Chapter 9 – Patient Assessment

*** Class vs Texts: Textbook displays History Taking as a separate step between primary and secondary assessment. In class, we are taught that history taking as part of the secondary assessment.

Patient Assessment

1)      Scene Size-up

a)      Standard Precautions

i)        Review dispatch data

ii)      Personal Protective Equipment (PPE) aka Body Substance Isolation (BSI)

b)      Scene Safety

c)      Mechanism of Injury (trauma)/Nature of Illness (medical)

d)      Number of Patients

e)      Additional Resources

f)       C-Spine Stabilization

2)      Primary Assessment

a)      General Impression

i)        Patient Parameters – Age, sex, race

ii)      Introductions – Name, EMT, ask about chief complaint

iii)    Consciousness

(1)   AVPU – assess for responsiveness

(a)    Awake and Alert

(i)      Ability to remember person, place, time, event à alert x 4

(b)   Verbal stimuli

(c)    Painful stimuli

(i)      Pinch test on back of upper arm/trapezius area/ear lobe, neck muscles

(d)   Unresponsive

(2)   Level of consciousness (LOC)

(a)    Unconscious

(b)   Conscious w/ altered LOC

(c)    Conscious w/ Unaltered LOC

iv)    Patient stability

(1)   Stable

(2)   Stable but potentially unstable

(3)   Unstable

v)      Identify immediate life threats – respiratory failure, severe bleeding, cardiac arrest, shock à treatment immediately!

(1)   #1 priority of life threat – targeted first, switch up assessment ABCD order accordingly

b)      ABCDE

i)        A – Airway

(1)   Airway open/closed? – sounds: normal, stridor, snoring?

(2)   Maintaining an open airway – Oropharyngeal Airway (OPA), nasopharyngeal airway (NPA)

(3)   Removing any possible obstructions – suction?

ii)      B – Breathing

(1)   Evaluate ventilation

iii)    Expose chest to evaluate respiratory ventilation and respiration. *** Done to determine extent of injuries (usually @ B/C)

(a)    Transport Decision

(b)   RR and depth, any signs of difficulty breathing? à Apply O₂ (Nonrebreather, Bag-valve-mask (BVM), nasal cannula) à goal of 94% - 99% oxgenation

(c)    Equal chest rise – auscultate for equal air entry (Expose)

(d)   Search for possible chest trauma

(i)      Can lead to pneumothorax (indicated by decreased breath sounds, crepitus, dyspnea)

iv)    C – Circulatory

(1)   Voids – Check behind the neck, behind the knees, and behind the ankles for blood

(a)    Also look for any obvious signs of bleed and any indication of bleeding with a quick sweep

(2)   Radial pulse – to determine adequate peripheral circulation (rate, rhythm, quality)

(3)   Skin – color, temperature, condition, capillary refill (nail test, eyelid mucosa look)

(4)   Treat for Shock if present
Depends on the type of shock

(a)    Treating external hemorrhage

(b)   O2 ventilation

(c)    Warmth – blanket

(d)   Legs raised*

v)      D – Disability[1]

(1)   Glasgow Coma Scale (can be possibly applied)

(a)    Eye response (1 – 4)

(i)      Spontaneously              4

(ii)    To speech                       3

(iii)  To pain                            2

(iv)  No response                   1

(b)   Verbal response (1 – 5)

(i)      Oriented to time, place, person           5

(ii)    Confused                                                     4

(iii)  Inappropriate words                                3

(iv)  Incomprehensible sounds                      2

(v)    No response                                               1

(c)    Motor response (1 – 6)

(i)      Obeys commands                                     6

(ii)    Moves to localize pain                            5

(iii)  Flexion withdrawal from pain               4

(iv)  Abnormal flexion (decorticate)            3

(v)    Abnormal extension (decerebrate)     2

(vi)  No response                                               1

Total:

Best response = 15

Comatose client = 8 or less

Totally unresponsive = 3

3)      Decision of Whether to Pack and go.

a)      Low/High Priority patient à Pack & go/Stay and treat?

i)        High

(1)   Unresponsive

(2)   Poor general impression

(3)   Difficulty breathing

(4)   Uncontrolled hemorrhage

(5)   Severe chest pain

(6)   Pale skin/poor perfusion

b)      Availability of advanced care

c)      Distance to transport

d)      Local protocols on time

4)      Secondary Assessment

a)      Medical History

i)        OPQRST (In regard to the chief complaint)

(1)   Onset – What happened up till then.

(2)   Provocation/palliation (Anything exacerbates pain/anything alleviates pain?)

(3)   Quality – Describe pain

(4)   Region/radiation

(5)   Severity (VAS scale)

(6)   Timing (chronic/sporadic?)

ii)      Note pertinent negatives

iii)    SAMPLE – General Medical history

(1)   Signs & symptoms

(2)   Allergies

(3)   Medication

(4)   Past Medical History

(5)   Last oral intake

(6)   Events previous

iv)    Vital signs

(1)   Pulse

(2)   BP

(3)   RR

(4)   Pupils

v)      Physical Exam

(1)   DCAP BTLS

(a)    Deformities

(b)   Contusions

(c)    Abrasions

(d)   Punctures

(e)   Burns

(f)     Tenderness

(g)    Lacerations

(h)   Swelling

(2)   Head to Toe Examination

(a)    Start with head

(i)      Palpate entire skull

1.      Cranium and back

2.      Front of skull

a.      Nasal bridge

b.      Zygomatic arches

c.       Maxilla

d.      Mandible

3.      Side protuberances

a.      Behind the ear

b.      Cervical spine

4.      Look into facial orifices for blood, CS fluid, smell, and other abnormalities

(ii)    Palpate Neck

1.      Look for Juglar vein distension and tracheal deviation

2.      Check trachea all the way to sternal notch

(b)   Check thorax (chest)

(i)      Expose and look for DCAPBTLS from now on

(ii)    Palpate sternum, ribs (anterior & posterior)

(iii)  Auscultate for equal air entry & abnormal breathing sounds

1.      6 positions: R/L mid clavicular, R/L base, R/L mid axillary

2.      Abnormal sounds:

a.      Wheezing

b.      Crackles (Rales) – high pitched popping sounds (like a straw sucking)

c.       Ronchi – Excess mucus secretions result in snoring, gurgling, rumbling sound.

d.      Stridor – Obstruction creates high pitched whining sound.

(c)    Check abdomen

(i)      DCAPBTLS

(ii)    Split into 4 quadrants

(iii)  Palpate for rigidity, pain, or tenderness

(d)   Examine Pelvis

(i)      Press inward and downward on pelvis

(ii)    Looking for possible dislocation, fracture, or tenderness

(e)   Examine Perineum

(i)      Look for bleeding/discharge

(ii)    Any signs of incontinence of urine/feces?

(iii)  Priapism (male – boner)? à If yes indicative of nerve damage

(f)     Extremities

(i)      Legs

1.      Single à bilateral

2.      Any signs of bleeding, deformity, swelling, pain

3.      Circulation check pulse

4.      Motor and sensory function

(ii)    Arms

1.      Single à bilateral

2.      Any signs of bleeding, deformity, swelling, pain

3.      Circulation check pulse

4.      Motor and sensory function

(g)    Posterior

(i)      Turn with shoulder and pocket hold

(ii)    Check spine

(iii)  Checks other soft tissues (use back of hand for buttocks to avoid issues)

(iv)  Auscultate lungs

5)      Reassessment

a)      Repeat every 5mins on critical patients

b)      Repeat every 15mins on stable patients

i)        Repeat primary assessment

ii)      Repeat vital signs

iii)    Reassess chief compliant

(1)   Treatment Improving/deteriorating condition

(2)   Problem getting better/worse

(3)   Any new issues?

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[1] Some protocols and instructors do not consider disability as the D step. They most likely see the tests (GCS, Cincinnati-stroke scale) as having to be in the secondary assessment.