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Chapter 10: Patient Assessment
Chapter 10
Patient Assessment
Unit Summary
After students complete this chapter presentation and the related course work, they will understand the scope and sequence of patient assessment for medical and trauma patients and all the phases and components of patient assessment. Please note that this chapter is divided into five sections: scene sizeup, primary assessment, history taking, secondary assessment, and reassessment. These divisions will help facilitate the instructor’s approach for teaching this skill as a whole concept.
National EMS Education Standard Competencies
Assessment
Applies scene information and patient assessment findings (scene size-up, primary and secondary assessment, patient history, reassessment) to guide emergency management. Scene Size-up
- Scene safety (pp 461-462)
- Scene management (pp 460-461) o Impact of the environment on patient care (p 460) o Addressing hazards (pp 461-462) o Violence (pp 461-462) o Need for additional or specialized resources (pp 466-467) o Standard precautions (pp 464-465) o Multiple patient situations (pp 465-
- Primary Assessment
- Primary assessment for all patient situations o Level of consciousness (pp 470-472) o ABCs (p 481) o Identifying life threats (p 485) o Assessment of vital functions (p 468) o Initial general impression (pp 469-470)
- Begin interventions needed to preserve life (p 485)
- Integration of treatment/procedures needed to preserve life (p 485) History Taking
- Determining the chief complaint (pp 489-491)
- Mechanism of injury/nature of illness (pp 462-464)
- Associated signs and symptoms (p 494)
- Investigation of the chief complaint (p 489)
- Past medical history (pp 494-495)
- Pertinent negatives (p 494) Secondary Assessment
- Performing a rapid full-body scan (p 502)
Chapter 10: Patient Assessment
- Focused assessment of pain (pp 506, 512)
- Assessment of vital signs (pp 502-504)
- Techniques of physical examination o Respiratory system (p 512) o Presence of breath sounds (p 474) o Cardiovascular system (p 517) o Neurologic system (pp 522-524) o Musculoskeletal system (p 527) o All anatomic regions (pp 524 - 525)
- Assessment of o Lung sounds (p 474) Monitoring Devices
- Obtaining and using information from patient monitoring devices including (but not limited to) o Pulse oximetry (p 503) o Noninvasive blood pressure (pp 503-504) o Blood glucose determination (p 506) Reassessment
- How and when to reassess patients (p 530)
- How and when to perform a reassessment for all patient situations (p 531) Knowledge Objectives
- Identify the components of the patient assessment process. (p 455)
- Explain how the different causes and presentations of emergencies will affect how you perform each step of the patient assessment process. (pp 455-457)
- Describe the key elements of the critical thinking process and how you can apply them in the field. (pp 457 - 461)
- Discuss some of the possible environmental, chemical, and biologic hazards that may be present at an emergency scene, ways to recognize them, and precautions to protect personal safety. (p
- Discuss how to survey a scene for signs of violence and protect yourself and bystanders from real or potential danger. (pp 461-462)
- Describe how to determine the mechanism of injury or nature of illness at an emergency and the importance of differentiating trauma patients from medical patients. (pp 463-464)
- List the minimum standard precautions that should be followed and personal protective equipment that should be worn at an emergency scene, including examples of when additional precautions would be appropriate. (pp 464-465)
- Explain why it is important 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, and triage. (pp 465-467)
- Describe the principal goals of the primary survey process. (pp 468-467)
- Explain the process of forming a general impression of a patient as part of the primary survey and the reasons why this step is critical to patient management. (pp 469-470)
- Describe the assessment of airway status in patients who are responsive and unresponsive. (pp 471 - 472)
Chapter 10: Patient Assessment
- List normal respiratory rate, pulse rate, and blood pressure ranges for adults, children, and infants. (p 514)
- Explain the importance of performing a reassessment of the patient and the steps in this process. (pp 530-531) Skills Objectives
- Demonstrate the techniques for assessing a patient’s airway, and correctly obtain information related to respiratory rate, rhythm, quality/character of breathing, and depth of breathing. (p 469)
- Demonstrate how to obtain a pulse rate in a patient. (p 477)
- Demonstrate how to assess a radial pulse in a responsive patient and an unresponsive patient. (p
- Demonstrate how to assess a carotid pulse in an unresponsive patient. (p 477)
- Demonstrate how to palpate a brachial pulse in a child who is younger than 1 year (or a manikin). (p 477)
- Demonstrate how to assess capillary refill in an adult or child older than 6 years. (p 480)
- Demonstrate how to assess capillary refill in an infant or child younger than 6 years. (p 480)
- Demonstrate how to use the AVPU scale to test for patient responsiveness. (p 471)
- Demonstrate how to evaluate a patient’s orientation and document the patient’s status correctly. (p 457)
- Demonstrate how to perform a rapid full-body scan during the primary survey of a patient. (pp 483 - 484, Skill Drill 10-1)
- Demonstrate the use of a pulse oximetry device to evaluate the effectiveness of oxygenation in the patient. (p 503)
- Demonstrate the use of electronic and manual devices to assist in determining the patient’s blood pressure in the field. (pp 504-505)
- Demonstrate the use of an end-tidal carbon dioxide monitoring device to assist in determining the patient’s concentration of expired carbon dioxide in the field. (pp 504-505)
- Demonstrate how to assess a patient’s blood glucose level. (p 507, Skill Drill 10-2)
- Demonstrate how to perform a full-body exam. (pp 508-511, Skill Drill 10-3)
- Demonstrate how to perform a focused assessment. (p 512)
- Demonstrate how to measure blood pressure by auscultation. (p 520, Skill Drill 10-4)
- Demonstrate how to measure blood pressure by palpation. (p 521, Skill Drill 10-5)
- Demonstrate how to test pupil reaction in response to light in a patient and document his or her status correctly. (p 523)
Chapter 10: Patient Assessment Readings and Preparation
- Review all instructional materials including Chapter 10 of Advanced Emergency Care and Transportation of the Sick and Injured , Fourth Edition , and all related presentation support materials. Support Materials
- Lecture PowerPoint presentation
- Case Study PowerPoint presentation
- Skill Drill PowerPoint presentations o Skill Drill 10-1, Performing a Rapid Full-Body Scan Presentation o Skill Drill 10-2, Assessing Blood Glucose Level Presentation o Skill Drill 10-3, Performing the Full-Body Exam Presentation o Skill Drill 10-4, Obtaining Blood Pressure by Auscultation Presentation o Skill Drill 10-5, Obtaining Blood Pressure by Palpation Presentation
- Equipment needed to perform the psychomotor skills presented in this chapter
- Patient assessment template from the beginning of Chapter 10 of the text (several copies)
- Skill Evaluation Sheets o Skill Drill 10-1, Performing a Rapid Full-Body Scan o Skill Drill 10- 2, Assessing Blood Glucose Level o Skill Drill 10-3, Performing the Full-Body Exam o Skill Drill 10-4, Obtaining Blood Pressure by Auscultation o Skill Drill 10-5, Obtaining Blood Pressure by Palpation Enhancements
- Direct students to visit Navigate. Content connections: Remind students that, as they progress through additional learning in the subsequent chapters, their ability to assess the patient will improve, but stress the importance of developing a strong foundation in patient assessment. Point out to students that the patient assessment skills will be used on every patient and in many later skills sessions. Medical conditions, trauma, and special populations will add to the complexity of later sessions on patient assessment. Cultural considerations: Patient assessment techniques such as palpating and exposing may be uncomfortable for some students for cultural reasons. Allow students to discuss potential conflicts privately. Point out to students that each patient has his or her cultural beliefs and practices and some populations may regard some techniques, both physical and verbal, as inappropriate. Stress the importance of cultural sensitivity, and have students suggest possible ways to accommodate certain beliefs without compromising good patient care.
Chapter 10: Patient Assessment may request help from the on-scene supervisor in a log roll or other necessary skills, but otherwise must complete the assessment alone. The on-scene supervisor will have a blank template and will check off each segment of the assessment as it is verbalized or performed by the AEMT. The entire scenario should be performed in less than 10 minutes, reminding students of the importance of the “platinum 10” minutes of the Golden Period. Skills instructors who may be facilitating at each station should use a blank template to assess and critique the skill upon completion, making note of the start and finish times. Prepare several manikins (one for each group) ahead of time by dressing them in old (unwanted) clothing after securing various index cards to the body indicating injuries and/or assessment findings. Write each finding on a separate card, fold it, number it in order of required discovery, and tape it in place. Dress the manikin, covering as many of the cards as is reasonable. Students must “discover” each symptom or sign as they perform the assessment. Students may not take clues out of order even if they are visualized. Students may not take clues without completing that part of the assessment in which the findings would be expected to be discovered. For example, if the student does not verbalize or perform auscultation of lung sounds, the student should not be allowed to take the index card indicating findings. Be sure to place cards on body parts that would necessitate log roll or exposure in order to find them. Medical terminology review: Prepare a patient assessment narrative ahead of time using longer descriptive definitions in place of correct medical terminology. Distribute the narrative to student groups for a timed exercise in which they need to replace the definitions with correct medical terminology. For example, the assessment narrative may state, “While examining the patient, a grinding, grating sensation was palpated over the proximal tibia.” Or, “The delicate membrane that lines the patient’s eyelids was found to be very pale.” Underlined words must be replaced with the correct terminology (ie, crepitus and conjunctiva, respectively). Visual thinking: Ask students to draw the breath sounds as they envision them. For instance, wheezing can be visualized as air squeezing past narrowed air passages. A diagram of crackles might be air moving through water. Encourage students to use simple diagrams and arrows to indicate air flow direction. Accept all attempts and ask students to explain their diagrams if time allows. Have students create a life-size “patient” by outlining a team member using several large pieces of poster paper. Assign a disease or trauma scenario to each group, and have the team display the picture of their patient on the wall. Each group then labels their patient’s signs and symptoms in the proper body location. Students can add to these posters as they learn more about each condition in subsequent lessons. Collect several photos of accident scenes, interiors of homes, large events, and so forth from the Internet or other sources. Arrange the photos in a PowerPoint presentation. Have students write down scene hazards, possible mechanisms of injury/illness, and their general impression for each photo. Display each photo for a limited amount of time (10–20 seconds). Discuss findings and the importance of good observation skills. Pre-Lecture You are the Provider “You are the Provider” is a progressive case study that encourages critical-thinking skills.
Instructor Directions
- Direct students to read the “You are the Provider” scenario found throughout Chapter 10.
Chapter 10: Patient Assessment
- You may wish to assign students to a partner or a group. Direct them to review the discussion questions at the end of the scenario and prepare a response to each question. Facilitate a class dialogue centered on the discussion questions and the Patient Care Report.
- You may also use this as an individual activity and ask students to turn in their comments on a separate piece of paper.
Chapter 10: Patient Assessment
- Integrate the information you obtain regarding the current incident with similar situations and experiences.
- Articulate assessment-based decisions and construct arguments.
- Defend your actions and justify the decisions on which you based your treatment.
- Factors that can hamper the ability to perform emergency medical care usually do not exist in other medical settings.
- Always base your treatment or transport decisions on your assessment of the patient.
III. Scene Size-up
A. Your evaluation of the conditions in which you will be operating
- Information-gathering stage of patient assessment process
- Continuous situational awareness is necessary throughout the call. a. Pay attention to the conditions and people around you at all times. b. Consider environmental conditions.
- Prepare for a specific situation based on the initial dispatch information.
- Consider a variety of factors that will impact how you operate on the scene and provide patient care. a. Road and traffic hazards b. Incident hazards c. Scenes of violence
- Scene size-up must combine an understanding of the situation based on the information the dispatcher provides with your observation of the scene itself.
B. Ensure scene safety
- Every prehospital scene has a potential for injury.
- Ensure safety for yourself and your partner first, other responders and bystanders second, and your patient last.
- Look for possible dangers as you approach the scene and before you step out of the vehicle. a. Hazards found at the scene include: i. Traffic ii. Chemical and biologic agents iii. Downed power lines or lightning iv. Secondary collapse v. Fire and explosions vi. Carbon monoxide vii. Unstable surfaces
Chapter 10: Patient Assessment
- When gaining access to a patient, remember that you will typically leave via the same route you entered, moving a heavy stretcher and patient.
- Working in unfavorable conditions and on unstable surfaces is a large part of prehospital care.
- Any actions you may take to protect yourself should also be considered for the patient.
- Take your time and stay focused on what you are doing.
- Protect bystanders from becoming patients.
- Be aware of scenes that have the potential for violence and request assistance of law enforcement personnel if required. a. Move to a safe location and call for additional resources.
C. Determine mechanism of injury/nature of illness
- Do not immediately categorize your patient as either a trauma or a medical patient. a. Some patients fall into both categories.
- Considering the mechanism of injury or nature of illness early will help you prepare for the rest of the assessment. a. You need to be able to identify all of the aspects of the emergency to which you were called to respond.
- Mechanism of injury a. Traumatic injuries are the result of physical forces applied to the outside of the body. i. Classified according to the type or amount of force applied, length of time the force was applied, and where it was applied on the body b. Mechanism of injury (MOI) describes how the patient became injured. c. Determining the MOI will provide many clues to help you focus your assessment. d. With blunt trauma, the force of the injury occurs over a broad area, and the skin is not broken. e. With penetrating trauma, the force of the injury occurs at the specific point of contact between the skin and the object. i. High risk of infection
- Nature of the illness a. Make an effort to determine the general type of illness, or nature of the illness (NOI). i. Examples: seizure, heart attack, diabetic condition, poisoning b. NOI is often best described by patient’s chief complaint and medical history. c. To quickly determine the NOI, talk with the patient, family, and/or bystanders about the emergency. i. Use your senses to check the scene for clues to the possible cause of the illness.
D. Take standard precautions
- Standard precautions and personal protective equipment (PPE) need to be considered and adapted to the prehospital task at hand.
- PPE includes clothing and specialized equipment.
Chapter 10: Patient Assessment f. Swift water rescue
- Search and rescue teams can help find, package, and transport patients over long distances and across uneven terrain.
- Law enforcement personnel may be needed to control traffic or intervene in potentially violent situations. a. Stage yourself and your vehicle at a safe distance until the scene has been secured.
- Ask yourself: a. How many patients are present? b. Are enough resources available to respond to their conditions? c. Does the scene pose a threat to you, your patient, or others?
- It is never wrong to call for backup, even if the extra units are instructed to turn back.
IV. Primary Survey
A. Goal of primary survey: Identify and initiate treatment of immediate or imminent life
threats
- Physically examine the patient to assess the level of consciousness (LOC) and airway, breathing, circulation, disability, and exposure (ABCDEs).
- Primary survey is neither an in-depth physical exam nor an assessment of vital signs.
- Always give priority to life threats.
B. Form a general impression
- Focus is on rapid identification of potentially life-threatening problems.
- First part of the primary survey a. Determines the priority of emergency medical care
- Note things such as the person’s age, sex, weight, level of distress, overall appearance, and the presence of any obvious bleeding.
- Overall visual assessment that helps you gather information as you approach the patient
- Note the patient’s position and whether the patient is moving or still.
- Avoid standing over a patient; ensure you are at eye level.
- Ensure the patient is breathing and assess skin color and condition.
- Make note of odors that suggest chemical hazards, smoke, or alcohol on the patient’s breath.
- If patient is responsive, introduce yourself and ask about the chief complaint.
- Patient’s response can provide insight into the LOC, airway patency, respiratory status, and overall circulatory status before you begin your exam.
- Treat life-threatening conditions as soon as they are found.
- Answer the following questions to begin to form your general impression:
Chapter 10: Patient Assessment a. Does the patient appear to have a life-threatening condition? b. Was the patient injured? If so, then what was the MOI? c. Does the patient seem coherent and able to answer questions?
- Determine whether your patient’s condition is stable, stable but potentially unstable, or unstable.
- Constantly be aware of changes in the patient’s condition.
- Maintain a high index of suspicion and begin treatment if the primary problem appears to be traumatic. a. Be alert to the possibility of a medical origin.
C. Assess level of consciousness
- Ascertain gross LOC by determining which of the following three categories best fits your patient: a. Unresponsive b. Responsive with an altered LOC c. Responsive with an unaltered LOC
- Sustained unresponsiveness indicates a critical respiratory, circulatory, or central nervous system (CNS) problem.
- Package the patient and provide rapid transport to the hospital.
- Further assessment will be required for any patient with an altered LOC. a. Altered LOC in a responsive patient may indicate inadequate perfusion and oxygenation are adversely affecting the brain and its ability to function. b. Can also be caused by medications, drugs, alcohol, poisoning, hypoglycemia, chemical imbalances, and/or neurologic conditions
- Test for responsiveness (the way in which a patient responds to external stimuli) using: a. Verbal (sound), tactile (touch), and painful stimuli b. Orientation
- Ensure the patient’s cervical spine is manually stabilized by either you or another provider if there is any indication to establish spinal motion restriction.
- Indicators for spinal motion restriction include the following: a. Blunt trauma with any of the following findings: i. An MOI that indicates the potential for spinal injury ii. Pain or tenderness on palpation of the neck or spine iii. Patient reports pain in the neck or back iv. Paralysis or neurologic complaint (numbness, tingling, partial paralysis of the legs or arms) v. Priapism (male patients) vi. Altered mental status vii. Intoxication (alcohol or drugs) viii.Glasgow coma score of less than 14 xi. Distracting injury (injury to another part of the body that potentially makes the patient’s report of neck or spine pain unreliable) x. Difficulty or inability to communicate
Chapter 10: Patient Assessment f. Signs of airway obstruction in an unresponsive patient include: i. Obvious trauma, blood, or other obstruction ii. Noisy breathing, such as snoring, bubbling, or other abnormal breath sounds iii. Extremely shallow or absent breathing g. Airway positioning depends on the age and size of your patient. h. For trauma patients or patients with an unknown illness, manually stabilize the cervical spine while using the jaw-thrust maneuver.
E. Assess breathing
- After you have made sure the patient’s airway is open, ensure breathing is adequate.
- A patient who is breathing without assistance is said to have spontaneous respirations or spontaneous breathing.
- Ask the following questions: a. Does the patient appear to be choking? b. Is the respiratory rate too fast or too slow? c. Are the patient’s respirations shallow or deep? d. Is the patient cyanotic? e. Do you hear abnormal breath sounds when listening to the lungs? f. Is the patient moving air into and out of the lungs?
- Rapidly assess respirations to determine if the: a. Rate is normal, fast, or slow b. Depth is normal or shallow c. Chest rise is equal or unequal
- Assess the patient’s breathing and listen to breath sounds with a stethoscope over each lung. a. Chest rise and breath sounds should be equal on both sides of the chest.
- When you assess breathing, obtain the: a. Respiratory rate b. Quality and character of breathing c. Degree of distress d. Use of accessory muscles in the chest or neck
- Never withhold oxygen from any patient who is having difficulty breathing.
- Provide positive-pressure ventilations for patients who are apneic or whose breathing is too slow, too fast, or too shallow.
- Administer oxygen if the patient is breathing adequately but remains hypoxic.
- The goal for oxygenation for most patients is an oxygen saturation level of 94% to 99%.
- If a patient develops difficulty breathing after your primary survey, immediately reevaluate the airway.
- Air exchange is the critical issue, not simply the number of breaths.
Chapter 10: Patient Assessment
- Observe how much effort is required for the patient to breathe. a. Shallow respirations can be identified by little movement of the chest wall or poor chest excursion. b. Deep respirations cause a significant rise and fall of the chest. c. Document when the patient’s respirations are shallow or deep.
- Labored breathing is characterized by patient’s position, concentration on breathing, and increased effort and depth of each breath.
- Signs of inadequate breathing: a. Presence of retractions b. Nasal flaring, seesaw breathing, and supraclavicular and intercostal retractions (in pediatric patients) c. Patient who can speak only two or three words without pausing to take a breath (two- to three-word dyspnea)
- Two common postures indicate that the patient is trying to increase airflow. a. Tripod position: Sitting and leaning forward on outstretched arms with head and chin thrust slightly forward b. Sniffing position (most commonly seen in children): Sitting upright or lying on back with head and chin thrust forward
- Respiratory distress occurs when a patient has difficulty breathing.
- Respiratory failure occurs when the blood is inadequately oxygenated or ventilation is inadequate to meet the oxygen demands of the body. F. Assess circulation
- Helps you to evaluate how well blood is circulating to the major organs
- Circulation is evaluated by assessing the patient’s mental status, pulse, and skin condition.
- Assess pulse. a. Pulse is the pressure wave that occurs as each ventricular contraction causes a surge in the blood circulating through the arteries. b. Most easily felt at a pulse point where a major artery lies near the surface i. In responsive patients older than 1 year, palpate the radial pulse at the wrist. ii. In unresponsive patients older than 1 year, palpate the carotid pulse in the neck. iii. Palpate the brachial pulse in children younger than 1 year. c. When you palpate a pulse, do not use your thumb. d. Normal pulse rate for an adult is 60 to 100 beats/min. e. During the primary survey, assess the pulse to determine if it is:
Chapter 10: Patient Assessment e. Skin moisture i. Dry skin is normal. ii. Skin that is wet or moist from sweat, or excessively dry and hot, suggests a problem. f. Because color, temperature, and moisture of the skin are often related signs, consider them together. i. When recording or reporting assessment of the skin, first describe color, then temperature, and whether the skin is dry, moist, or wet. g. Capillary refill time (CRT) i. Often evaluated in pediatric patients to assess the ability of the circulatory system to restore blood to or perfuse the capillary system in the fingers and toes ii. May provide an indication of the pediatric patient’s level of perfusion (a) Not considered an accurate indication in adults iii. Can be affected by the patient’s body temperature, position, preexisting medical conditions, history as a smoker, and medications iv. To test capillary refill, place your thumb on the patient’s fingernail with your fingers on the underside of the patient’s finger and gently compress. v. Capillary refill should be prompt, and nail bed color should be pink. vi. Suspect poor peripheral circulation when capillary refill takes more than 2 seconds or the nail bed remains blanched.
- Assess and control external bleeding a. Identify and immediately control any major external bleeding. b. Should be performed before addressing airway or breathing concerns c. Signs of blood loss include active bleeding from wounds and/or evidence of bleeding. d. Serious bleeding from a large vein may be characterized by steady blood flow. e. Bleeding from an artery is characterized by a spurting flow of blood. f. Do a sweep for blood by running your gloved hands from head to toe, pausing periodically to see if your gloves are bloody. g. Direct pressure with a gloved hand followed by a sterile bandage over the wound will control bleeding in most cases. h. When direct pressure is not quickly successful or whenever you encounter obvious arterial hemorrhage of an extremity, apply a tourniquet.
- Restoring circulation a. Take immediate action to restore or improve circulation. b. Apparent absence of a palpable pulse in a responsive patient is indicative of a low cardiac output state. c. If you cannot feel a pulse in an unresponsive adult, begin CPR if an AED or manual defibrillator is not readily available.
Chapter 10: Patient Assessment d. Once an AED or manual defibrillator is available, immediately assess the need for defibrillation. e. Any patient with impaired circulation should receive high-flow oxygen via a nonrebreathing mask or assisted ventilation.
G. Assess the patient for disability.
- Perform a brief neurologic evaluation of the patient.
- Determine the patient’s normal mental status.
- Any deviation from alert and oriented to person, place, time, and event, or from a patient’s normal baseline, is considered an altered mental status.
- Orientation tests patients’ mental status by checking their memory and thinking ability. a. The most common test evaluates a patient’s ability to remember four things: i. Person ii. Place iii. Time iv. Event
- Glasgow Coma Scale (GCS) assigns a point value (score) for eye opening, verbal response, and motor response.
H. Expose then cover
- Visually inspect each area to ensure an accurate and thorough assessment.
- When you are finished, cover up patients to respect their privacy and to maintain body heat.
I. Performing a rapid full-body scan
- Identifies other injuries that must be managed and/or protected before transporting a. Takes about 60 to 90 seconds
- Guidelines on how and what to assess during the rapid full-body scan: a. Inspection: Looking at your patient for abnormalities b. Palpation: Touching or feeling patient for abnormalities c. Auscultation: Listening to body sounds using a stethoscope
- DCAP-BTLS is a mnemonic to remind you what to look for when you are inspecting and palpating various body regions. a. Deformities b. Contusions c. Abrasions d. Punctures/penetrations e. Burns f. Tenderness g. Lacerations h. Swelling
