitive function (attention and memory) Skin • Serves three major functions − Regulates the temperature of the body − Transmits information from the environment to the brain − Protects the body from the environment Skin • Epidermis (outermost layer) − Barrier against water, dust, microorganisms, and mechanical stress • Dermis − Composed of collagen and elastic fibers, and a mucopolysaccharide gel − Divided into: Papillary dermis and reticular layer Skin Skin • Examine: − Color − Moisture − Temperature − Texture − Turgor − Significant lesions • Evidence of diminished perfusion: − Pallor − Cyanosis − Diaphoresis − Vasodilation (flushing) Skin • Pallor: poor red blood cell perfusion to the capillary beds • Vasoconstriction: indicated by pale skin • Cyanosis: low arterial oxygen saturation • Mottling: severe hypoperfusion and shock Skin • Ecchymosis: localized bruising or blood collection within or under the skin • Turgor: relates to hydration • Skin lesions: may be only external evidence of a serious internal injury Hair • Examine by inspection and palpation. − Note: • Quantity • Distribution • Texture Nails • Note: − Color − Shape − Texture − Presence or absence of lesions − Normal nail should be firm and smooth. Head • Cranium: contains the brain − Occiput: posterior portion − Temporal regions: each side of the cranium − Parietal regions: between temporal regions and occiput − Frontal region: forehead Head • The scalp covers the cranium. • Meninges: suspend the brain and spinal cord (dura matter, arachnoid, pia matter) • Cerebrospinal fluid: fills between meninges Head • Inspect and feel the entire cranium. − Deformity − Asymmetry − − − − Warm, wet areas Tenderness Shape and contour Scars or shunts © E. M. Singletary, M.D. Used with permission. Head • Evaluate the face. − Color − Moisture − Expression − − − − Symmetry and contour Swelling or apparent areas of injury DCAP-BTLS See Skill Drill 13-4. Eyes • Assess functions of CNS. • Anterior chamber • Posterior chamber • Inspect and palpate the upper and lower orbits. Eyes Eyes • Note periorbital ecchymosis (raccoon eyes). − Snellen (“E”) chart − Light/dark discrimination − Finger counting © German Ariel Berra/ShutterStock, Inc. • Assess visual acuity Eyes • Assess pupils. − Normally round and equal size − Pupils should react instantly to change in light level. − Check for size, shape, and symmetry, and reaction to light. Ears • Involved with hearing, sound perception, and balance control • Includes: − External ear − Middle ear − Inner ear Ears Ears • Assess for changes in hearing perception, wounds, swelling, and drainage. − Assess mastoid process of the skull for discoloration and tenderness. − Examine by using an otoscope (see Skill Drill 13-7). Nose • Nasal cavity is divided into two chambers − Each chamber contains three layers of bone. − Assess anteriorly and inferiorly. Nose • Look for: − Asymmetry − Deformity − Wounds − − − − Foreign bodies Discharge or bleeding Tenderness Evidence of respiratory distress Throat • Evaluate mouth, pharynx, and neck − Prompt assessment is mandatory in patients with altered mental status. − Assess for a foreign body or aspiration. • Be prepared to assist with manual techniques and suction. Throat • Mouth − Lips − Symmetry − Gums − Look for cyanosis around the lips. • Inspect airway for obstruction. Throat • Tongue − Size − Color − Moisture • Maxilla and mandible − Integrity − Symmetry • Oropharynx − Discoloration − Pustules − Unusual odors on the breath − Fluids that might need suctioning − Edema and redness Throat • Neck − Symmetry − Masses − Venous distention − Palpate carotid pulses. − Palpate the suprasternal notch . − See Skill Drill 13-8. Cervical Spine • Consider MOI − Evaluate for: • Pain • Altered mental status • Loss of consciousness at the time of the event Cervical Spine • Inspect and palpate. − Stop exam if pain, tenderness, or tingling results. − Assess range of motion when there is no potential for serious injury. • Passive exam • Active exam Chest • Contains lungs, heart, and great vessels • Three phases of exam − Chest wall exam − Pulmonary evaluation − Cardiovascular assessment − See Skill Drill 13-9. Chest • Check for: − Symmetry − Respiratory effort − Signs of obstruction − − − − General shape of the chest wall Signs of abnormal breathing Chest deformities Tenderness or crepitus − Normal − Tracheal − − − − Bronchial Bronchovesicular Vesicular Adventitious • Wheezing, rales, rhonci, stridor, pleural friction rubs © Jones & Bartlett Learning. Courtesy of MIEMSS. • Auscultate breath sounds. © Jones & Bartlett Learning. Courtesy of MIEMSS. Chest Chest • Are sounds: − Dry or moist? − Continuous or intermittent? − Course or fine? • Are breath sounds diminished or absent? − In a portion of one lung or entire chest? − If localized, assess transmitted voice sounds. Chest • Assess respiratory rate, depth, and effort. − Check for accessory muscle use, retractions, or ventilatory fatigue. − Check for jugular venous distention (JVD). Cardiovascular System • Circulates blood throughout the body − Plasma − Red blood cells − White blood cells − Platelets Cardiovascular System • System of tubes: − Arteries − Aterioles − Capillaries − Venules − Veins • Two circuits: − Systemic circulation • Carries oxygenrich blood − Pulmonary circulation • Carries oxygenpoor blood Cardiovascular System • Cardiac cycles involves: − Cardiac relaxation (diastole) − Filling − Contraction (systole) • Heart consists of four chambers − Two atria − Two ventricles Cardiovascular System Cardiovascular System • The contraction and relaxation of the heart generates heart sounds. Cardiovascular System Cardiovascular System • Splitting: events on the right of the heart usually occur later than those on the left − Creates two discernible sounds • Heart sounds can be heard in: − Parasternal areas − Region superior to the left nipple − Refer to Skill Drill 13-10. Cardiovascular System • Korotkoff sounds: related to blood pressure − There are 5 (1st and 5th are significant) • First: thumping of the systolic • Fifth: disappears as the diastolic pressure drops below that created by the blood pressure cuff Cardiovascular System • Bruit: abnormal “whoosh”-like sound − Turbulent blood flow through narrowed artery • Murmur: abnormal “whoosh”-like sound − Turbulent blood flow around a cardiac valve − Graded by range of intensity from 1 to 6 Cardiovascular System • Arterial pulses are an expression of systolic blood pressure. − Palpable where artery crosses bony prominence • Venous pressure tends to be low. − Assess extremities for signs of obstruction or insufficiency. Cardiovascular System • Jugular venous distention (JVD) − With penetrating left chest trauma, may indicate cardiac tamponade − With pedal edema, consider heart failure. − Note how much distention is present. Cardiovascular System • Pay attention to arterial pulses. • Obtain blood pressure and repeat. − Note history and class of hypertension. Cardiovascular System • Palpate and auscultate carotid arteries. • Listen where cardiac valves are located: − Aortic valve: right of the sternum − Pulmonic valve: left of the sternum − Tricuspid valve: lower left sternal border − Mitral valve: lateral to the lower left sternal border Cardiovascular System • For a suspected heart problem, assess: − Pulse − Skin − Breath sounds − Baseline vital signs − Extremities Cardiovascular System • The definition of normal and abnormal findings is different in a neonate or infant. − Neonates often have cyanosis following birth. − “Abnormal” heart sounds may be a normal variant. Abdomen • Divided into imaginary quadrants • Contains: − Organs of digestion − Organs of urogenital system − Significant neurovascular structures Abdomen • Peritoneum: a well-defined layer of fascia made up of the parietal and visceral peritoneum − Intraperitoneal organs − Extraperitoneal organs Abdomen • Organs are organized by viewing the abdominal wall in a subdivided fashion. − Quadrants • Left upper quadrant • Right upper quadrant • Left lower quadrant • Right lower quadrant Abdomen • Abdomen can also be divided by ninths. Abdomen • Three basic mechanisms produce pain: − Visceral pain − Inflammation − Referred pain • Appropriate and relevant history is critical. Abdomen • Inspect and palpate the abdomen. − Tightness: internal bleeding or inflamed organ − Upper left pain: ruptured spleen − Lower left pain: diverticulitis − Lower right pain: appendicitis − Generalized pain in women: obstetric or gynecologic problem Abdomen • Orthostatic vital signs (tilt test) − Blood pressure and pulse are taken in the supine and sitting or standing positions. − Determines extent of volume depletion • If volume-depleted, there is not enough circulating blood to push into core circulation Abdomen • Orthostatic vital signs (tilt test) (cont’d) − Generally considered positive if: • Decrease in systolic pressure • Increase in diastolic pressure of 10 mm Hg • Increase in pulse rate by 20 beats/min Abdomen • Examine the area of complaint last. − Work slowly. − Avoid quick movements. − Proceed in a systematic fashion. − Refer to Skill Drill 13-11. Abdomen • Inspect: − Skin − Contour and appearance − Symmetry − Rash or signs of allergic reaction − Scars − Wounds − Swelling/bruising − Discoloration in periumbilical area or along the flanks − Localized masses − Striae − Dilated veins − Distention Abdomen • Abdomen can be described as: − Flat − Rounded − Protuberant (bulging out) − Distinguish from obesity − Scaphoid − Pulsatile Abdomen • Auscultation − Setting must be quiet. − Note bowel sounds. • Hyperactive, hypoactive, increased, decreased, absent − Bruits Abdomen • Palpation − Palpate each quadrant gently but firmly. • Should appear soft without tenderness or masses. − Guarding: contraction of abdominal muscles − Rebound tenderness: pain upon release − Abdominal rigidity: peritoneal irritation and guarding Abdomen • Palpation (cont’d) − To palpate the liver: • Place left hand behind patient, parallel to right 11th and 12th ribs • Place right hand on right abdomen below rib cage. • Ask patient to take a deep breath. • Try to feel the liver edge. Abdomen • Palpation (cont’d) − To palpate the gallbladder: • Use same technique as for liver • Response indicating pain may mean possible inflammation • When patient takes deep breath, move fingers under liver edge Abdomen • Palpation (cont’d) − To palpate the spleen: • With left hand, reach over and around patient • Press forward lower left rib cage and adjacent soft tissues. • With right hand below costal margin, press toward the spleen. Abdomen • Aortic aneurysm − May be seen pulsating in the upper midline − Do not palpate an obvious pulsatile mass. • Hernia − Place patient in supine position and raise the head and shoulders. • Bulge of hernia will usually appear. Female Genitalia • Consists of: − External genitalia − Ovaries − Fallopian tubes − Uterus − Vagina Female Genitalia • Limited and discreet assessment − Reasons to examine include: • Life-threatening hemorrhage • Imminent delivery in childbirth − Assessment includes: • Palpating the bilateral inguinal regions • Palpating the hypogastric region Female Genitalia • Reasons for pain on palpation include: − Ectopic pregnancy − Complications of third trimester pregnancy − Nonpregnant ovarian problems − Pelvic infections Male Genitalia • Consists of: − Reproductive ducts − Testes − Urethra − Prostate − Penis Male Genitalia • Limited exam with partner present. − Assess for bleeding, injury, or fracture. − Note inflammation, discharge, swelling, or lesions. − Priapism: prolonged erection − Look for evidence of urinary incontinence. Musculoskeletal System • Joints: areas where bone ends abut each other and form a kind of hinge • Skeletal muscles: used to flex and extend joints − Joints become more vulnerable to injury, stress, and trauma as they age. Musculoskeletal System • Common injuries: − Fractures − Sprains − Strains − − − − Dislocations Contusions Hematomas Open wounds Musculoskeletal System • Note: − Structure and function − Limitation or pain in range of motion − Bony crepitance − Inflammation or injury − Obvious deformity − Diminished strength − Atrophy − Asymmetry − Pain − Refer to Skill Drill 13-12. Musculoskeletal System • Problems with the shoulders can often be determined by noting posture. − Assess: • Sternoclavicular joint • Acromioclavicular joint • Subacromial area • Bicipital groove Musculoskeletal System • Assess range of motion: − Ask patient to raise arms above the head. − Have patient demonstrate external rotation and abduction. − Perform internal rotation. Musculoskeletal System • Inspect elbows. − Palpate between the epicondyles and olecranon. − Range of motion: • Flex and extend passively and actively. • Pronate the forearms while the elbows are flexed. Musculoskeletal System • Inspect hands and wrists. − Palpate the hands. − Palpate the carpal bones. − Range of motion: • Make fists, then extend fingers • Flex/extend wrists • Move hands laterally and medially Musculoskeletal System • Inspect knees and hips. − Range of motion: • Ask patient to bend each knee and raise toward chest. • Assess for rotation and abduction of hips. − Palpate each hip. − Palpate pelvis. Musculoskeletal System • Observe ankles and feet. − Palpate feet and ankles. − Assess range of motion: • Have patient plantar flex, dorsiflex, and invert and evert ankles and feet. • Inspect, palpate, and check forefoot and toes. Peripheral Vascular System • Comprises aspects of circulatory system − Lymphatic system: network of nodes and ducts dispersed throughout the body − Lymph nodes: larger accumulations of lymphatic tissues Peripheral Vascular System • Perfusion occurs in the peripheral circulation. − Diseases of the peripheral vascular system are often seen in patients with other underlying medical conditions. Peripheral Vascular System • During assessment, pay attention to upper and lower extremities. − Signs of acute or chronic vascular problems − Refer to Skill Drill 13-13. Peripheral Vascular System • Assessment − Inspect upper extremities. − Five Ps of acute arterial insufficiency: • Pain • Pallor • Parasthesias/Paresis • Poikilothermia • Pulselessness Peripheral Vascular System • Assessment (cont’d) − Palpate epitrochlear and axillary lymph nodes. − Inspect lower extremities. − Palpate lower extremities. − Note temperature of feet and legs. − Attempt to palpate edema. − Palpate superficial inguinal lymph nodes. Spine • Consists of 33 individual vertebrae • Anchoring point for the skull, shoulders, ribs, and pelvis • Protects the spinal cord Spine • Inspect the back. − Lordosis − Kyphosis − Scoliosis Spine © Wellcome Trust Library/National Medical Slide Bank/Custom Medical Stock Photo © Dr. P. Marazzi/Photo Researchers, Inc. © Southern Illinois University/Photo Researchers, Inc.GA5323 Spine • Palpate the spine. • Check back for any other findings. − Tap over costovertebral angles. − Palpate scapulae, paraspinal areas, and base of neck. − Check the buttocks. Spine • Range of motion: − Check passively first, then actively. • See Skill Drill 13-14. Nervous System • Central nervous system: brain and spinal cord • Peripheral nervous system: remaining motor and sensory nerves Nervous System • Brain comprises cerebrum, cerebellum, and medulla • Except for cranial nerves, nerves are channeled to the brain via the spinal cord. − Motor nerves control motion or movement. − Sensory nerves send external signals to the brain. Nervous System • Cranial nerves go directly to and from the brain. Nervous System • Voluntary nervous system • Involuntary (autonomic) nervous system − Sympathetic − Parasympathetic − Reflexes − Primitive reflexes Nervous System • Neurologic exam − − − − Mental status (AVPU) Cranial nerve function Distal motor function Distal sensory function − Deep tendon reflexes • Mental status exam (COASTMAP) − − − − − − − − Consciousness Orientation Activity Speech Thought Memory Affect (mood) Perception Nervous System • Glasgow Coma Scale may also be used to assess people with alterations in mental status. • See Skill Drill 13-15. Nervous System • Cranial nerve examination − Determines presence and degree of disability − Can be performed in less than 3 minutes Nervous System • Evaluation of the motor system − Posture and body position − Involuntary movements − Muscle strength − Coordination − Proprioception Nervous System • Check sensory function. − Assess primary and cortical sensory functions. − Evaluate deep tendon reflexes. • See Skill Drill 13-16. Nervous System • Results of the neurologic exam − Delirium • Consistent with an acute sudden change in mental status − Dementia • Representative of deterioration of cognitive cortical functions Secondary Assessment of Unresponsive Patients • After ruling out trauma, position in recovery position. − If trauma, position in neutral alignment • Perform a thorough assessment of the body and look for signs of illness. Secondary Assessment of Unresponsive Patients • Perform at least two sets of vital signs. − Should include: • Auscultated blood pressure • Accurate pulse and respiratory rates • Patient’s temperature • Consider unresponsive patients to be in unstable condition. Secondary Assessment of Trauma Patients • Two classifications of trauma patients: − Isolated injury − Multisystem trauma • “High visibility factor” − Do not become distracted by obvious but nonlife-threatening injuries. Secondary Assessment of Trauma Patients • Patient who is unresponsive or has altered mentation is considered high risk. • Perform rapid exam. − When time and condition permit, perform physical examination. Secondary Assessment of Infants and Children • Attempt to elicit information from the patient before parents. • Obtain permission of a parent before examining if possible. • Examine from toe to head. Secondary Assessment of Infants and Children • When examining a newborn or neonate, be aware of normal variants: − Vernix − Edema − Mongolian spots − Jaundice − Asymmetry of the head Secondary Assessment of Infants and Children • Provide support of the head and neck. • Examine eyes for irregularities. • Inspect the umbilical cord. • Children are prone to dehydration and infection. Secondary Assessment of Infants and Children • Ages 1 to 3 years − Will object to being touched or manipulated − Use toe-to-head approach. • Ages 4 to 5 years − Usually cooperative and helpful • School-age − Be sure to explain what you are doing. • Adolescents − Concerned with bodily integrity Secondary Assessment of Infants and Children • General principles: − Remain calm. − Be patient, gentle, and honest. − Attempt to keep children with their parents. − Do not neglect a child’s pain. Secondary Assessment of Infants and Children • Exam techniques can vary slightly: − Auscultation of a quiet infant’s abdomen is simple. − Active tinkling bowel sounds may be heard. − A more tympanic sound might be heard on percussion of an infant’s abdomen. − Palpation techniques will vary with age. Recording Secondary Assessment Findings • Should be orderly and concise • Document using the forms recommended by your medical director. − Note: • Objective signs • Pertinent negatives • Similar relevant information Limits of the Secondary Assessment • Evaluation by a trained physician, laboratory testing, and radiographic studies may be needed for a definitive diagnosis. Monitoring Devices • Continuous ECG monitoring − Purpose is to establish a baseline − Electrodes must be placed properly. • The leads are usually colored and labeled to help with placement. • Continuous ECG monitoring (cont’d) − Bipolar leads consist of two electrodes. • Placed on different limbs • Einthoven triangle From Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD. Monitoring Devices Monitoring Devices • 12-lead ECG monitoring © Jones & Bartlett Learning − Patient should be supine. − Prepare the skin. − Connect electrodes. − Connect and apply the precordial leads. − Record the ECG. Monitoring Devices • Carbon dioxide monitoring − Capnometry • Measures carbon dioxide output − Capnography • Measures carbon dioxide output and provides a waveform Monitoring Devices Courtesy of Physio-Control, Inc. Courtesy of Physio-Control, Inc. Courtesy of Physio-Control, Inc. Monitoring Devices • Blood glucometer − Can obtain reading in two ways in the field: • From the hub of an IV catheter • From a finger stick − Most take only a few seconds. − Should be calibrated regularly Monitoring Devices • Cardiac biomarkers − Used to assess presence of damage to cardiac muscle − May take several hours following a myocardial infarction for the cardiac biomarkers to become elevated Monitoring Devices • Other blood tests − Basic and complete metabolic profile (CHEM 7 and CHEM 12) − Brain natriuretic peptide (BNP) test − Arterial blood gases Reassessment • Stable patients should be reassessed every 15 minutes. • Unstable patients should be reassessed every 5 minutes. Reassessment of Mental Status and the ABCs • Compare LOC with baseline assessment. • Review the airway. • Reassess breathing, circulation, pulse Reassessment of Mental Status and the ABCs • Response of pediatric and geriatric patients may differ. − Children decompensate very quickly. − Geriatric patients may not show signs of deterioration. Reassessment of Patient Care and Transport Priorities • Have you addressed all life threats? • Do priorities need to be revised? • Is initial transport decision appropriate? • Obtain another complete set of vital signs and compare with expected outcomes. − Priority patients: minimum three sets Reassessment of Patient Care and Transport Priorities • Look for trends. • Revisit patient complaints. • Document all of your findings. Summary • Patient assessment is the most important skill a paramedic has. • Patient assessment has five components: − − − − − Scene size-up Primary assessment History taking Secondary assessment Reassessment Summary • The first step of the patient assessment process is the scene size-up. • During the size-up, you also make a determination of the mechanism of injury or nature of the patient’s illness. • Another important step in protecting yourself is to take standard precautions. Summary • The first step in the primary assessment is to form a general impression of the patient’s condition. • During the primary assessment, you should be able to identify threats to the ABCs; these life threats should be addressed immediately. Summary • After assessing the patient for disability, you must make a transport decision and, if the patient has sustained trauma, perform a rapid exam. • Once the primary assessment is complete and all life threats have been addressed, you can move into the history-taking phase of patient assessment. Summary • Patient history is a primary means of diagnosing the chief complaint in the field. • The first part of a patient’s history also serves as a good mental status examination: ask for the patient’s name; the date, time, and location; the chief complaint; and the events leading up to the request for EMS assistance. Summary • After clarifying the history of the present illness, ask the patient about his or her past medical history, the state of his or her health, and any pertinent family history. • For responsive patients, the history may generally be obtained directly from the patient; for unresponsive medical patients and trauma patients, it may be necessary to obtain the history from family. Summary • Use constructive communications skills as you talk with patients. • At times you will need to ask patients about sensitive topics. Be familiar with techniques for successfully asking patients about these topics. • Obtaining a history from a geriatric patient may involve challenges. Summary • Work on strategies within your service and with your partner for positive communications with patients. • Secondary assessment is the process by which quantifiable, objective information is obtained from a patient about his or her overall state of health. Summary • There are times when you may not have time to perform a secondary assessment. The two types of physical examinations are the full-body exam and the focused assessment. Summary • The secondary assessment includes obtaining vital signs and performing a headto-toe survey. • The techniques of inspection, palpation, percussion, and auscultation allow you to use your physical senses to obtain physical information and to understand the normal functions of a patient’s body. Summary • Vital signs consist of a measurement of blood pressure; pulse rate, rhythm, and quality; respiratory rate, rhythm, and quality; temperature; and pulse oximetry. • Monitoring devices used by the paramedic include continuous ECG monitoring, 12-lead ECG, carbon dioxide monitoring, blood chemistry analyses, and cardiac biomarkers, among others. Summary • You need to alter your approach to patient assessment when dealing with infants and children. • After the primary assessment, the reassessment is the single most important assessment process you will perform. Summary • The reassessment is performed on all patients. It gives you an opportunity to reevaluate the chief complaint and to reassess interventions to ensure that they are still effective. • A patient in stable condition should be reassessed every 15 minutes, whereas a patient in unstable condition should be reassessed every 5 minutes. Credits • Chapter opener: Courtesy of Rhonda Beck • Backgrounds: Green—Jones & Bartlett Learning; Purple—Jones & Bartlett Learning. Courtesy of MIEMSS; Blue—Courtesy of Rhonda Beck; Red— © Margo Harrison/ShutterStock, Inc. • Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or have been provided by the American Academy of Orthopaedic Surgeons.