Download Physical Examination

Chapter 7
Patient
Assessment
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Outline
• Scene Size-Up
• Initial Assessment
• Physical Examination
• Patient History
• Ongoing Assessment
• Hand-Off Report
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Patient Assessment
• The process of
determining the
problems a patient
is experiencing
• Goal of FR is to
identify and treat
critical problems
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Patient Assessment
• Scene size-up
• Initial assessment
• Physical examination
• Ongoing assessment
• Hand-off report
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Scene SizeUp
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Scene Size-Up
• First step of patient assessment
• Quick determination of scene
– Personal safety
– Safety of scene
– Assessment of Mechanism of Injury (MOI) or
Nature of Illness (NOI)
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Size up this scene
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Personal Safety
• First concern is PPE
– BSI
– Protective clothing
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Size up this scene
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Safety of the Scene
Common hazards:
• Unstable vehicles
• Undeployed airbags
• Leaking fluids
• Traffic
• Agitated or violent patient or bystanders
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Safety of the Scene
Common hazards
• Hazardous materials
– Tractor-trailer crashes, train derailments,
industrial sites, farm incidents
– Notify HAZMAT team
– Do not approach scene until directed
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Safety of the Scene
Common hazards:
• Crime Scenes
– Violent crime
– Domestic violence
• Environment
– Slopes, ice, water, etc.
– Weather conditions
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Bystanders
• Often not aware of hazards and may put
themselves at risk
• May also put others at risk
– Smoking in presence of oxygen or spilled fuel
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If the scene is not safe, and you cannot
make it safe, do not enter.
STOP!
Wait for specially trained rescue personnel to
make scene safe or bring patient to you.
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Scene Size-Up
Also includes
• Mechanism of injury (MOI)
• Nature of illness (NOI)
• Number of patients
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MOI
• An evaluation of forces that caused an
injury
• May help anticipate injuries
• Systematically survey scene and question
bystanders
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What would you ask or look for?
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Determine:
• Vehicle speeds
• Seat belt use
• Presence of airbags
• Patient ejected or thrown from vehicle
• Point of impact
• Damage to vehicle or equipment
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Determine:
• If patient assaulted
(shot, beaten,
stabbed)
• Weapon used
• Height of fall
• Surface patient
landed on
• Position patient
landed
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Nature of Illness
• What are some
clues to illness?
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Nature of Illness
• Why did patient
call for help?
• What is the
patient’s
complaint?
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Clues to Illness
• Patient confined to bed
• Patient uses walker or cane
• Patient lacks adequate food/shelter
• Patient takes medications
• Other clues?
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Number of Patients
• Incident may involve more than 1 patient
• Must be determined before patient care
• Call for additional resources if needed
• If more than 1 patient, perform triage
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Initial
Assessment
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The initial assessment is performed to
identify any immediate threats to the
patient’s life.
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Initial Assessment
• General impression
• Level of responsiveness
• Checking A,B,C,D of patient
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General Impression
• Gather information about patient and
patient’s environment
– What is the patient’s position?
– What is the patient’s appearance?
– Any sights/sounds/smells?
– Does it appear to be medical or trauma?
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What is your general
impression?
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LOC
• Evaluation of
patient alertness
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Caution!
If patient condition
caused by trauma
with significant
mechanism of
injury begin by
stabilizing patient’s
cervical spine.
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Unconscious Patient
• Speak to patient
• If no response
– Shake patient’s
shoulder
– Pinch earlobe or
shoulder
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AVPU Scale
• Alert
• Verbal
• Painful
• Unresponsive
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Alert
• Patient awake
• Eyes open
• Speaks
spontaneously
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Verbal
• Not alert
• Patient responds to voice by:
– Opening eyes
– Speaking
– Moving
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Painful
• Not alert
• No response to
voice
• Responds
to painful
stimulus
– Pinch
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Unresponsive
• Not alert
• No response
to voice
• No response
to painful
stimulus
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Infants & Children
• AVPU not a good scale
• To determine
responsiveness
note if interaction
with parents and
actions normal
for age
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A - Airway
Responsive Patient
• Can patient speak without difficulty?
Unresponsive Patient
• Perform head-tilt chin-lift/jaw-thrust
• Inspect airway
• Clear airway as needed
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Assess & Treat
If patient’s airway is
not open ….
OPEN IT!
Before moving on to
B - Breathing
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B - Breathing
Responsive Patient
• Ability to speak without stopping to catch breath
• Noisy breathing
• Patient position
• Use of accessory muscles
• Rate and depth of ventilations
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B - Breathing
Unresponsive patient
• Look
• Listen
• Feel
Any signs of inadequate breathing?
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Assess & Treat
If breathing is absent, too fast, too slow, too
shallow,
Immediately begin ventilations
before moving to C - Circulation
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C - Circulation
• Evaluation of
circulation of
patient’s blood
– Assess pulse
– Look for major
blood loss
– Assess skin
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Assess Pulse - Where?
• Responsive adult
– Radial pulse
• Unresponsive adult
– Carotid pulse
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Assess Pulse - Where?
• Responsive child
– Radial or brachial
pulse
• Unresponsive child
– Carotid or femoral
pulse
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Assess Pulse - Where?
• Responsive or
unresponsive infant
– Brachial pulse
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Assess Pulse
Determine:
• Presence or
absence
• Rate
• Strength
• Regularity
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Assess & Treat
If no pulse,
Immediately begin chest
compressions
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Check for Blood Loss
• Major external bleeding
– Actively bleeding?
– Pool of blood anywhere?
– Collection of blood in patient clothes/hair?
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Assess & Treat
Control major
bleeding
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Assess Skin
• Color
• Temperature
• Moisture
• Inadequate circulation causes pale, cool,
clammy skin
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D - Disability
• Assessment of brain function
• Use Glasgow Coma Scale (GCS)
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Glasgow Coma Scale
Eye Opening
Verbal Response
Motor Response
•
Spontaneous
4
To Voice
3
To Pain
2
None
1
Oriented
5
Confused
4
Inappropriate Words
3
Incomprehensible Words
2
None
1
Obeys Command
6
Localizes Pain
5
Withdraw (pain)
4
Flexion (pain)
3
Extension (pain)
2
None
1
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Make a decision!
• Is the patient critical?
• Is the patient non-critical?
What is critical?
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Critical Indicators
• Unresponsive
• Cyanosis
• Noisy airway
• Cool, clammy skin
• Compromised airway
• GCS ≤ 13
• Inadequate breathing
• Confused/disoriented
• Absence of breathing
• Pediatric – flaccid;
glassy stare
• Uncontrolled bleeding
• Weak, absent or
irregular pulse
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Communicate
• Patient’s age and sex
• Chief complaint
• Level of responsiveness
• Status of airway and breathing
• Status of circulation and disability
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Any questions on initial assessment?
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Physical
Examination
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Physical Examination
• Begins once life-threatening problems
addressed
• Purpose is locating and beginning
management for signs and symptoms of
injury and illness
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Take Note!
• May not perform
PE if life-saving
care still required
• Not all patients will
require all steps of
PE
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Physical Examination
• Inspection
– Look for signs
of illness or
injury
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Physical Examination
• Palpation
– Feel for signs of
illness or injury
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DOTS
D - Deformities
O – Open injuries
T – Tenderness
S - Swelling
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Systematic and Orderly
• Often done “head to toe”
• Assess all body areas for DOTS
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Physical Examination
• Assess head
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Physical Examination
• Assess the face
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Physical Examination
• Assess the eyes,
nose, and mouth
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Physical Examination
• Assess the neck
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Physical Examination
• Assess the chest
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Physical Examination
• Listen to lung
sounds
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Physical Examination
• Assess the
abdomen
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Physical Examination
• Assess the back
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Physical Examination
• Assess the pelvis
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Physical Examination
• Assess the
extremities
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Physical Examination
• Check
Circulation
(Post Tibial Pulse)
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Physical Examination
• Check
Circulation
(Dorsalis Pedis
Pulse)
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Physical Examination
• Check for
– Motion
– Sensation
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Physical Examination
• Repeat for upper
extremities
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Physical Examination
• Assess
circulation
(Radial Pulse)
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Physical Examination
• Assess
circulation
(Sensation)
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Physical Examination
• Assess sensation
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Physical Examination
• Look for medical
insignia tags
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Any questions on
physical examination?
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Patient
History
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When?
• Take patient history either before, after, or
during physical examination
– Depends on situation
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Who?
• Begin with patient
• If patient can’t
answer
– Ask family
members
– Ask bystanders
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SAMPLE History
S – Signs and symptoms
A – Allergies
M – Medications
P – Pertinent past history
L – Last oral intake
E – Events leading to injury or illness
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What is?
A sign?
A symptom?
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S – Signs and Symptoms
A sign is a finding you can hear, see, feel or
measure.
A symptom is something a patient describes.
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Ask Questions …
• Can you describe the problem?
• What kind of symptoms?
• What makes the symptoms better/worse?
• When did the symptoms start?
• How long have you had problem?
• Anything like this happen before?
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A - Allergies
• Medications
• Foods
• Substances in
environment
• Any medical
insignia tags?
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M - Medications
• Prescription
medications
• Over-the-counter
medications
• Another person’s
medications
• Has patient recently
stopped taking any
medications
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P – Pertinent Past History
• Are you seeing physician for anything?
• Ever been hospitalized?
• Any medical problems?
• Any pertinent surgeries?
• Any significant injuries?
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L – Last Oral Intake
• When did you last eat or drink?
• What was it?
• How much?
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E – Events Leading up to
injury or illness
• What were you doing when the problem
started?
• Were there any other symptoms at that
time?
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Any questions on patient
history?
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Ongoing
Assessment
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Ongoing Assessment
• Assessment doesn’t end after physical
examination and patient history
• Continue to reassess patient until
additional help arrives
• Frequency depends on patient’s condition
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Ongoing Assessment
Critical patient
– Reassess at least every 5 minutes
Non-critical patient
– Reassess at least every 15 minutes
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What do I Reassess?
• Airway
• Breathing
• Circulation
• Disability (mental status)
– AVPU
– GCS
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Don’t forget …
• Reassure the patient while waiting for help
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Hand-Off
Report
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When EMS Unit Arrives
Provide:
• Patient age and
sex
• Chief complaint
• Level of
responsiveness
• Airway and
breathing status
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When EMS Unit Arrives
Provide:
• Circulation and
mental status
• Physical
examination
findings
• SAMPLE history
• Interventions
provided
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Summary
• Before treatment of a patient can be
started, the First Responder must make it
to the patient’s side safely, protect others
at the scene, and make sure that needed
additional resources are on their way.
• Patient assessment begins with scene sizeup. This step gives clues about the
mechanism of injury or nature of illness.
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Summary
• The initial assessment gives the First
Responder a general impression of the
patient’s condition.
• All immediately life-threatening problems
are to be detected and treated during the
initial assessment.
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Summary
• Following the initial assessment, the First
Responder will perform a physical exam
and obtain a brief medical history.
• Assessment is ongoing to detect changes
in the patient’s condition.
• The First Responder completes the patient
assessment process by communicating
findings to EMS personnel assuming care
of the patient.
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Vital Signs
Team Work
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Respiratory Rate
• Count the number
of breaths for 30
seconds and
double it
• Note the depths,
regularity and
symmetry of
breathing
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Pulse
• Count the number
of beats for 30
seconds and
multiply by two
• Note the regularity
and strength of the
pulse
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Skin
• Assess the color,
temperature and
moisture of the
patient’s skin
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Blood Pressure
• Wrap cuff around
arm
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Blood Pressure
• Palpate the
brachial pulse
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Blood Pressure
• Place the
stethoscope over
the location where
you found the
pulse
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Blood Pressure
• Close the valve
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Blood Pressure
• Use the balloon to
pump up the cuff
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Blood Pressure
• Loosen the valve
and let air escape
slowly while
listening for a beat
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Blood Pressure
• Note the gauge
reading when you
hear the first
sound
• This is the systolic
blood pressure
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Blood Pressure
• Note the gauge
reading when you
stop hearing
sounds
• This is the diastolic
blood pressure
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Blood Pressure
• Although less
desirable, a blood
pressure can be
palpated by feeling
for a radial pulse
• The systolic
reading is felt
instead of heard
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