Chapter NINE Knowledge Objectives - Patient Assessment

19. List the steps EMTs should follow during the primary assessment of a trauma patient, including examples of abnormal signs and appropriate related actions. (pg. 334-335)

DCAP-BTLS In Order: - Head - Neck - Chest - Abdomen - Pelvis - Four Extremities - Back & Buttocks

1. Identify the components of the patient assessment process. (pg. 315)

- Scene Size-Up - Primary Assessment - History Taking - Secondary Assessment - Reassessment - The steps represent a logical approach to evaluation, but the order should be dictated by the patients chief complaint MOI/NOI

9. 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. (pg. 323-324)

General Impression: Formed to determine the priority of care and is the first part of your primary assessment. Like age, sex, race, level of distress, and overall appearance. Always approach the patient from the front. Ask about the chief complaint to find LOC, 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.

Vocabulary

Accessory Muscles - The secondary muscles of respiration. They include the neck muscles (sternocleidomastoids), the chest pectoralis major muscles, and the abdominal muscles. Altered Mental Status - Any deviation from alert and oriented to person, place, time, and event, or any deviation from a patient's normal baseline mental status. Auscultate - To listen to sounds within an organ with a stethoscope. AVPU scale - A method of assessing the level of consciousness by determining whether the patient is awake and alert, responsive to verbal stimuli or pain, or unresponsive; used principally early in the assessment process. Blood Pressure - The pressure that the blood exerts against the walls of the arteries as it passes through them. Bradycardia - A slow heart rate, less than 60 beats/min. Breath Sounds - An indication of air movement in the lungs, usually assessed with a stethoscope. Capillary Refill - A test that evaluates distal circulatory system function by squeezing (blanching) blood from an area such as a nail bed and watching the speed of its return after releasing the pressure. Capnography - A noninvasive method to quickly and efficiently provide information on a patient's ventilatory status, circulation, and metabolism; effectively measures the concentration of carbon dioxide in expired air over time. Carbon Dioxide - Carbon dioxide is a component of air and typically makes up 0.3% of air at sea level; also a waste product exhaled during expiration by the respiratory system. Chief Complaint - The reason a patient called for help; also, the patient's response to questions such as "What's wrong?" or "What happened?" Coagulate - To form a clot to plug an opening in an injured blood vessel and stop bleeding. Conjunctiva - The delicate membrane that lines the eyelids and covers the exposed surface of the eye. Crackles - A crackling, rattling breath sound that signals fluid in the air spaces of the lungs. Crepitus - A grating or grinding sensation caused by fractured bone ends or joints rubbing together; also air bubbles under the skin that produce a crackling sound or crinkly feeling. Cyanosis - A blue-gray skin color that is caused by a reduced level of oxygen in the blood. DCAP-BTLS - A mnemonic for assessment in which each area of the body is evaluated for Deformities, Contusions, Abrasions, Punctures/penetrations, Burns, Tenderness, Lacerations, and Swelling. Diaphoretic - Characterized by light or profuse sweating. Diastolic Pressure - The pressure that remains in the arteries during the relaxing phase of the heart's cycle (diastole) when the left ventricle is at rest. Distracting Injury - Any injury that prevents the patient from noticing other injuries he or she may have, even severe injuries; for example, a painful femur or tibia fracture that prevents the patient from noticing back pain associated with a spinal fracture. Focused Assessment - A type of physical assessment typically performed on patients who have sustained nonsignificant mechanisms of injury or on responsive medical patients. This type of examination is based on the chief complaint and focuses on one body system or part. Frostbite - Damage to tissues as the result of exposure to cold; frozen or partially frozen body parts are frostbitten. General Impression - The overall initial impression that determines the priority for patient care; based on the patient's surroundings, the mechanism of injury, signs and symptoms, and the chief complaint. Golden Hour - The time from injury to definitive care, during which treatment of shock and traumatic injuries should occur because survival potential is best; also called the Golden Period. Guarding - Involuntary muscle contractions of the abdominal wall to minimize the pain of abdominal movement; a sign of peritonitis. History Taking - A step within the patient assessment process that provides detail about the patient's chief complaint and an account of the patient's signs and symptoms. Hypertension - Blood pressure that is higher than the normal range. Hypotension - Blood pressure that is lower than the normal range. Hypothermia - A condition in which the internal body temperature falls below 95°F (35°C) after exposure to a cold environment. Incident Command System - A system implemented to manage disasters and mass- and multiple- casualty incidents in which section chiefs, including finance, logistics, operations, and planning, report to the incident commander. Also referred to as the incident management system. Jaundice - Yellow skin or sclera that is caused by liver disease or dysfunction. Labored Breathing - Breathing that requires greater than normal effort; may be slower or faster than normal and characterized by grunting, stridor, and use of accessory muscles. Mechanism of Injury (MOI) - The forces, or energy transmission, applied to the body that cause injury. Metabolism - The biochemical processes that result in production of energy from nutrients within the cells. Nasal Flaring - Widening of the nostrils, indicating that there is an airway obstruction. Nature of Illness (NOI) - The general type of illness a patient is experiencing. OPQRST - A mnemonic used in evaluating a patient's pain: Onset, Provocation/palliation, Quality, Region/radiation, Severity, and Timing. Orientation - The mental status of a patient as measured by memory of person (name), place (current location), time (current year, month, and approximate date), and event (what happened). Palpate - To examine by touch. Paradoxical Motion - The motion of the portion of the chest wall that is detached in a flail chest; the motion—in during inhalation, out during exhalation—is exactly the opposite of normal chest wall motion during breathing. Perfusion - The flow of blood through body tissues and vessels. Personal Protective Equipment (PPE) - Protective equipment that blocks exposure to a pathogen or a hazardous material. Pertinent Negatives - Negative findings that warrant no care or intervention. Priapism - A painful, tender, persistent erection of the penis; can result from spinal cord injury, erectile dysfunction drugs, or sickle cell disease. Primary Assessment - A step within the patient assessment process that identifies and initiates treatment of immediate and potential life threats. Pulse - The pressure wave that occurs as each heartbeat causes a surge in the blood circulating through the arteries. Pulse Oximetry - An assessment tool that measures oxygen saturation of hemoglobin in the capillary beds. Reassessment - A step within the patient assessment process performed at regular intervals during the assessment process to identify and treat changes in a patient's condition. A patient in unstable condition should be reassessed every 5 minutes, whereas a patient in stable condition should be reassessed every 15 minutes. Responsiveness - The way in which a patient responds to external stimuli, including verbal stimuli (sound), tactile stimuli (touch), and painful stimuli. Retractions - Movements in which the skin pulls in around the ribs during inspiration. Rhonchi - Coarse, low-pitched breath sounds heard in patients with chronic mucus in the upper airways. SAMPLE History - A brief history of a patient's condition to determine signs and symptoms, allergies, medications, pertinent past history, last oral intake, and events leading to the injury or illness. Scene Size-Up - A step within the patient assessment process that involves a quick assessment of the scene and the surroundings to provide information about scene safety and the mechanism of injury or nature of illness before you enter and begin patient care. Sclera - The tough, fibrous, white portion of the eye that protects the more delicate inner structures. Secondary Assessment - A step within the patient assessment process in which a systematic physical examination of the patient is performed. The examination may be a systematic exam or an assessment that focuses on a certain area or region of the body, often determined through the chief complaint. Shallow Respirations - Respirations characterized by little movement of the chest wall (reduced tidal volume) or poor chest excursion. Sign - Objective findings that can be seen, heard, felt, smelled, or measured. Situational Awareness - Knowledge and understanding of your surroundings and situation and the risk they potentially pose to your safety or the safety of the EMS team. Sniffing Position - An upright position in which the patient's head and chin are thrust slightly forward to keep the airway open. Spontaneous Respirations - Breathing that occurs without assistance. Standard Precautions - Protective measures that have traditionally been developed by the Centers for Disease Control and Prevention (CDC) for use in dealing with objects, blood, body fluids, and other potential exposure risks of communicable disease. Stridor - A harsh, high-pitched, breath sound, generally heard during inspiration, that is caused by partial blockage or narrowing of the upper airway; may be audible without a stethoscope. Subcutaneous Emphysema - A characteristic crackling sensation felt on palpation of the skin, caused by the presence of air in soft tissues. Symptom - Subjective findings that the patient feels but that can be identified only by the patient. Systolic Pressure - The increased pressure in an artery with each contraction of the ventricles (systole). Tachycardia - A rapid heart rate, more than 100 beats/min. Tidal Volume - The amount of air (in milliliters) that is moved in or out of the lungs during one breath. Triage -The process of establishing treatment and transportation priorities according to severity of injury and medical need. Tripod Position - An upright position in which the patient leans forward onto two arms stretched forward and thrusts the head and chin forward. Two- to Three-Word Dyspnea - A severe breathing problem in which a patient can speak only two to three words at a time without pausing to take a breath. vasoconstriction Narrowing of a blood vessel. Vital Signs -The key signs that are used to evaluate the patient's overall condition, including respirations, pulse, blood pressure, level of consciousness, and skin characteristics. Wheezing - A high-pitched, whistling breath sound that is most prominent on expiration, and which suggests an obstruction or narrowing of the lower airways; occurs in asthma and bronchiolitis.

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

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

15. Explain the variations required to obtain a pulse in infant and child patients compared with adult patients. (pg. 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.

24. Discuss different challenges EMTs may face when taking a patient history on sensitive topics and strategies that can be used to facilitate each situation. (pg. 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 pills.

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

Be aware of: - Violent Patients - Distraught Family Members - Angry Bystanders - Gangs - Unruly Crowds

23. Describe examples of different techniques EMTs may use to obtain information from patients during the history-taking process. (pg. 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.

5. 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. (pg. 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. To quickly determine: Talk with patient, family, or bystanders, use your senses, and keep observations of the scene in mind.

6. 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. (pg. 319-320)

Personal Protective Equipment (PPE): includes clothing or specialized equipment that protects the wearer. Standard Precautions: Consistent hand-washing before and after, gloves, eye protection, mask, and gown.

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

17. Discuss the process of assessing and methods for controlling external bleeding. (pg. 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.

16. 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. (pg. 330-331)

Skin Color: Poor peripheral circulation or cold/frozen skin will appear pale, ashy gray; low oxygen will cause cyanosis (Blue or gray skin). Skin Temperature: Fever, sunburn, hyperthermia (hot); Early shock, mild shock, inadequate perfusion (cold).

18. Discuss the steps used to identify and subsequently treat life-threatening conditions that endanger a patient during an emergency. (pg. 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.

26. 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. (pg. 353-373)

- look for lacerations, bruises, and deformities. - inspect area around eyes and eyelids - examine eyes for redness and contact lenses., check pupil function. - look behind ears for battle sign - check ears for drainage or blood - observe and palpate the head - palpate the zygomas - palpate the maxillae - check nose for blood and drainage - palpate the mandible - assess mouth and nose - check for unusual breath odors - inspect neck, observe for jugular vein distention - palpate front and back of neck - inspect chest, and observe breathing motions - gently palpate over the ribs - listen to anterior breath sounds (midaxillary, midclavicular) - listen to posterior breath sounds (bases, apices) - observe and palpate abdomen and pelvis - gently compress pelvis from sides - gently press the iliac crests - inspect extremities; assess distal circulation and motor and sensory function - log roll patient and inspect back

3. 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. (pg. 317-318)

Environmental: - location (in/outdoor, public/private) - weather - terrain - uneven/unstable surfaces - sharp metal, broken glass - road and traffic hazards - violence - fire, explosions Chemical: - hazardous materials - carbon monoxide Electrical: - down power lines Biological: - biohazards such as blood or body fluids - airborne pathogens Precautions: Wear proper BSI and PPE, safety vest, traffic markers (cones, flares, signs), traffic personnel, strategic positioning of vehicles, call for additional resources, any actions to protect yourself should also be done for the patient whenever possible.

12. 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. (pg. 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 indicates inadequate breathing.

22. Discuss the process of taking a focused history, its key components, and its relationship to the primary assessment process. (pg. 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.

21. Discuss the importance of protecting a trauma patient's spine and identifying fractured extremities during patient packaging for transport. (pg. 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.

7. 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. (pg. 320-321)

Incident Command System: Identifying number of patients, and then begin triage. Triage: 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: - Does the scene pose a threat to you, your patient, or others? - How many patients are there? - Do we have the resources to respond to their conditions?

25. 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. (pg. 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.

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

Reassessment is performed at regular intervals during the assessment process, and its purpose is to identify and treat changes in a patients condition. - repeat the primary assessment - reassess vital signs - reassess the chief complaint - recheck interventions - identify and treat changes in the patients condition - reassess patient

13. List the signs of respiratory distress and respiratory failure. (pg. 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

11. 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. (pg. 326-327)

Responsive Patients: Any patient talking or crying has 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

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

Road and traffic hazards can affect where you park your ambulance which makes it difficult to get to and from the scene / hospital. Incident hazards such as fire, hazardous materials or scenes of violence may affect how and if you approach the scene.

14. 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. (pg. 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

10. 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. (pg. 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)

20. 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. (pg. 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.