Patient Assessment

Patient Assessment#Learning ObjectivesUnderstand the purpose of the scene size-up in patient assessmentIdentify immediate life threats and recognize the need for immediate transportDefine and describe techniques to determine the Chief ComplaintUnderstand the use of vital signs as a measure of the patients health statusDistinguish the need for a full-body scan or focused assessmentFull list of competencies and learning objectives on p. 250-251#Prehospital Emergency CarePatient assessment is the basis for decisions regarding treatment and transportEvery patient you encounter will require some form of assessment

Rarely does a single symptom or sign reveal the patients status or underlying problem. The algorithm taught in this class is the basis for assessments used at all levels of medical care. #Patient Assessment ProcessScene Size-UpPrimary AssessmentHistory TakingSecondary AssessmentReassessmentThe five basic elements of patient assessment are listed here. Scene-Size Up allows the EMT to ensure the safety of everyone involved and to recognize the need for additional resources.During the Primary Assessment, the EMT identifies and treats immediate threats to life.In History Taking, the EMT questions the patient and/or bystanders to determine what the Chief Complaint, or worst problem, is for the patient.During the Secondary Assessment, the EMT performs a physical exam on the patient and checks vital signs.Reassessment is the continuous process of assessing the patient and repetition of parts of the exam depending on the patients status. More seriously ill or injured patients require more frequent, if not constant, reassessment.This outline can be used for both medical and trauma patients. As you master patient assessment, you will be able to use different elements of the assessment at different times, but the basic outline will remain the same for all patients. This section begins on page 250 of your textbook.#Scene Size-UpEnsure scene safetyDetermine mechanism of injury or nature of illnessTake standard precautionsDetermine number of patientsConsider additional/specialized resourcesPatient AssessmentPrimary AssessmentHistory TakingSecondary AssessmentReassessment#What is the Scene Size-Up?An ongoing assessment of the scene and surroundings that will provide you with information about scene safetyScene size-up begins with dispatch and continues until you leave. Information from your dispatcher can help you determine what additional resources may be needed or whether special care may be required by the patient.#Scene SafetyIs it safe to approach the patient?If the scene is not safe, can it quickly be made safe?Are additional resources necessary?7#Potential Hazards: Overview

The goals of the scene size-up are to:Identify possible hazards at the scene to ensure the safety of yourself, other members of the team, the patient, and bystandersIdentify what led you to being called to the scene either an injury or a medical problemDetermine which factors of the scene may require additional resources

What possible hazards are present in this image (and those that follow it)?-Where to park? Does this ambulance have an easy exit?Can you determine anything about the patient?What additional resources might be necessary?#

Crash or Rescue ScenesRoger Nomer/AP (http://www.cbc.ca/gfx/images/news/photos/2008/05/10/wideshot-usweather-cp-23311.jpg)Is it safe for the EMT to approach the patient? (Is the car stable yet?)What challenges might the EMT face when trying to reach the patient? (Possible hazards may include oncoming traffic, unstable vehicle and possibly difficult extrication, gas leaking from vehicle, downed wires, fire or smoke.)#Unstable Surfaces: Slopes, Ice, Water

The route you take to reach a patient will usually be the route you must take to evacuate the patient. Be sure that you can safely transport yourself, your equipment, and then the patient as well.#Crime Scenes and Violence

Patients, distraught family members, bystanders, crowds, and other individuals may be hostile and present a threat to the EMT. Be observant not only of actual weapons but other objectsscrewdrivers, heavy objects, etc.that may be used as weapons.#Toxic Substances or Hazmat

Placards may identify hazardous materials, or you may be altered to their presence by odor, fumes, or visible spills. Unless you can determine that it is safe to enter an area, call for additional resources.#Environmental Considerations

Your patients location will determine what impact the environment will have on your care. Inclement weather may contribute to your patients symptoms or create challenges to effective treatment. Be sure you can effectively protect yourself and your patient against environmental hazards, or that you can safely and quickly relocate your patient.#Actions for Protection

Park in a visible, safe place that with easy accessTalk to law enforcement before entering scene if they are present.Follow local protocol for crime scenes.Call for additional resources when scene is unsafe.#MOI and NOIConsider Mechanism of Injury (MOI) or Nature of Illness (NOI) to predict the extent of injury or cause of illness15#Mechanism of InjuryThe physical event that caused an injury E.g. Fall, motor vehicle accidentConsiderAmount of force applied to the bodyLength of time force was appliedArea(s) of body involved

E.g. blunt trauma (falls, MVC), penetrating trauma (stab wounds, GSW). At the scene of a motor vehicle collision, look at damage to the vehicles externally and internally, intrusion into the passenger compartment, and the use of safety devices (seat belts, airbags).# Nature of IllnessThe medical condition or complaint causing sufferingE.g. Chest pain, abdominal pain, difficulty breathing, etc. ConsiderThe patients symptomsThe patients medical historyThe patients surroundingsAsk the patient, family, bystanders, and observe of the scene for clues to identify the cause of illness.

#Standard PrecautionsAlways remember to take appropriate precautions to assure your own safety!Three commonly used terms used when discussing standard precautions:Universal Precautions describe operational and systematic procedures intended to prevent exposure to potentially pathogenic substances. It typically describes prevention of exposure to HIV.Body Substance Isolation refers to practices of isolating any substance of patients from contact with providers by use of Personal Protective Equipment and handwashing.Personal Protective Equipment includes gloves, masks, and other protective gear worn to prevent exposure or injury.Universal precautions#Body Substance IsolationNitrile or vinyl gloves should always be worn during patient contactEye protection should be used if splattering is possibleMask and gown should be used as needed19Always assume that blood, body fluids (except sweat), open wounds, and mucous membranes are potentially infectious.Standard precautions protect against exposure from blood, other body fluids, potentially infectious objects, and other exposure risks.#Gloves

20Vinyl, nitrile, or other non-latex gloves are typically used in EMS. You should practice safe removal of gloves.#Mask and Eye Protection

21You should wear a mask and eye protection in any instance in which patient substances could become airbornecoughing, spitting, profuse bleeding, vomiting, etc.#Respirator Mask

22High-Efficiency Particulate Air (HEPA), N100 or N95 respirators prevent inhalation of bacteria and some toxic particles.HEPA masks are equivalent to N100, but N95 (above) are most commonly seen in medical use.#Gown

For patients who have topical infections, such as MRSA, or when there is a high risk of contact with blood or bodily fluids, a full gown helps to prevent exposure. #Number of PatientsIdentify how many patients require careMore than one seriously ill or injured patient will require additional resourcesFor multiple patients, triage is used to determine who is in greatest need

The Incident Command System is used for disasters and mass-casualty incidents. If you determine that there are more patients than you are able to care for, call for additional units.#Adequacy of ResourcesNumber of patients?ALS or air medical support?Hazardous materials?Fire or rescue?Unusual or violent situations?Contact additional resources before beginning your assessmentQuestions to ask are: How many patients are there?What is the nature of their condition?Who contacted EMS?Is the scene potentially dangerous to you, your patient, or others?#ReviewList potential hazards you may find at the scene and the appropriate additional resources you would request for eachDescribe a situation that would require: gloves, goggles, gown, mask, HEPA respiratorExplain the difference between MOI and NOI#Patient AssessmentPrimary AssessmentForm a general impressionAssess level of consciousnessAssess the AIRWAY; identify and treat life threatsAssess BREATHING; identify and treat life threatsAssess CIRCULATION; identify and treat life threatsPerform rapid scanDetermine priority of patient care and transportHistory TakingSecondary AssessmentReassessmentScene Size-UpGoal of the Primary Assessment is to identify and begin treatment of immediate/potential life threatsThe patients condition, and vital signs (once taken), will determine the extent of care provided at the scene#General ImpressionAge, Sex, RaceLevel of distressGood, bad, ugly?Overall appearanceNeed for spinal immobilization?

Approach the patient so that they see you comingIntroduce yourself and call the patient by nameAsk the patients chief complaint

Good: StableBad: Potentially UnstableUgly: Unstable#Assessing Level of ConsciousnessResponsivenessAlertness and response to external stimuliOrientationThought process and memory functionLOC is considered a vital sign. Patients may be alert and oriented (conscious and unaltered), responsive but not oriented (conscious but altered), or unconscious/unresponsive.Altered Mental Status is frequently abbreviated AMS.AMS is frequently caused by inadequate perfusion, so treatment of ABCs should facilitate adequate perfusion (provide oxygen).Unresponsiveness is a sign of a potentially critical respiratory, circulatory, or central nervous system problem.#Assess ResponsivenessA V P UAlertNot alert but responds to:Verbal stimulusPainful stimulusUnresponsive#Mental Status: Alert

An alert patient opens eyes spontaneously and will look at you. The patient is aware of his or her surroundings/environment.

#Mental Status: Verbal Stimulus

Response to verbal stimuli may include eye opening and/or some meaningful response when spoken to.Give a command, such as Open your eyes if you can hear me, or Squeeze my hand if you can hear me.

#Mental Status: Painful StimulusPinch the earlobeOr the neck muscles

Response to painful stimuli will not include eye opening or meaningful responses, but will react by moving or crying out in response to pain.

#Response to StimuliResponse to questions or commands may be APPROPRIATE or INAPPROPRIATEResponse to painful stimulus:Normal is to withdraw from painAbnormal: Decorticate: Flexion of arms toward the core - into the bodyAbnormal: Decerebrate: Extension of arms & legs outward from bodyThese responses are useful when calculating the Glasgow Coma Score (p. 263)#Mental Status: Unresponsive

Unresponsive patients will not respond to verbal or painful stimuli, and lack cough and gag reflexes. The patient typically cannot protect his or her own airway.

#OrientationPerson Tells you his/her namePlace Identifies locationTimeYear, month, approximate dateEventMOI/NOI, what happenedIf abnormal, look for causes. Was the patient like this before? What happened? What is the patients normal mental status?

Ex. Conscious, Alert & Oriented X 2 = Person & PlaceEx. Conscious, Alert & Oriented X 4 = Person, Place, Time & Event

The questions evaluate long-term, intermediate, and short term memory (in that order).When reporting, remember that hospital staff use Alert and Oriented x 3 as fully alert, which does not include Event. #Assess the AirwayPatentOpen and maintained by the patientPatient is responsive, speakingPotentially obstructedObvious trauma or other obstructionNoisy or absent breathingPatient is unresponsive#Open and Maintain AirwayHead-Tilt Chin LiftModified Jaw Thrust

If there is no indication of trauma, the head-tilt chin lift should be used to open the airway.If there is any risk of head or spine injury, use the modified jaw thrust to keep the spine in neutral position.After opening the airway, suction if necessary and use an airway adjunct (OPA/NPA) to maintain.#Assess breathing

Assess presence and adequacy of breathing. A patient who is breathing without assistance is said to have spontaneous breathing.Assess and treat injuries that may interfere with breathing#Look, Listen & Feel

Rate, Rhythm, QualityBreath and Lung SoundsInjuriesAssess rate (fast/normal/slow), rhythm (regular/irregular), and quality (shallow/normal/deep, labored/unlabored) of breathing by assessing the rise and fall of the chest.Check breath sounds (Present, diminished, absent) comparing the right and left side by auscultating with a stethoscope.Check lung sounds (Quality of sounds, will be discussed later in vitals) comparing the right and left and upper, middle, and lower fieldsAssess for injuries affecting breathing (Open Wounds, Paradoxical Motion, Asymmetrical Breathing). Expose the chest and palpate.

#Breath SoundsMid-clavicular

Mid-axillary

Listen below the curve of the clavicle and below the armpit on each side.#BreathingGive high-concentration oxygen if:Respirations are adequate but faster than 24/minute or slower than 8/minutePatient has difficulty breathingPatient shows signs of hypoxiaAssist with ventilations if:Patient is unable to breathe adequatelyPatient has injuries to the chest#Assess CirculationPulseBleedingSkin

#Check PulseConscious: Radial PulseUnresponsive: Carotid Pulse

Rate (fast/normal/slow), rhythm (regular/irregular), quality (bounding/strong/weak/thready)In conscious adults and children, check radial pulse first.If unconscious or if there is no radial pulse, check carotid pulse.If no carotid pulse, begin CPR and connect the AED.

#Infants: Check brachial pulse

#Check SkinColorTemperatureMoisture

The skin provides clues to the adequacy of perfusion. Cyanosis (blue coloring) is a sign of hypoxia that is best seen at the lips and conjunctiva of the eyes (and fingertips/palms in children).Skin may be pale or ashen when there is inadequate perfusion, white or waxy when very cold, flushed when blood pressure is extremely high or the patient is hot, and yellowish when the patient has acute liver disease.Warm skin can indicate a heat emergency or fever, cool skin a cold emergency or inadequate perfusion.The moisture of the skin can indicate dehydration, stress, or acute illness in the case of diaphoresis (excessive sweating).#Infants/Children: Capillary Refill

In children, capillary refill is a good indicator of perfusion, and may be a better indicator than blood pressure for risk of shock.#Capillary Refill

Check capillary refill by pressing on the nail bed and then releasing pressure. Color should return in less than two seconds.#Identify External Bleeding

Perform a blood sweep to identify major bleeding or pooling blood.#Control Severe Bleeding

Control arterial or other life-threatening bleeding as soon as it is identified.#(Check for Disability)If the patient has altered mental status, perform a brief neurological exam:PupilsCSMsPosturing #Assessing PupilsNormal pupils are PERRLPupilsEqualRoundRegular in sizeReactive to Light

Useful as a sign of brain activity: is the controller (brain) working? Pupillary movement is controlled by cranial reflexes. If there is brain injury, these reflexes may not function normally.Dilated Normal ConstrictedEqual or unequalReactive or nonreactive (fixed)Equally or unequally reactiveSluggish#Abnormal Pupil Conditions

Fixed with no reaction to lightDilate with light or constrict without lightReact sluggishlyUnequal in sizeBecome unequal when light is introduced or removed#Circulation, Sensation, MovementCSMs are used to test distal perfusion and neurological functionIs there blood flow distal to an injury?Are sensory and motor functions intact?

#Circulation

Check the pulse at a distal pulse point to ensure perfusion of the limb.If the injury is distal to these pulse points, check capillary refill in a digit.

#Circulation

Check dorsal pedal or posterior tibial pulses in the feet. Capillary refill can also be used on toes.#Assess Sensation in All Extremities

Assess sensation by touching a finger and asking the patient to identify which finger is being touched. Repeat for the opposite hand and both feet individually.#Assess Motor Function

Have the patient move his or her fingers and toes. Look for equal ability to move. Pain that restricts motion is one way to reduce motor function.#Strength & Equality of Grip

To assess neurological function when there is no trauma, have the patient squeeze your hands. Check for equal grip strength.

#Assess Strength & Motion

Have the patient push against your hands (plantarflex) and pull (dorsiflex).#Posturing

http://www.paramedicine.com/pmc/AVPU_files/droppedImage.jpgPosturing is a sign of head trauma. Decorticate (de-cortexed) indicates injury to the brain cortex, and decerebrate indicates injury to the brainstem. Either can occur with herniation.#Rapid ScanQuickly assess the patient to identify injuries that must be managed or protected immediatelyUse the mnemonic DCAP-BTLS to recall the kinds of injuries you may find

#Deformities

Deformities are parts of the body that have been injured to change their shape broken bones, dislocated joints, etc.#Contusions

Contusions, bruises, and ecchymosis all describe the same thing: bleeding under the skin associated with pain, swelling, and discoloration. A Hematoma is caused by significant bleeding and swelling.#Abrasions

Abrasions are shallow soft tissue injuries. They may have significant potential for infection if large in size, but are relatively easy to clean.#Punctures/Penetrations

Penetrating objects (impalements) enter and may exit the body. If the object is no longer in the wound, it is called a puncture wound. There may be injury to deeper tissues.Penetrating wounds have significant potential for infection, as they are difficult to clean.#Burns

Burns damage tissue through heat, and are described by their cause and depth.#

TendernessEven without physical signs of injury, the patient may report pain on palpation.#Lacerations

Lacerations are breaks caused in the skin by stretching/tearing. Incisions are cuts in the skin by an object. These are technically incisions, but laceration is used as a general term for longitudinal wounds.#Swelling

Swelling is best assessed by comparing an uninjured area to an injured area.#Rapid ScanTreat any life threatening injuries as you find themAirway/Breathing compromiseUncontrolled bleedingUnstable injuriesScanning should take no more than 90 seconds#Check Head, Hold C-spine

#Neck

Also check for Jugular Venous Distension (JVD), crepitus at the vertebrae, tracheal deviation, subcutaneous emphysema (air bubbles under the skin).#Size and Apply C-Collar

If the patient reports neck or back pain, there was a significant MOI, or there was trauma and the patient is unresponsive, size and apply a c-collar.#Chest

Palpate the ribs and sternum and auscultate breath sounds.#Abdomen

Palpate the four quadrants, checking for tenderness, distension, guarding, and pulsating masses.#Pelvis

Press inward on the iliac crests, and if stable, press downward. If unstable when pressing inward, do not test with downward pressure.If unstable in either direction, immobilize before transport.#Legs, then Arms

Palpate circumferentially, moving proximally to distally, then check CSMs on each limb.#Log-Roll, Check Back

Palpate the vertebrae, scapulae, and ribs. Check the buttocks. If necessary, place the patient on a backboard.#Transport DecisionWhat priority is the patient?When will you go?How should the patient go?Where are you going?Who is going with you?What priority: High, medium, lowWhen: Immediately, after further examination, after certain care is providedHow to transport: In what position, what packaging is necessaryWhere: Nearest hospital or to a specific hospital, e.g. trauma center, stroke center, pediatric hospitalWho: ALS, additional resources (police protection), family

Why: Initial assessment should determine life-threats, age, chief complaint, need for rapid vs. delayed transport, need for ALS or other resources, to answer all transport decision questions

High-priority patients may have:Poor general impression, altered mental status, inadequate respirations, uncontrolled bleeding, shock (hypoperfusion), complicated childbirth, chest pain, severe pain anywhere

#The Golden Period

The Golden Period is roughly the time frame for discovery, assessment, and transport to definitive care to ensure the patients best chances for survival. This is your goal for arrival to the scene, primary assessment, and transport decisions to be made.#REVIEWList the steps of the primary assessmentExplain how to assess a patients level of responsiveness using AVPUExplain how to assess airway, breathing, and circulation during the primary assessmentDescribe how to identify priority patients

82#Patient AssessmentPrimary AssessmentSecondary AssessmentReassessmentScene Size-UpHistory TakingInvestigate the chief complaint (History of Present Illness)Obtain SAMPLE historyHistory taking provides detail about the patients chief complaint and other signs and symptoms and the patients medical history.#History Taking

Record the date of the incident, and the time of each assessment and interventionAsk the patient forDemographic information: Name, age, gender, racePast medical history: medical problems, past injuries, surgeriesCurrent health status: diet, medications, drug use, living environment (and hazards), family historyIf the patient is unable to provide this information ask family members or witnesses and look for medical alert jewelry#SAMPLESigns/SymptomsAllergiesMedicationsPertinent past medical historyLast oral intakeEvents leading up to the injury/illnessSAMPLE is the outline used by EMTs to organize a patients medical history. It begins with inquiry about the patients chief complaint and any other complaints, and then discusses more specific aspects of the history.#Signs & SymptomsSigns are objectiveCyanosis, dilated pupilsSymptoms are subjectiveI think Im going to throw upI cant feel my feetSymptoms are experienced by the patient pain, dizziness, nausea, etc. These are things the patient must tell you.Signs are observable conditions swelling, cyanosis, dilated pupils, absent pulse, abnormal lung sounds, etc. These can be seen, heard, felt, smelled, or measured by the EMT.

#Chief ComplaintAsk whats wrong? or what happened? Usually the symptom bothering the patient most is the Chief ComplaintRecord in the patients own wordsIm having chest pain.After asking about the patients symptoms, ask about the History of Present Illness, which will tell you more information about the symptoms. The patient may have already told you many of the answers.You should ask about the history of each of the patients symptoms, which may or may not be related.#OPQRSTHistory of Present Illness can be assessed using the mnemonic:OnsetProvocation/PalliationQualityRegion/RadiationSeverityTimeThe mnemonic OPQRST will help you to remember the features of a symptom or sign. Not all of these features are relevant to every symptom. (p. 282)

#History of Present Illness OnsetHow did the problem start, gradually or rapidly?It is also useful to find out what the patient was doing when the symptom started, and whether any other symptoms began at that time.#History of Present Illness Provocation/PalliationWhat makes the problem better or worse?How are you most comfortable?

Symptoms that are not constant may be triggered or relieved by outside stimuli. These can include medications, foods, movements or positions that the patient performs. #History of Present Illness QualityDescribe what you are feeling. Ex. Aching, burning, weakness, etc.Quality refers to how the symptom is affecting the patient.#History of Present IllnessRegion/RadiationWhere is the pain?Does the pain move or hurt anywhere else?Point to where the pain is worst.R: It is often helpful to have the patient point with one finger to where the pain is worst, and then indicate anywhere else there is pain.#History of Present IllnessSeverityHow much does it hurt?

S: A scale from 0 or 1 to 10, 0 being no pain/10 being worst pain ever felt, can be useful for quantifying pain when treatment is provided. Mild/moderate/severe is a more simple format. The image shows Wong-Baker Faces, which are especially useful with children.#History of Present IllnessTimeHow long have you had this problem?Has this happened before?What was it then?What was done?#Common ComplaintsLoss of Consciousness Shortness of BreathChest PainHeadache/Dizziness/Tingling/WeaknessNausea/Vomiting/DiarrheaPainOnce you have discussed the patients chief complaint (and any others the patient has), ask about other common complaints.Common complaints may be secondary to the chief complaint or life-threatening.This is a non-exhaustive list used to identify or rule-out commonly found symptoms.

#Pertinent NegativesChief complaints often have associated signs and symptomsIf the patient does not have these signs and symptoms, they are pertinent negativesA patient has sub-sternal chest pain, but has pink, warm, dry skin and denies radiating pain#AllergiesAre you allergic to anything?MedicationsFoodEnvironmental factors: pollen, beesWhat has happens when you are exposed to _____?

Allergic reaction: Reddening of skin, hives, itching, wheezing, shortness of breathAnaphylactic Reaction: Loss of perfusion due to respiratory failure and blood pressure collapse

#MedicationsWhat medications do you take?What are they for?Prescription, Over-the-counter (OTC), Herbal, RecreationalHave you taken them as prescribed?Have there have been any recent changes?

Find pill bottles to make a list of medications and dosages (or take them with you if you do not have time to make a list).Quite a bit of medical history can be deduced or inferred from the list of medications.#Pertinent Past Medical HistoryWhat medical problems do you have?The patient may be unable to give you an accurate history

Ask family members, friends, or bystanders if they know about the patients history. If transferring between facilities (e.g. from a nursing home to the ED) look at the patients medical record.Ask about recent illnesses or injuries, chronic illnesses or old injuries, and surgeries.Some history can be reconstructed from a list of medications.#Last Oral IntakeWhat is the last thing you ate or drank?When was that?

This may indicate the cause of the patients current problem. You may also want to inquire they ate or drank anything new, or if they were following their normal eating habits.Allergies, Alcohol, or lack of intake are common causes of medical problems.It is also important for the hospital to know if the patient is going to the Operating Room, as anesthesia can cause nausea and vomiting.#Events Leading to the ProblemWhat were you doing when this started?What do you think happened?Verbally reconstruct the event to show what happened to the patient.It is helpful to review information gained in SAMPLE to correct any miscommunication and remember any missed steps.

#Sensitive TopicsAlcohol and drug useSexual historyPhysical abuse and violence

Use non-judgmental, normative language when asking questions about sensitive topics. Dont ask these questions in public, as they represent private information the patient may not be willing to share.Substance use: Remember that patients who are dependent or who chronically use alcohol or drugs may not know accurately how much they use, or may be unwilling to say.Sexual history: When potentially relevant, ask about sexual history, including sexual activity, use of contraceptives/protection, and possibility of pregnancy or STD exposure.Document any signs of physical abuse, and be sure to ask the patient when they are alone or away from possible abusers (such as in the back of the ambulance).

#Challenges to CommunicationSilent or overly talkative patientsMultiple symptoms or confusing historyAnxiety, anger, hostility, cryingDepressionSilence: Be patient, the patient may need time to formulate answers. Using closed-ended questions may help.Overly talkative: It may be difficult to get specific or timely information from nervous, chemically-stimulated, or confabulating patients. Try to redirect tangents back to your assessment and questions.The patient may have multiple symptoms, which is common in the elderly, or multiple complaints that are exclusive or interact. Take your time to understand the history so that you dont miss something.Emergency situations cause many strong emotions that your patient may have difficulty expressing or controlling. By remaining calm, gentle, and reassuring, you can ensure that you dont exacerbate the situation. With these patients, and depressed patients as well, it is important to listen to the patient actively, and not force answers.#Challenges to CommunicationImpairments: Hearing, seeing, learning, intoxicationLanguage barriers

Patience is necessary when working with impaired patients. They may need special assistance or techniques: you may need to write your questions/answers, lead your patient or direct them to where their possessions are, or use simple language to communicate what you are asking and doing.When working with a language barrier, find an interpreter. Be aware that your questions might not be translated directly, and that your patient may not want your interpreter to know the answers. More information on p. 284-287.

#ReviewExplain the purpose of the History of Present Illness as it relates to the Chief ComplaintList appropriate questions to ask patients for each part of SAMPLEDiscuss challenges to communication, and techniques to overcome them#Patient AssessmentHistory TakingReassessmentScene Size-UpPrimary AssessmentSecondary AssessmentAssess vital signs using the appropriate monitoring deviceSystematically assess the patientFull-body scan and/or Focused assessmentThe secondary assessment is a systematic assessment of the entire patient or affected region.Three words describe your actions in the secondary assessment: inspect, palpate, and auscultate.Secondary assessment can be performed on scene or in the ambulance. If you must manage life threats while en route, you may not complete the secondary assessment before reaching the hospital or transferring care.#Vital SignsKey indicators used to evaluate patients conditionReflect changes in respiratory, circulatory, and central nervous systemsThe first complete set is called baseline vitals#Common PrefixesA- (an-) not, without, lacking, deficientDys- bad, difficult, abnormal, incomplete Hypo- below normal, deficient, under, beneathBrady- slowBi- (di-) two, twice, double, both

Hyper- above normal, excessive

Tachy- fast

#Common Suffixes-cardia: Heart-itis: Inflammation-oxia: Oxygen -pnea: Breath, breathing-stasis: Stopping, controlling-tension: Physiological stress or pressure

#Vital SignsRespirationsBreath Sounds/Lung SoundsPulseSkinBlood PressurePupils*Oxygen saturation#Assessing RespirationsAssess breathing by:Observing a patients chest rise and fallFeeling air be expelledListening to breath sounds and lung sounds with a stethoscopeChest rise and breath sounds should be equal on both sides of the chestE.g. Diminished Breath Sounds

Breathing is normally spontaneous.There are an inspiratory and an expiratory phase, the inspiratory phase takes about 1/3 the time of the expiratory.Assess the rate, depth, and effort of breathing. Place your hands on the patients ribs to assess equal chest rise.Listen for sounds at the mouth as well.#Respiratory Rate

Count the number in respirations in a 30 second period and multiply by 2Count for 60 seconds with irregular breathingDont let the alert patient know you are counting!#Normal Respiratory RatesAGERANGEAdults12 20 breaths/minChildren15 30 breaths/minInfants25 50 breaths/min#Respiration RhythmIrregular frequent variations and changes in breathing intervalRegular breathing is consistentRecord when respirations are regular or irregular#Respiration Quality - EffortNormal breathing is effortlessLabored breathingChoppy speechPatient position: sniffing or tripodPursed lips, nasal flaringAccessory muscle useRetractions

Supraclavicular and intercostal retractions can be a sign of partial or complete obstruction of the upper airway#Respiration Quality NoiseNormal breath sounds (by ausculation)Air movement through bronchiSoft, low-pitched murmur-like soundOther sounds indicate a significant problemFully obstructed airwayWont make any sounds#Breath SoundsAssess with stethoscopeMidclavicularMidaxilary Check side to side for comparisonDetermine whether or not air is moving in the lungsAre the sounds present and equal?#Lung SoundsAssess with stethoscopeMeasure side to side at upper, middle, lower fields (6 locations front or back)Determine the quality of the air movementCheck for abnormal sounds#Noisy RespirationsBubbling or gurglingFluid in the airway (suction!)StridorHigh-pitched crowing soundIndicates partial upper airway obstructionWheezes and snoring

Thick yellowish sputum: Possible advanced respiratory infectionBloody or frothy sputum: Chest injury may have blood in alveoli, CHF may have fluid buildup in alveoli#Other Lung SoundsBone CrepitusCracklesCoarse (Rhonchi) inspiratory and expiratory cracklesFine (Rales) inspiratory cracklesMedium inspiratory and expiratory cracklesMedium inspiratory crackles with severe expiratory wheezesSubcutaneous Emphysema

#Respiration Quality DepthAir exchange during respiration depends on respiratory rate and tidal volumeBreath depth (chest excursion) determines whether tidal volume is:NormalLess than normal (shallow)Greater than normal (deep)#Inadequate BreathingRate:Tachypnea: rapid respirationsHyperpnea: abnormally rapid or deep breathingRhythm: May be irregularDepth/Quality: Too shallow or too much effortDyspnea: shortness of breath or difficulty breathingApnea: absence of breathing

Tachypnea can prevent adequate oxygenation due to dead space (unused air) limiting tidal volume.Hyperpnea can indicate chemical imbalance or brain injury in addition to hypoxia.#Abnormal RespirationsCheyne Stokes RespirationBiots Respiration Kussmaul HyperpneaApneusticThese are useful terms to describe irregular breathing patterns. #Cheyne-Stokes RespirationGradual increases and decreases in respirations with periods of apnea

Failure of the respiratory center in the brain to compensate quickly for changing blood levels of oxygen and carbon dioxide.Can be associated with strokes, head injuries, and congestive heart failure.

#Biots ResipirationAbnormal pattern of rapid, shallow inspirations (gasps) followed by regular or irregular periods of apneaPoor prognosis

Also called ataxic or cluster respiration.Caused by damage to the medulla oblongata due to strokes or trauma or by pressure on the medulla due to herniation.#Kussmaul RespirationRapid, deep, and labored breathing, also called "air hunger"The patient feels an urge to breathe deeply, and it appears almost involuntary

Respiratory compensation for a metabolic acidosis, most commonly occurring in diabetics in diabetic ketoacidosis

#HyperpneaFaster or deeper (hyper) breathing than necessary, reducing the carbon dioxide concentration of the blood below normal

May see symptoms such as numbness or tingling in the hands, feet and lips, lightheadedness, dizziness, headache, chest pain, slurred speech and sometimes faintingStress or anxiety commonly cause hyperventilation; this is known as hyperventilation syndrome.

#Apneustic RespirationAbnormal pattern of breathing characterized by deep, gasping inspiration with a pause at full inspiration followed by a brief, insufficient expirationPoor prognosis

Caused by damage to the pons or upper medulla caused by strokes or trauma.Accompanying signs and symptoms may include decerebrate or decorticate posturing; fixed, dilated pupils; coma.#PulsePulse is the pressure wave that occurs when the left ventricle contracts, sending a surge of blood through the arteriesMost easily felt where major arteries lie near the surface of the skin and against a bone or other rigid structure#Palpating the Radial Pulse

Place index and middle finger against the radius near the wristThe radial artery lies against the radiusPress gently against the arteryDo not palpate with your thumb#Palpating the Carotid Pulse

Place the tips of the index and middle fingers on the tracheaSlide fingers towards yourself until you find the groove lateral to the tracheaUse gentle pressureDont press on both sides of the neck simultaneously#Palpating the Brachial PulseLocated at the underside of the upper armElevate the infants arm over his or her headThe brachial artery lies along the humerus below the bicepsPress fingertips firmly to palpate the brachial artery

#Determining Pulse Rate

Count number of pulses felt in 30 sec and multiply by 2Weak, irregular, or extremely slow pulses should be counted for a full minute#Average Pulse RatesAdult 60 100 bpmChildren 80 120 bpmToddlers 90 150 bpmNewborns 120 160 bpmBradycardia (adult): Pulse rate < 60 beats/minTachycardia (adult): Pulse rate > 100 beats/minPulse rates can vary significantly from person to personIn athletes or in individuals taking heart medications (beta-blockers) pulse rate may be considerably lower than average#Quality of the PulseRegularity (Rhythm)Pulse should occur at a constant, regular rhythmMany elderly patients have irregular pulsesStrength (Quality)Stronger than normal pulse is boundingFaint or difficult to feel pulse is weak or thready#SkinAn easily observed indicator ofPeripheral circulation and perfusionBlood oxygen levelsBody temperatureMany blood vessels lie near the skin surface, which #Assessing the SkinColorTemperatureCondition

This is the same sign as is used in the initial assessment.#Assessing Skin ColorPigmentation may hide changes in the skins underlying colorAssess perfusion at theFingernail bedsMucous membranes in the mouth, the lipsUnderside of the arm and handThe conjunctiva of the eye#Skin ColorsBluish gray color: cyanosisSigns of poor peripheral circulation or Low oxygenationFlushed (red) skin: heat illness Can indicate other injuriesYellow/orange: jaundiceLiver disease or dysfunction

Poor perfusion: Pale, Cyanotic, White, Ashen, Gray, Waxy and translucent like a white candleFlush: Heatstroke, Sunburn, Mild thermal burns, Other heat related illness, Significant fever (can present pale), Carbon monoxide poisoning (late)Skin may also be mottled: gray & blotchyThe image shows a patient with jaundiced skin.

#Assessing Skin TemperatureFeel the patients skin at the core Normal skin is warm to the touchAbnormal skin will be cold, cool, or hot

http://www.electronichealing.co.uk/resources/image/far-infrared-scan.jpgThe neck, chest, or abdomen are good places to check skin temperature. The extremities are good vasoconstrictors, and will cool to maintain core temperature. The image shows the temperature change moving from the patients neck and upper back to the flanks and extremities.Hot skin may be caused by fever, hyperthermia, or burns (including sunburn).Cool skin can be a sign of hypoperfusion, hypothermia, or caused by profuse sweating or local cold injury (frostbite).

#Skin ConditionNormal moisture is dryAbnormal conditionDiaphoreticMoistExcessively dryDont confuse oily skin with moist, and be aware of sweating due to environmental conditions.#Blood PressureSystolic pressure (max)pressure produced by the contraction of the ventricles (Systole)Diastolic pressure (min)pressure remaining in arteries while the heart is relaxing and refilling (Diastole)Blood pressure is measured in millimeters of mercury (mmHg)Reported as a fraction (systolic / diastolic)In adults, blood pressure is the best measure of perfusion, and with heart rate, indicates overall cardiovascular function. Measure blood pressure in any patient older than three years old.#Blood Pressure and PulseThe minimum systolic blood pressure can be estimated using distal pulses

Radial PulseSystolic BP > 80 mmHgFemoral PulseSystolic BP > 70 mmHgCarotid PulseSystolic BP > 60 mmHg#Sphygmomanometer

A BP cuff contains the following:Wide outer cuff to fasten around arm/legA bladder sewn into the cuffA ball-pump and turn-valve that can be closedThe sphygmomanometer is used to apply pressure to an artery and stop blood flow. The pressure required to stop blood flow is the systolic pressure. Pressure on the artery causes turbulent flow, which makes noise. The stethoscope is used to listen to these noises, called Korotkoff sounds, which are audible between the systolic pressure (when flow resumes) and the diastolic pressure (when pressure no longer causes turbulence).#Three Sizes of BP Cuffs:

XL, normal, smallUse the appropriate size cuffIf too small, readings might be falsely highIf too large, readings might be falsely lowSize is based on width of cuff (not length)#Techniques for MeasurementPalpation

Auscultation

Palpation measures the return of palpable pulses as pressure is released and only gives the systolic pressure.Auscultation measures the Korotkoff sounds made by pressue on the artery, and give both systolic and diastolic pressures.#Apply CuffExtend patients arm and place the cuff with distal end at least 1 proximal to the elbowSecure Cuff

#AusculatationPalpate the arm to find the brachial pulseThis is where you will auscultate

#Auscultation

Place stethoscope over arteryIf stethoscope has a bell, use that sideUse as little pressure as possible to hold the stethoscope against the armAdditional pressure can give false readings and can also interfere with the functioning of the stethoscope.#Close valveInflate cuff until sounds are no longer heardSounds will not be heard until cuff is partly inflatedInflate an additional 30 mmHgAuscultation

When inflating the cuff, sounds will be audible above the diastolic pressure, and disappear at the systolic pressure. Some patients will have auscultatory gaps, intervals between the systolic and diastolic pressure, where no sounds are audible. Inflating 30mmHg above where sounds stop ensures that you wont falsely measure a lower blood pressure than is present. #Slowly deflate the cuffNote pressure at which tapping or whooshing sound returns (systolic) and then stops (diastolic)Once sound has stopped quickly deflate cuffAuscultation

#Palpation

Place fingertips on radial artery and feel the radial pulseInflate cuff 30mmHg past point where pulse disappearsSlowly release air until pulse is felt (record systolic pressure)

No stethoscope is used for palpation, which is useful in noisy environments.This technique only measures systolic pressure, not diastolic.Record as BP by palpation: 120/P

#Normal Ranges of Blood PressureAGERANGEAdults100 140 mmHg (systolic)60 90 mmHg (diastolic)Children (1 8 years)80 110 mmHg (systolic)Infants (Up to age 1)60 mmHg (systolic)#HypertensionElevated BP may indicate:StressChronic hypertensionSevere head injuryIncreased risk for stroke or cardiac emergencyThe body can attempt to reduce BP by:Decreasing heart rateDilating the arteriesDilating blood vessels in the skin and peripheryIncreasing urine output

#HypotensionA drop in BP may indicate:Loss of bloodLoss of vessel toneCardiac pumping problemDecrease in perfusionThe body can attempt to elevate BP by:Increasing the heart rateConstricting the arteriesShunting blood away from the skin and peripheryDecreasing urine output

#DecompensationThe bodys response mechanisms can no longer maintain blood pressureA drop in blood pressure is a late sign and indicates a need for supportive treatment#Orthostatic Blood PressureIndicates bodys ability to compensate for postural changeTake BP in the supine, seated, and standing positionsTake pressure within 60 seconds of posture changeMeasurements should not change more than 20 mmHg systolic/10mm diastolic10 beats per minuteOrthostatic blood pressure measures decrease in pressure and increase in heart rate with change in posture. In some cases compensation is delayed, and the patient will achieve normal pressure/heart rate if supported, in other instances these mechanisms have failed and the patient must be kept supine or in trendelenburg.#Limb ConsiderationsInjured limbsDo not assess BP, pulse, skin temperature, or capillary refill on an injured limb for vital sign purposesObtain vital signs on the uninjured sideCompare vitals found on uninjured side to injured sideUseful in evaluating whether the injured side has compromised circulationDo not measure BP on the affected side for patients with PICC lines, fistulas, or recent mastectomies

#PupilsNormal pupils are PERRLPupilsEqualRoundRegular in sizeReactive to Light

Assess the pupils by shining a pen light first into one eye, then the other. Note constriction of both pupils consensually when light is directed at the eye.This can also be achieved by covering one eye, then watching the eyes dilate and constrict when the eye is uncovered.#Abnormal Pupil ConditionsPinpoint pupilsConstricted very smallCommon with opiate useBlown pupilFully dilated and unresponsive to lightMedication, injury, or condition of the eye may cause unequal dilation or non-reaction

Fixed with no reaction to lightDilate with light or constrict without lightReact sluggishlyUnequal in sizeBecome unequal when light is introduced or removed#Special ConditionsAnisocoriaUnequal pupil sizeCan indicate a normal physiological difference or a range of abnormal conditions Glass eye

Ask if you suspect a patient has a glass eye.#Pulse Oximetry*Pulse oximeters measure the oxygenation of the bloodThey can show the effectiveness of breathing or of interventions on oxygenationReported values can be misleading

*Not all EMTs in MA have access to pulse oximetry, but it is becoming common in many parts of the country and is used in hospitalsOnly use pulse oximetry as an adjunct to your assessment, if a patient appears to be having difficulty breathing, treat with oxygen regardless of the reported value.Falsely high numbers: Carbon monoxide poisoningFalsely low numbers: Anemia, cold extremities#End-Tidal Carbon Dioxide**Measures carbon dioxide released during respiration to measure ventilatory status and metabolismColorimetric devices change color in contact with CO2

http://www.ariamedical.com/**Not used by EMT-Basics in Massachusetts. Not all ambulances with Paramedics require end tidal capnography (yet).Normal values are 35-45. Increased metabolism will elevate CO2, reduced circulation and hyperventilation will decrease CO2. #Reassessment of Vital SignsMonitor for changes during careEvery 15 minutes in stable patientEvery 5 minutes in unstable patientAfter every medical interventionRecord the time for each set#Physical AssessmentFull-body ScanSystematic examination of the entire bodyIdentify injuries not found during rapid scanFocused Assessment:Assess based upon the patients chief complaintAnatomic region or system-based assessmentThe full-body scan is typically used for significant mechanism of injury or when the patient is unresponsive or otherwise unable to communicate specific regions to assess. The full-body scan is on p. 292-295.

#Full-Body ScanThe full-body scan assesses all the areas of the rapid scan with additional detailUse DCAP-BLTS to identify kinds of injuriesTreat injuries as you find them#Head

The first step for any body part is to expose and inspect visually.#Check Eyes

Look for trauma to the eyes and eyelids.Look for foreign bodies.#Check Pupils

Also look for contacts, discoloration, or blood in the anterior chamber.#Check Behind Ears

Look for Battles Sign (bruising over the mastoid process behind the ear).#Check Ears for Drainage

Look for blood or other discharge. If blood is present, perform a halo test.#Halo TestFold gauze in half and in half again Place corner of gauze in fluidOpen and wait a few minutes for resultPositive halo test will create a ring that resembles a bullseye, a light yellow-colored fluid will surround the spot of blood

#Palpate Head

Feel for deformities and depressions.#Palpate Facial BonesZygomasMaxillae

Check for crepitus and stability#Check Nostrils

Look for blood and drainage. Check stability of nasal bone.#Check Mandible

Check for stability#Check Mouth

Look for blood, vomit, broken teeth, trauma to the tongue, or other potential airway obstructionsSmell for unusual breath odors (alcohol, acetone)#Check Neck

Inspect the neck. Look for jugular venous distension and tracheal deviation.#Palpate Cervical Spine

Palpate each vertebrae to check for step-offs and midline pain.Check for subcutaneous emphysema. Maintain c-spine alignment if necessary. If indicated, apply a c-collar. #Inspect the Chest

Inspect the chestLook for equal chest rise and paradoxical motion#Palpate the Chest

Palpate the shoulders, clavicles, ribs, and sternum. Feel for crepitus in addition to DCAP-BTLS.Use two hands to compare structures and feel for equal chest rise but otherwise use one hand at a time for palpation.#Check Breath Sounds

Compare mid-clavicular (shown) and mid-axillary side-to-side.#Palpate the Abdomen

Palpate all four quadrants. Assess for tenderness, rebound tenderness, guarding, rigidity, and pulsating masses.

#Check the Pelvis

First press downward on the iliac crests. If they are stable, move on. If not, prepare to immobilize, and use a scoop stretcher to transfer to a long board.#Check the Pelvis and Genitalia

Press downward on the iliac crests.Check the genitalia for incontinence and priapism in men.#Check All Extremities

Inspect the legs, then the arms. Check joints: knee, patella, ankle, elbow, wristCheck CSMs in each extremity.#Check the Back

Log-roll the patientPalpate the scapulae, posterior ribs, and each vertebrae. Check for incontinence.#Check Lung Sounds

Compare upper, lower, middle fields (side-to-side)Place the patient on a longboard if necessary#Focused AssessmentSystemsRespiratoryCardiovascularNeurologicMusculoskeletalAnatomical RegionsHead and NeckChestAbdomenPelvis and GenitaliaExtremitiesFocuses assessment is appropriate for patients with non-significant MOI and responsive medical patientsInspect the system involved and/or the anatomical region for the patients chief complaint. Knowledge of the signs and symptoms associated with a disease or condition will help guide your focused assessment. Examples of respiratory, cardiovascular, and neurologic assessments follow.

#Focused Assessment: RespiratoryCheck chest for trauma and equal expansionListen to breath and lung soundsAssess skin, pulse, and blood pressure

Since respiratory difficulty may cause hypoxia and hypoperfusion, checking cardiovascular status Also look for subclavicular and intercostal retractions#Focused Assessment: CardiovascularCheck chest for traumaCheck skin, pulse, and blood pressureCompare distal pulsesAssess any sites of radiating pain

Checking pulses: compare right/left radial, femoral, and dorsal pedal pulses and note inequality#Focused Assessment: NeurologicCheck level of consciousness, pupils, CSMsPerform the Massachusetts Stroke Scale (MASS)Check grip strengthCheck for unusual odors on the breath

MASS: Have the patient smile, inspect for facial drop (unevenness). Have the patient close both eyes and lift both arms, watch for one arm to drift. Have the patient repeat the sky is blue in Massachusetts, listen for slurring, accurate repetition of words.#Glasgow Coma ScaleAssessment based on numeric scoring of a patients response base on eye opening, verbal response, and motor response

Glasgow coma scale is useful for patients who have altered mental status. Eye opening is the same as AVPU.Verbal response can be summarized as oriented, not oriented, nonsense words, nonsense sounds.Motor response is responsive to verbal (squeeze my hand), appropriate response to pain, inappropriate response, decerebrate, decorticate.Lowest possible score is 3.#ReviewList normal findings for each vital signDescribe the steps of a full-body scanDiscuss some common complaints and the focused assessment that would be appropriate for each#Patient AssessmentScene Size-UpPrimary AssessmentHistory TakingSecondary AssessmentRepeat the primary assessmentReassess vital signsReassess the chief complaintRecheck interventionsIdentify and treat changes in the patients conditionReassess patientUnstable patients: every 5 minutes Stable patients: every 15 minutesReassessment#Reassessment Cycle#ReviewExplain the difference between a stable and an unstable patientExplain how the EMT should evaluate the patients conditionExplain how the EMT should evaluate interventions#