Chapter 9: Patient Assessment

Assessing Neurovascular Status

- Check for bilateral muscle strength or weakness - Complete a thorough sensory assessment - Test for pain, sensations, and position - Compare distal and proximal sensory and motor responses and one side with the other Step 1: Palpate the radial pulse in the upper extremity Step 2: Palpate posterior tibial and dorsalis pedis pulses in the lower extremity Step 3: Assess capillary refill by blanching a fingernail or toenail Step 4: Assess sensation on the flesh near the tip of the index finger and thumb, as well as the little finger. Step 5: On the foot, first check sensation on the flesh near the tip of the big toe Step 6: Check sensation on the side of the foot Step 7: For upper extremity injury, evaluate motor function by asking patient to open the hand. Step 8: Ask patient to make a fist Step 9: For lower extremity injury, ask patient to flex the foot and toes. Step 10: Have patient extend the foot and ankle and pull the toes and foot towards the nose

Normal Ranges for Respirations

Adults: 12 to 20 breaths/min Adolescents (13 to 18 years): 12 to 16 School-Aged Children (6 to 12 years): 18 to 30 Preschoolers (4 to 5 years): 22 to 34 Toddlers (1 to 3 years): 24 to 40 Infants: 30 to 60

Explain the variations required to obtain a pulse in infant and child patients compared with adult patients. (P 329-330)

Adults: Easily felt at pulse point, Palpate at radial pulse in responsive patients, and palpate at carotid pulse in the neck in unresponsive patients Infant/Childs: palpate the brachial pulse in medial area of the upper arm, have infant lying supine,

Discuss different challenges EMTs may face when taking a patient history on sensitive topics and strategies that can be used to facilitate each situation. (P 341-343)

Alcohol and Drugs- establish a rapport with patient, do not judge a patient and be professional, be honest and open, information is confidential Physical abuse or violence- Do not make accusations, see if information is consistent, separate people present and interview separately, avoid subjective comments in documentation Sexual History- Female: consider all women reporting lower abdominal pain to be pregnant unless ruled out by history. Questions: last menstrual period, are periods normal, sexually active, birth control pils Male: must inquire about urinary symptoms

Explain the process of forming a general impression of a patient as part of primary assessment and the reasons why this step is critical to patient management. (P 323-324)

General Impression: is formed to determine the priority of care and is the first part of your primary assessment. Like age, sex, race, level of distress, overall appearance. Approach patient from the front. Ask about the chief complain to find level of consciousness, airway patency, respiratory status, and overall circulatory status. You will define your patient's condition as stable, stable but potentially unstable, or unstable to direct further assessment and treatment.

Discuss the steps EMTs should take to survey a scene for signs of violence and protect themselves and bystanders from real or potential danger. (P 317-318)

Be aware of: Violent Patients Distraught family members Angry bystanders Gangs Unruly crowds

Describe examples of different techniques EMTs may use to obtain information from patients during the history-taking process. (P 340-346)

Begin by making introductions, make patient feel comfortable and obtain permission to treat. Ask simple and direct questions/ open ended questions do not interrupt, get information from surrounding people if patient is unresponsive

Describe how to determine the mechanism of injury (MOI) or nature of illness (NOI) at an emergency and the importance of differentiating trauma patients from medical patients. (P 318-319)

Mechanism of Injury (MOI): type or amount of force, how long it was applied, and where it was applied to the body. Falls, motor vehicle crashes, assaults, industrial accidents Nature of Illness (NOI): For patients with medical problems. Seizures, heart attack, diabetic problems, and poisoning. MOI associated with: Blunt and Penetrating Trauma. To quickly determine: Talk with patient, family, or bystanders, use your senses, and keep observations of the scene in mind.

Characteristics of Respirations

Normal: not shallow nor deep, equal chest rise and fall Shallow: Decreased chest or abdominal wall motion Labored: increased breathing effort, nasal flaring Noisy: increase in sound of breathing, includes snoring.

List the minimum standard precautions that should be followed and personal protective equipment (PPE) that should be worn at an emergency scene, including examples of when additional precautions would be appropriate. (P 319-320)

Personal Protective Equipment (PPE): includes clothing or specialized equipment that protects the wearer. Standard Precautions: Consistent handwashing before and after, gloves, eye protection, mask, and gown. An minimum of gloves must be in place

Describe the principal goals of the primary assessment process, including how to identify and treat life threats and determine if immediate transport is required. (P 323)

Primary Assessment: Has a single, all-important goal: to identify and begin treatment of immediate or imminent life threats. Examine the Level of Consciousness (LOC), and Airway, breathing, and circulation (ABCs)

Discuss the process of assessing and methods for controlling external bleeding. (P 332)

Serious bleeding from a large vein may be characterize by steady blood flow Bleeding from an artery is characterized by a spurting flow of blood. Controlling external bleeding includes directing pressure with your gloved hand, and soon thereafter a sterile bandage, over the wound. When direct pressure is not quickly successful or whenever you encounter obvious arterial hemorrhage of an extremity, apply a tourniquet

Describe the assessment of a patient's skin color, temperature, and condition, including examples of both normal and abnormal findings and the information this provides related to the patient's status. (P 330-331)

Skin color: Skin Temperature: Skin Moisture: Capillary Refill:

Measuring Blood Pressure by Auscultation

Step 1: Apply cuff snugly. Lower border of cuff should be about 1 inch above the antecubital space. Step 2: Support exposed arm at the level of the heart. Palpate the brachial artery. Step 3: Place the stethoscope over the brachial artery, and grasp the ball-pump and turn-valve. Step 4: Close the valve and pump to 30 mm Hg above the point at which you stop hearing pulse sounds. Noe the systolic and diastolic pressures as you let air escape slowly Step 5: Open the valve and quickly release the remaining air

Assessing Blood Glucose Level

Step 1: Cleanse the site with an antiseptic Step 2: Puncture the site with the lancet needle Step 3: Dispose of the needle in a sharps container Step 4: Obtain a drop of blood on the test strip. Insert the test strip in to the glucometer and activate the device Step 5: Place a bandage over the puncture site.

List normal blood pressure ranges for adults, children, and infants. (P 364)

Systolic Pressure: increased pressure that is caused on contraction of ventricles. Represents max pressure to which the arteries are subjected Diastolic Pressure: residual pressure in arteries during relaxing phase of the hearts cycle. Represents min pressure present in the arteries. Adults: 90 to 130 systolic Adolescent (15 years): 110 to 131 Child (7 years): 96 to 115 Child (2 years): 88 to 106 Infant (1 year): 85 to 104 Neonate: 60 to 84

Discuss the steps used to identify and subsequently treat life-threatening conditions that endanger a patient during an emergency. (P 332-333)

Takes 60 to 90 seconds Step 1: assess head, looking and feeling for DCAP-BTLS (Deformities, Contusions, Abrasions, Punctures, Burns, Tenderness, Lacerations, and Swelling) Step 2: Assess the neck Step 3: Apply a cervical collar if indicated Step 4: Assess the chest. Listen to breath sounds on both sides of the chest. Step 5: Assess the abdomen Step 6: Assess the pelvis. If there is no pain, gently compress the pelvis downward and inward to look for tenderness and instability. Step 7: Assess all four extremities. Assess the pulse and motor and sensory function Step 8: Assess the patient's back. If spinal immobilization is indicated, do so with minimal movement to the patient's spine by log rolling the patient in one movement.

SAMPLE

S- Signs and Symptoms A- Allergies M- Medications P- Pertinent past medical history L- Last oral intake E- Events leading up to the injury or illness

Explain how the different causes and presentations of emergencies will affect how EMTs perform each step of the patient assessment process. (P 315)

-Road and traffic hazards that will affect where you park your vehicle -Incident hazards such as fire, hazardous materials, or scenes of violence that may affect how and if you approach the scene

Explain situations in which patients may receive a focused assessment, including examples by body system of what each focused assessment should include based on a patient's chief complaint. (P 353-373)

1. Look for lacerations, bruises, and deformities. 2. Inspect area around eyes and eyelids 3. Examine eyes for redness and contact lenses. Check pupil function 4. Look behind ears for Battle sign 5. Check ears for drainage or blood 6. Observe and palpate the head 7. Palpate the zygomas 8. Palpate the maxillae 9. Check nose for blood and drainage 10. Palpate the mandible 11. Assess mouth and nose 12. Check for unusual breath odors 13. Inspect neck, observe for jugular vein distention 14. Palpate front and back of neck 15. Inspect chest, and observe breathing motions 16. Gently palpate over the ribs 17. Listen to anterior breath sounds (Midaxillary, midclavicular) 18. Listen to posterior breath sounds (bases, apices) 19. Observe and palpate abdomen and pelvis 20. Gently compress pelvis from sides 21. Gently press the iliac crests 22. Inspect extremities; assess distal circulation and motor and sensory function 23. Log roll patient and inspect back

Measuring Blood Pressure by Palpation

Easier to do Step 1: Secure cuff around patients upper arm Step 2: With non dominant hand, palpate the patient's radial pulse on the same arm as the cuff. Once you locate it do not move your fingertips until you have completed taking the blood pressure. Step 3: While holding ball-pump in your other hand, close the turn-valve and slowly inflate the cuff until the pulse disappears and then continue to inflate another 30 mm Hg. As the cuff inflates, you will no longer feel the pulse Step 4: Open the turn-valve so that air slowly releases and carefully observe the gauge. When you can feel the radial pulse note the reading on the gauge as the systolic blood pressure. Step 5: Next, open the turn-valve further, and completely deflate the cuff. Document and note that the pressure was taken by palpation.

Discuss some of the possible environmental, chemical, and biologic hazards that may be present at an emergency scene, ways to recognize them, and precautions to protect personal safety. (P 317-318)

Environmental, Physical, Chemical, Electrical, Water, and Biological Hazards: Blood and Body Fluids Place yourself between the patient and the potential danger to prevent possible access to the object Request the assistance of law enforcement if the scene is unsafe with the potential for violence

Identify the components of the patient assessment process. (P 315)

Five Main Parts: Scene Size-Up- Refers to your evaluation of the conditions in which you will be operating. Have Situational Awareness Primary Assessment History Taking Secondary Assessment Reassessment

Discuss the process of taking a focused history, its key components, and its relationship to the primary assessment process. (P 338)

History Taking- provides details about the patient's chief complain and an account of the patient's signs and symptoms. Document: date of incident, patient's age, gender, race, past medical history, and current health status.

Discuss the importance of protecting a trauma patient's spine and identifying fractured extremities during patient packaging for transport. (P 335-336)

If a spinal injury is suspected or found on assessment, consider spinal immobilization. If you are unsure if spinal immobilization is necessary, err on the side of caution and provide immobilization.

Explain why it is important for EMTs to identify the total number of patients at an emergency scene and how this evaluation relates to determining the need for additional or specialized resources, implementation of the incident command system (ICS), and triage. (P 320-321)

Incident Command System: identifying number of patients, and then begin triage. Triage: Is the process of sorting patients based on the severity of their condition. Helps allocate personnel, equipment, and resources to provide the most effective care to everyone. To determine if additional resources are needed ask yourself: 1. Does the scene pose a threat to you, your patient, or others? 2. How many patients are there? 3. Do we have the resources to respond to their conditions?

Describe the assessment of a patient's breathing status, including the key information EMTs must obtain during this process and the care required for patients who have both adequate and inadequate breathing. (P 327-328)

Key questions: Is the patient breathing? Is the patient breathing adequately? Is the patient hypoxic? Perform positive-pressure ventilations for patients who are not breathing or breathing slow/shallow Shallow Respirations are identified by little movement of the chest wall. Nasal Flaring: indicate inadequate breathing.

Describe the purpose of a secondary assessment and a physical exam; include how to determine which aspects of the physical exam to use, and the steps. (P 348-353)

Purpose- perform a systematic physical examination of the patient. may be head-to-toe or focuses on certain area or system of the body. Inspection: inspect for abnormalities Palpation: feeling for abnormalities Auscultation: process of listening to sounds the body makes by using a stethoscope

Explain the importance of performing a reassessment of the patient and the steps in this process. (P 375)

Reassessment: performed at regular intervals during the assessment process, nad its purpose to identify and treat changes in a patients condition 1. Repeat the primary assessment 2. Reassess vital signs 3. Reassess the chief complaint 4. Recheck interventions 5. Identify and treat changes in the patient's condition 6. Reassess patient

List the signs of respiratory distress and respiratory failure. (P 329)

Respiratory Distress: -Agitation, anxiety, restlessness -Stridor, wheezing -Accessory muscle use -Tachypnea -Mild tachycardia -Nasal flaring, seesaw breathing, head bobbing Respiratory Failure: -Lethargy, difficult to rouse -Tachypnea with periods of bradypnea or agonal respirations -Inadequate chest rise/poor excursion -Inadequate respiratory rate or effort -Bradycardia -Diminished muscle tone

Describe the assessment of airway status in patients who are both responsive and unresponsive, including examples of possible signs and causes of airway obstruction in each case as well as the appropriate EMT response. (P 326-327)

Responsive Patients: -any patient talking or crying have an open airway -conscious patient who cannot speak or cry most likely has a severe airway obstruction -stop assessment process and clear the patient's airway -take airway-management techniques if patient has signs of difficulty breathing or is not breathing. Unresponsive Patients: - If there is a potential for trauma, use jaw-thrust maneuver - Another cause if relaxation of tongue muscles, address by positioning airway, followed by placing an oral or nasal airway Signs of airway obstruction - obvious trauma, blood, or other obstruction - Noisy breathing, such as snoring, bubbling, gurgling, crowing, stridor You should: Open airway using head tilt-chin lift maneuver, suction as necessary, use an airway adjunct as necessary

Describe the assessment of a patient's circulatory status, including the different methods for obtaining a pulse and appropriate management depending on the patient's status. (P 329-330)

To determine if a pulse is present, you will need to palpate (Feel) it. Hold index and long fingers and place their tips over a pulse point. If the patient has a pulse but is not breathing: Adults: provide ventilations at 10 to 12 breaths/min Infant/Child: provide ventilations at 12 to 20 breaths/min An AED is indicated for use on patients who have been assessed to be unresponsive and pulseless

Explain the importance of assessing a patient's level of consciousness (LOC) to determine altered mental status and include examples of different methods used to assess alertness, responsiveness, and orientation. (P 324-325)

Unconscious: focus on initial assessment on problems with Airway, breathing, and circulation. Focus on critical respiratory, circulatory, or central system problem. Conscious with altered LOC can be caused by: Medications, drugs, alcohol, and poisoning. AVPU Scale tests a patient's responsiveness based on: -Awake and Alert -Responsiveness to verbal stimuli -Responsiveness to pain -Unresponsiveness Orientation tests a patient's mental status by checking his or her memory and thinking ability. Evaluate: Person- able to remember his or her name Place- able to identify his or her current location Time- able to tell you current year, month, and date Event- able to describe event (MOI or NOI)

OPQRST

Used for questions about pain O- Onset P- Provocation/palliation Q- Quality R- Region/radiation S- Severity T- Timing

Explain the process for determining the priority of patient care and transport at an emergency scene and include examples of conditions that necessitate immediate transport. (P 335-336)

Used to determine if a patient needs immediate transport or will tolerate a few more minutes on scene. High-priority patients: Unresponsive, poor general impression, difficulty breathing, uncontrolled bleeding, responsive but unable to follow commands, severe chest pain, pale skin, complicated childbirth, severe pain in any area of the body.