Assessment of the Patient

Assessment of Assessment of the Patientthe PatientConcepts of Emergency Concepts of Emergency

MedicineMedicine

Pam Knepp, RN BSNPam Knepp, RN BSN

Assessment of the Assessment of the PatientPatient

Scene Size-upScene Size-up Initial AssessmentInitial Assessment Focused History and Physical ExamFocused History and Physical Exam Vital SignsVital Signs Hand-off to EMTsHand-off to EMTs

Patient AssessmentPatient Assessment

Bergeron, J. David & Chris Le Bandour. (2009). First Responder. 8th Edition. Pearson Prentice Hall. Upper Saddle River:NJ.

Patient AssessmentPatient Assessment

Bergeron et al. (2009). First Responder. 8th Edition. Pearson Prentice Hall. Upper Saddle River:NJ.

Scene Size-upScene Size-up

Every patient assessment begins with Every patient assessment begins with scene size-up, which includes:scene size-up, which includes:

Taking BSI precautions (body substance Taking BSI precautions (body substance isolation)isolation)

Determining if the scene is safe Determining if the scene is safe Identifying the MOI (mechanism of injury) or Identifying the MOI (mechanism of injury) or

nature of illnessnature of illness Determining the number of patientsDetermining the number of patients Identifying any additional resources neededIdentifying any additional resources needed


BSI precautionsBSI precautions

Rescuer wears Rescuer wears protective eye protective eye wear.wear.



Rescuer dons gloves.Rescuer dons gloves.



Rescuer wears both Rescuer wears both a gown and a a gown and a simple surgical simple surgical mask.mask.



Rescuer wears a Rescuer wears a HEPA mask. HEPA mask. (filters the air so (filters the air so less allergens or less allergens or pollutants are pollutants are being inhaled)being inhaled)


*Scene Safety:*Scene Safety:

An assessment of An assessment of the scene and the scene and surroundings will surroundings will provide valuable provide valuable information to information to the First the First Responder and Responder and will ensure the will ensure the well-being of the well-being of the First Responder.First Responder.


Scene Safety:Scene Safety:

1)1) Personal protectionPersonal protection2)2) Protection of the patientProtection of the patient3)3) Protection of bystandersProtection of bystanders

**If the scene is not safe, make it safe. **If the scene is not safe, make it safe. Otherwise, DO NOT ENTER. Otherwise, DO NOT ENTER.


Unstable situationUnstable situation

HazMAT situationHazMAT situation

Violent situationViolent situation


*Identify Mechanism of Injury:*Identify Mechanism of Injury: In trauma situationsIn trauma situations

An evaluation of the forces that caused an An evaluation of the forces that caused an injuryinjury

May be beneficial in determining the presence May be beneficial in determining the presence of internal injuriesof internal injuries

Determined from the patient, family, or Determined from the patient, family, or bystanders, and inspection of the scenebystanders, and inspection of the scene


*Identify Mechanism *Identify Mechanism of injuryof injury

Trauma patientTrauma patient


*Identify mechanism of injury*Identify mechanism of injury Impact #1Impact #1

“A car collides head on with a tree.”


*Identify Mechanism *Identify Mechanism of injuryof injury

Impact #2Impact #2

“The car collision causes the drivers chest to hit steering wheel.”

“The steering wheel causes damage to the chest area and broken ribs.”


*Identify mechanism *Identify mechanism of injuryof injury

Impact #3Impact #3

“The impact of the steering wheel to the drives chest area cause additional damage to inner organs.”


*Identify nature of illness:*Identify nature of illness:

In medical situationsIn medical situations

Determined from the patient, family, or Determined from the patient, family, or bystandersbystanders

Why was EMS called?Why was EMS called?


*Identify nature of *Identify nature of illnessillness

Scene Size-upScene Size-up Determine the number of patients and additional Determine the number of patients and additional

resources needed:resources needed:

It is important to account for all patients involved.It is important to account for all patients involved.

Request additional resources if needed: Request additional resources if needed: Fire departmentFire department PolicePolice ALS crews (Advanced Life Support)ALS crews (Advanced Life Support) RescueRescue Utilities Utilities

Call for resources early.Call for resources early.

Initial AssessmentInitial Assessment Form a general impression of the patient.Form a general impression of the patient.

Assess the patient’s mental status.Assess the patient’s mental status.

Assess the patient’s airway.Assess the patient’s airway.

Assess the patient’s breathing.Assess the patient’s breathing.

Assess the patient’s circulation. Assess the patient’s circulation.

Make a decision on the priority the patient (notify Make a decision on the priority the patient (notify dispatch)dispatch)

Initial AssessmentInitial Assessment

The initial assessment is completed to The initial assessment is completed to assist the First Responder in assist the First Responder in identifyingidentifying Immediate Threats to LifeImmediate Threats to Life..


Form a General Impression of the Form a General Impression of the PatientPatient

Based on the First Responder’s Based on the First Responder’s immediate assessment of the immediate assessment of the environment and the patient’s environment and the patient’s chief complaint.chief complaint.

Initial AssessmentInitial Assessment Form a general impression of Form a general impression of

the patientthe patient

Assess the Patient’s Mental Assess the Patient’s Mental Status:Status:

Classify the patient’s Classify the patient’s mental status into one of mental status into one of the following categories:the following categories:

Alert Alert

Verbal Verbal

Painful Painful

UnresponsiveUnresponsive


*Assess the *Assess the patient’s mental patient’s mental status.status.

Assessing the Assessing the apparently apparently unresponsive patientunresponsive patient


*Assess the patient’s *Assess the patient’s mental statusmental status

Assessing the apparently Assessing the apparently responsive patientresponsive patient


*Assess the *Assess the patient’s airwaypatient’s airway

Head-Tilt; Chin-LiftHead-Tilt; Chin-Lift


*Assess the patient’s airway*Assess the patient’s airway

Jaw-thrust maneuver (with suspected neck Jaw-thrust maneuver (with suspected neck injury)injury)


*Assess the patient’s *Assess the patient’s airwayairway

Suction of neededSuction of needed


*Assess the patient’s *Assess the patient’s airwayairway

Insert an airway adjunct as Insert an airway adjunct as neededneeded


*Assess the patient’s breathing*Assess the patient’s breathing

Look at the effort of breathing.Look at the effort of breathing.

Look, listen, and feel for presence of Look, listen, and feel for presence of ventilations.ventilations.

Ventilate as needed.Ventilate as needed.


Assess the patient’s circulationAssess the patient’s circulation

Check for a pulse (carotid artery in Check for a pulse (carotid artery in adults and brachial artery in infants).adults and brachial artery in infants).

Check for serious bleeding (control Check for serious bleeding (control bleeding).bleeding).

Check skin color.Check skin color.


Make a decision on the priority of Make a decision on the priority of the patient and alert dispatch.the patient and alert dispatch.

High priority:High priority: Poor general impressionPoor general impression UnresponsivenessUnresponsiveness Breathing difficultiesBreathing difficulties Severe bleeding or shock Severe bleeding or shock Complicated childbirthComplicated childbirth Chest painChest pain Severe painSevere pain

Focused History and Focused History and Physical ExamPhysical Exam

Trauma Patient Trauma Patient Medical PatientMedical Patient

Significant Mechanism of InjurySignificant Mechanism of Injury Unresponsive Medical PatientUnresponsive Medical Patient

• • Perform a rapid trauma assessmentPerform a rapid trauma assessment• Take vital signs• Take vital signs• Gather SAMPLE history • Gather SAMPLE history

• • Perform a rapid physical assessmentPerform a rapid physical assessment

• • Take vital signsTake vital signs

• • Gather SAMPLE history Gather SAMPLE history

No Significant Mechanism of InjuryNo Significant Mechanism of Injury Responsive Medical PatientResponsive Medical Patient

• • Perform a focused trauma assessmentPerform a focused trauma assessment

• • Take vital signsTake vital signs

• • Gather SAMBLE history Gather SAMBLE history

• • Gather SAMPLE historyGather SAMPLE history• Perform focused physical exam• Perform focused physical exam

• • Take vital signs Take vital signs


Trauma Patient—Significant MOI:Trauma Patient—Significant MOI: Significant mechanisms of injury include:Significant mechanisms of injury include:

Ejection from a vehicleEjection from a vehicle Death of another passengers in a MVCDeath of another passengers in a MVC Falls greater than 15 feetFalls greater than 15 feet Rollover vehicle collisionRollover vehicle collision High-speed vehicle collisionHigh-speed vehicle collision Vehicle-pedestrian collisionVehicle-pedestrian collision Motorcycle crashMotorcycle crash Unresponsiveness or altered mental statusUnresponsiveness or altered mental status Penetrations of the head, chest, or abdomenPenetrations of the head, chest, or abdomen


* Trauma Patient—Significant MOI:* Trauma Patient—Significant MOI:

Significant mechanisms of injury in a Significant mechanisms of injury in a child include:child include:

Falls greater than 10 feetFalls greater than 10 feet

Bicycle collisionBicycle collision

Medium-speed vehicle collisionMedium-speed vehicle collision


* * Physical Exams or Assessments:Physical Exams or Assessments:

DDeformitieseformities CContusionsontusions AAbrasionsbrasions PPunctures and Penetrationsunctures and Penetrations BBurnsurns TTendernessenderness LLacerationsacerations SSwellingwelling


Trauma patient – Trauma patient – Rapid trauma Rapid trauma assessmentassessment

Stabilize the head and Stabilize the head and neck, and check the neck, and check the head (scalp and face).head (scalp and face).


* Trauma * Trauma assessment – rapid assessment – rapid trauma assessmenttrauma assessment

Check the neck and apply a Check the neck and apply a cervical collar (if trained cervical collar (if trained to do so). Note any to do so). Note any swelling or tenderness.swelling or tenderness.

Focused history and Focused history and physical examphysical exam

Trauma patient – Trauma patient – rapid trauma rapid trauma assessmentassessment

Check the chestCheck the chest Check each quadrant Check each quadrant

of the abdomen (note of the abdomen (note any abnormalities, any abnormalities, tenderness, or foreign tenderness, or foreign bodies)bodies)

Focused History and Focused History and Physical examPhysical exam

Trauma Patient—Trauma Patient—Rapid Trauma Rapid Trauma AssessmentAssessment

Check the pelvis, pressing Check the pelvis, pressing gently down and inward.gently down and inward.


* Trauma Patient—* Trauma Patient—Rapid Trauma Rapid Trauma AssessmentAssessment

Check the extremities, legs, Check the extremities, legs, and then arms (look for and then arms (look for

any deformity, swelling, or any deformity, swelling, or discoloration).discoloration).


* Trauma Patient—* Trauma Patient—Rapid Trauma Rapid Trauma AssessmentAssessment

Check for distal pulse, motor Check for distal pulse, motor function, and sensation in function, and sensation in each extremity.each extremity.


* Trauma Patient—Rapid * Trauma Patient—Rapid Trauma AssessmentTrauma Assessment

Check the back and buttocks Check the back and buttocks while maintaining c-spine while maintaining c-spine immobilization:immobilization:

1)1) keep arms close to center keep arms close to center of body and patient is of body and patient is moved keeping the entire moved keeping the entire body aligned while rolling body aligned while rolling patient on his side.patient on his side.

2)2) the patient is rolled on the the patient is rolled on the count of the person count of the person holding c-spine.holding c-spine.


* * Trauma Patient—No Significant MOI:Trauma Patient—No Significant MOI:

Steps of assessment include:Steps of assessment include: Perform a focused trauma assessment.Perform a focused trauma assessment. Take vital signs.Take vital signs. Gather SAMPLE history.Gather SAMPLE history.

S-signs/symptomsS-signs/symptomsA-allergiesA-allergiesM-medicationM-medicationP-past historyP-past historyL-last oral intakeL-last oral intakeE-events priorE-events prior


* Trauma Patient—Focused * Trauma Patient—Focused Trauma AssessmentTrauma Assessment

1)1) Examine the area that is injured.Examine the area that is injured.

2)2) Take vital signs.Take vital signs.

3)3) Provide appropriate care (i.e. Provide appropriate care (i.e. stabilize any injuries, control stabilize any injuries, control bleeding, dress wounds)bleeding, dress wounds)


Trauma Patient:Trauma Patient:

SAMPLE History:SAMPLE History:

SSigns and symptomsigns and symptoms AAllergies llergies MMedicationsedications PPertinent past medical historyertinent past medical history LLast oral intakeast oral intake EEvents leading to the illness or injuryvents leading to the illness or injury


* * Medical Patient—Unresponsive:Medical Patient—Unresponsive:

Steps of assessment include:Steps of assessment include:

Perform a rapid physical exam (head-to-toe).Perform a rapid physical exam (head-to-toe).

Take vital signs (pulse, respirations, blood Take vital signs (pulse, respirations, blood pressure – if equipment available, mental pressure – if equipment available, mental status).status).

Gather SAMPLE history.Gather SAMPLE history.


* Medical Patient—Responsive:* Medical Patient—Responsive: Steps of assessment include:Steps of assessment include:

Gather SAMPLE history. Gather SAMPLE history.

Take vital signs (pulse, respirations, blood Take vital signs (pulse, respirations, blood pressure-if equipment available, mental status) pressure-if equipment available, mental status)

Perform a focused physical exam.Perform a focused physical exam. Area of chief complaintArea of chief complaint

**Note any medical identification devices (i.e. allergy **Note any medical identification devices (i.e. allergy bracelets)bracelets)

Vital SignsVital Signs

* * Pulse: Pulse:

Assess for three characteristics:Assess for three characteristics: Rate (number of beats per minute)Rate (number of beats per minute) Strength (weak, bounding, thready, absent)Strength (weak, bounding, thready, absent) RhythmRhythm (regular or irregular) (regular or irregular)

Carotid pulse in the neck (most distinct pulse felt)Carotid pulse in the neck (most distinct pulse felt)

Radial pulse in the lateral portion of the forearm, Radial pulse in the lateral portion of the forearm, on the thumb side of the wrist (most easily on the thumb side of the wrist (most easily accessible)accessible)


* * Pulse: Pulse:

To measure a radial pulse rate (number of To measure a radial pulse rate (number of beats/minute)beats/minute)

Use your 1Use your 1stst and 2nd fingertips to feel for an artery. and 2nd fingertips to feel for an artery. Do not use your thumb.Do not use your thumb. Find the artery (usually radial or carotid)Find the artery (usually radial or carotid) Apply moderate pressure. Apply moderate pressure. Count the beats for 30 seconds.Count the beats for 30 seconds. Multiply your 30-second count by 2.Multiply your 30-second count by 2.


*PULSE

Bergeron et al. (2009) First Responder. 8th Edition. Pearson Prentice Hall. Upper Saddle River:NJ.

ObservationObservation Possible ProblemPossible ProblemRapid, strong pulse Rapid, strong pulse Internal bleeding (early stages), Internal bleeding (early stages),

fear, heat emergency, fear, heat emergency, overexertion, high blood pressure, overexertion, high blood pressure, fever fever

Rapid, weak pulse Rapid, weak pulse Shock, blood loss, heat Shock, blood loss, heat emergency, diabetic emergency, emergency, diabetic emergency, failing circulatory system failing circulatory system

Slow, strong pulse Slow, strong pulse Stroke, skull fracture, brain injury Stroke, skull fracture, brain injury

No pulse No pulse Cardiac arrest Cardiac arrest


* Pulse: * Pulse:

The normal pulse rate for adults is 60–The normal pulse rate for adults is 60–100 bpm.100 bpm.

Rate > 100 = Rate > 100 = TachycardiaTachycardia Rate < 60 = Rate < 60 = BradycardiaBradycardia

Newborn infants = 120 to 160 bpmNewborn infants = 120 to 160 bpm Up to 5 years old = 80 to 140 bpmUp to 5 years old = 80 to 140 bpm 5 to 12 years of age = 70 to 110 bpm5 to 12 years of age = 70 to 110 bpm


* Respirations:* Respirations:

Assess for 2 characteristics:Assess for 2 characteristics:

Rate:Rate: SlowSlow NormalNormal RapidRapid

Character:Character: RhythmRhythm——(Regular or Irregular)(Regular or Irregular) Depth—(Normal, Shallow, or Deep)Depth—(Normal, Shallow, or Deep) Sound—(Abnormal Sounds)Sound—(Abnormal Sounds) Ease—(Labored, Difficult, or Painful)Ease—(Labored, Difficult, or Painful)


Respirations: Respirations:

To measure & assess respirations:To measure & assess respirations:

After pulse count, leave your hand on the wrist.After pulse count, leave your hand on the wrist. Observe the rise and fall of the chest.Observe the rise and fall of the chest. Listen for sounds.Listen for sounds. Count the number of breaths in 30 seconds.Count the number of breaths in 30 seconds. Multiply your 30-second count by 2.Multiply your 30-second count by 2. Note rhythm, depth, sound, and ease of Note rhythm, depth, sound, and ease of

breathing.breathing.



ObservationObservation Possible ProblemPossible ProblemRapid, shallow breathsRapid, shallow breaths Shock, heart problems, heat Shock, heart problems, heat

emergency, diabetic emergency, heart emergency, diabetic emergency, heart failure, pneumoniafailure, pneumonia

Deep, gasping labored breaths Deep, gasping labored breaths Airway obstruction, heart failure, Airway obstruction, heart failure, heart attack, lung disease, chest heart attack, lung disease, chest injury, diabetic emergencyinjury, diabetic emergency

Slow breathingSlow breathing Head injury, stroke, chest injury, Head injury, stroke, chest injury, certain drugscertain drugs

SnoringSnoring Stroke, fractured skull, drug or Stroke, fractured skull, drug or alcohol abuse, partial airway alcohol abuse, partial airway obstructionobstruction

CrowingCrowing Airway obstruction, airway injury due Airway obstruction, airway injury due to heatto heat

GurglingGurgling Airway obstruction, lung disease, lung Airway obstruction, lung disease, lung injury due to heatinjury due to heat

WheezingWheezing Asthma, emphysema, airway Asthma, emphysema, airway obstruction, heart failureobstruction, heart failure

Coughing bloodCoughing blood Chest wound, chest infection, Chest wound, chest infection, fractured ribs, punctured lung, fractured ribs, punctured lung, internal injuryinternal injury


* Respirations:* Respirations:

The normal respiratory rate for adults is The normal respiratory rate for adults is 12–20 breaths per minute.12–20 breaths per minute.

> 28 or < 8 are considered serious.> 28 or < 8 are considered serious.

Newborn infants = 25–50 breaths per min.Newborn infants = 25–50 breaths per min. Up to 5 years old = 20–30 breaths per min.Up to 5 years old = 20–30 breaths per min. 5 to 12 years of age = 15–30 breaths per 5 to 12 years of age = 15–30 breaths per

min.min.

Vital SignsVital Signs*Skin color, temperature, moisture

Bergeron et al. (2009). First Responder. 8th Edition. Pearson Prentice Hall. Upper Saddle Hall:NJ.

ObservationObservation Significant / Possible Significant / Possible ProblemProblem

Pink Pink Normal in light-skinned patients; Normal in light-skinned patients; normal in inner eyelids, lips, and nail normal in inner eyelids, lips, and nail beds of dark-skinned patientsbeds of dark-skinned patients

Pale Pale Constricted blood vessels possibly Constricted blood vessels possibly resulting from blood loss, shock, resulting from blood loss, shock, decreased blood pressure, emotional decreased blood pressure, emotional distressdistress

Blue (cyanotic) Blue (cyanotic) Lack of oxygen in blood cells and Lack of oxygen in blood cells and tissue resulting from inadequate tissue resulting from inadequate breathing or heart function breathing or heart function

Red (flushed) Red (flushed) Heat exposure, high blood pressure, Heat exposure, high blood pressure, emotional excitement; cherry red emotional excitement; cherry red indicates late stages of carbon indicates late stages of carbon monoxide poisoning monoxide poisoning

Yellow (jaundiced) Yellow (jaundiced) Liver abnormalities Liver abnormalities

Blotchiness (mottling) Blotchiness (mottling) Occasionally in patients that are in Occasionally in patients that are in shock shock

Vital SignsVital Signs*Skin signs


Skin SignsSkin Signs Significant / Possible Significant / Possible ProblemProblem

Cool, clammyCool, clammy Shock, anxiety, heart attackShock, anxiety, heart attack

Cold, moistCold, moist Body is losing heatBody is losing heat

Cold, dryCold, dry Exposure to coldExposure to cold

Hot, dryHot, dry High fever, heat emergency, spinal High fever, heat emergency, spinal injuryinjury

Hot, moistHot, moist High fever, heat emergencyHigh fever, heat emergency

Goose bumps accompanied by Goose bumps accompanied by shivering, chattering teeth, blue lips, shivering, chattering teeth, blue lips, and pale skinand pale skin

Chills, communicable disease, Chills, communicable disease, exposure to cold, pain, or fearexposure to cold, pain, or fear

Vital SignsVital Signs* Pupils


ObservationObservation Possible ProblemPossible Problem

Dilated, nonreactive pupilsDilated, nonreactive pupils Unresponsiveness, shock, cardiac Unresponsiveness, shock, cardiac arrest, bleeding, certain medications, arrest, bleeding, certain medications, head injuryhead injury

Constricted, nonreactive pupilsConstricted, nonreactive pupils Central nervous system damage, Central nervous system damage, certain medicationscertain medications

Unequal pupilsUnequal pupils Stroke, head injuryStroke, head injury

Ongoing AssessmentOngoing Assessment

While awaiting the While awaiting the additional EMS additional EMS resources, the resources, the First Responder First Responder should continue should continue to assess the to assess the patient.patient.

Ongoing AssessmentOngoing Assessment Repeat initial assessment:Repeat initial assessment:1)1) Repeat every 15 minutes for a stable patient.Repeat every 15 minutes for a stable patient.2)2) Repeat every 5 minutes for an unstable Repeat every 5 minutes for an unstable

patient.patient.

Repeat exams as needed.Repeat exams as needed. Repeat vital signs.Repeat vital signs. Check interventionsCheck interventions.. Calm and reassureCalm and reassure.. Provide comfort measuresProvide comfort measures..

Hand-off Report to EMSHand-off Report to EMS Verbal Report:Verbal Report:

Patient’s mental statusPatient’s mental status Age and sexAge and sex Chief complaintChief complaint Airway, breathing, and circulatory statusAirway, breathing, and circulatory status Physical findingsPhysical findings SAMPLE historySAMPLE history Interventions appliedInterventions applied Patient’s response to interventionsPatient’s response to interventions

Accurate Documentation if RequiredAccurate Documentation if Required

SummarySummary Scene Size-upScene Size-up




Hand-off to EMTsHand-off to EMTs

ReferencesReferences

Bergeron, J. David & Chris Le Bergeron, J. David & Chris Le Bandour. (2009). Bandour. (2009). First First ResponderResponder. 8th Edition. Pearson . 8th Edition. Pearson Prentice Hall.Prentice Hall. Upper Saddle Upper Saddle River: NJ.River: NJ.

Knepp, Pamela RN BSN. Knepp, Pamela RN BSN. Personal experience.Personal experience.

Smith, Travis NREMT-P, CCEMT-Smith, Travis NREMT-P, CCEMT-P. Personal experience.P. Personal experience.

Assessment of the Patient

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