Ch. 9 EMR Book: Patient Assessment Flashcards
What are the 5 steps in the patient assessment?
- Scene size-up
- Primary assessment
- History Taking
- Secondary assessment
- Reassessment
What is assessment-based care?
Conducting a careful and thorough evaluation of the patient so that you can provide appropriate care
What is a scene size-up?
General overview of the incident and its surroundings
What are the 5 parts of the scene size-up?
- Ensure scene safety
- Determine mechanism of injury or nature of illness
- Take standard precautions
- Determine number of patients
- Consider additional resources
When does the scene size-up start?
After receiving information from the dispatcher
What information does dispatch give you?
- Location of incident
- Type of incident
- Number of people involved
- Safety issues at the scene
What other factors should you consider while responding to a call?
- Time of day
- Day of the week
- Weather conditions
What are some examples of visible hazards?
Downed electrical wires, traffic, spilled gasoline, unstable buildings, a crime scene, weather, crowds, unstable surfaces etc.
What are some examples of invisible hazards?
Electricity, biologic hazards, hazardous materials (look for placards on vehicles), poisonous fumes, etc.
What are some additional resources you can call for if hazards are present?
Fire department, additional EMS units, law enforcement, heavy-rescue equipment, hazardous materials teams, electric or gas company personnel, other specialized resources
What should you do early on in a scene that seems unsafe?
- Wait for additional resources
- Ensure the patient, bystanders, and rescuers are not exposed to the hazard unnecessarily
- Identify potential exit routes from the scene if the hazard becomes life threatening
How do you determine the mechanism of injury (MOI) or nature of illness (NOI)?
By looking for clues that may indicate how the incident happened while approaching the scene and asking the patient later on if they’re conscious
What is the knowledge of the MOI or NOI helpful for?
Predicting the patient’s injuries and what kind of care they may need
* NOT for ruling out possible injuries or determining the injuries without a secondary assessment on the patient’s entire body
Who else can you ask information from to determine the MOI or NOI?
Bystanders or the patient’s family members if present
What are examples of PPE?
- Gloves (worn all the time)
- Eye protection (in case of splashing of bodily fluids)
- Gowns (usually for large amounts of blood loss present)
- Masks
What should you do with the information of how many patients there are at an incident?
Determine if you can handle treating everyone or if you need additional resources
What is a strategy to determine which patients should be treated and transported first?
Grouping patients according to the severity of their injuries
What can additional EMS units help with?
Treatment and transport
What can law enforcement help with?
Securing the scene if unsafe, traffic control, and crowd control
What can fire departments help with?
Spilled fuel, fire, or extrication
What can utility company personnel help with?
Damaged utility lines
What can wrecker operators help with?
Removal of vehicles
When should you request for additional resources?
While reporting the number of patients to dispatch, before beginning to treat patients
What are the 4 parts of the primary assessment?
- Form a general impression (WASPM)
- Assess level of responsiveness (AVPU)
- Perform a rapid exam to identify life threats (ABC)
- Update responding EMS units
What is the purpose of the primary assessment?
To identify life threats to the patient
What are life threats to the patient?
Problems with the patient’s airway, breathing, and circulation
What does the WASPM acronym stand for in the general impression?
W: weight
A: age
S: sex
P: position patient is found in
M: movement
What is the general impression useful for?
Determining whether the patient has experienced trauma or illness
What should you do if you do not know if the patient experienced trauma or illness?
Treat the patient as if they are a trauma patient
What does the AVPU acronym stand for when assessing the patient’s level of responsiveness?
A: alert (patient can answer questions about themselves and their situation)
V: verbal (patient responds to verbal stimuli, even if it’s only loud sounds)
P: pain (patient withdraws from painful stimuli such as pinching of the earlobe)
U: unresponsive (patient does not respond to stimuli and is unconscious)
How should you introduce yourself when approaching the patient?
- State your name and ask for the patient’s name to know what to refer to them as
- State your reason for being at the scene
- State that you will be helping the patient
Why should you still introduce yourself and speak to the patient while performing the primary assessment if they’re unconscious?
They may still be able to hear your voice and it can be reassuring
What should you avoid saying while talking to the patient?
Telling them that everything’s going to be okay; do not provide false reassurance
What should you do if the patient has sustained any type of major trauma?
Provide manual stabilization of the patient’s neck as soon as possible to prevent any further injury
What is the usual order for performing a rapid exam to identify life threats?
A: airway
B: breathing
C: circulation
What is the order for performing a rapid exam to identify life threats on a patient who is in cardiac arrest?
C: circulation
A: airway
B: breathing
What does the ABC or CAB acronym stand for when performing a rapid exam to identify life threats?
A: correct any serious airway problems like blockages/make sure it’s clear, open, and patent
B: check for breathing and correct any serious breathing problems like lack of breathing or open chest injuries
C: check the status of circulation and correct serious problems like lack of circulation or serious external bleeding
What is an easy way to check if the patient’s airway is blocked?
If the patient can talk, their airway is not blocked
When should you assume the patient’s airway is blocked?
If the patient is unresponsive to verbal stimuli
How can you manually check if the airway of an unconscious patient is blocked on?
Head tilt-chin lift maneuver or jaw-thrust maneuver (if patient sustained trauma)
What should you do once the airway is open?
Check for foreign bodies or secretions and clear it if necessary using finger sweeps or suction
What are airway adjuncts used for?
Keeping the airway open
How do you assess the patient’s breathing?
Rate: normal is 12-20 breaths per minute
Rhythm: irregular or regular
Quality: bradypnea (slow) or tachypnea (fast)
What should you do if the patient is having trouble breathing or has abnormal breathing sounds?
Check for objects in the patient’s mouth and remove it
What should you do if you do not see any movement of the chest and no sounds of air coming from the mouth or nose?
Check their carotid pulse
What should you do if a carotid pulse is present but the patient is not breathing?
Perform rescue breathing
Where do you check for a pulse in an unconscious patient?
The carotid pulse on the neck
What should you do if you do not feel a pulse within 10 seconds?
Begin CPR
Where do you check for a pulse in a conscious patient?
The radial pulse on the thumb side of the wrist
If severe bleeding is present, what should you do?
Apply direct pressure over the wound or use a tourniquet to stop circulation to that area and avoid more blood loss
What do you assess in relation to skin while assessing circulation?
Skin temperature, color, and condition
Why should you check the color of the patient’s skin when you first arrive to the scene?
To monitor changes in skin color as time goes on
What does a pale skin color indicate?
Decreased circulation to that part of the body or all of the body caused by blood loss, poor blood flow, low body temperature, or shock
What does a flushed (red) skin color indicate?
Excess circulation to that part of the body, fever, or sunburn
What does cyanosis (blue skin) indicate?
Lack of oxygen and possible airway problems
What does jaundice (yellow skin) indicate?
Liver problems
What does a pink-ish skin color indicate?
Normal
Where should you check for changes in skin color on patients with deeply pigmented skin?
Fingernail beds, whites of their eyes, palm of their hands, or inside the mouth
What should you include on your report updating responding EMS units on the patient’s condition?
- Age and sex of patient
- Chief complaint
- Level of responsiveness
- Status of airway, breathing, and circulation
If rescue breaths are needed for a patient in respiratory arrest, how should they be delivered?
One breath every 6 seconds over 1 second until chest rises
What is the chief complaint?
The patient’s response to questions such as “What’s wrong?” or “What happened?”
Why should you never allow a patient to distract you from completing the entire patient assessment sequence?
Because the injuries they point out may not be the most serious injuries they have sustained
What is the primary complaint in an unconscious patient?
Unconsciousness
Why is it important to obtain the patient’s medical history?
To gather an account of the patient’s past medical injuries, illnesses, and conditions to determine the signs and symptoms of the current condition
What are the acronyms for history taking?
SAMPLE, OPQRST, and ASPN
What does the SAMPLE acronym stand for?
S: signs and symptoms
A: allergies
M: medications
P: pertinent past medical history
L: last oral intake
E: events associated or leading up to the illness or injury
What should you ask in relation to the patient’s signs and symptoms of the injury or illness?
Why the patient called 911, signs and symptoms at the beginning of the event and currently, if they’re in pain, and to describe pain if needed
What should you ask in relation to the patient’s allergies?
If they’re allergic to medication, food, or airborne particles/seasonal allergies and how their usual allergic reactions are
What should you ask in relation to medications?
If the patient is taking prescription medications and the purpose for them
If they are taking OTC supplements or herbal remedies
A list of all their medications if they have one
If they take any drugs (including smoking and alcohol), how often they take drugs, the last time they took drugs, and if they stopped, why
What should you ask in relation to pertinent past medical history?
If they have an existing medical condition
Any past serious illness or injuries
If they have been hospitalized recently or had surgery
Symptoms leading up to the incident
What should you ask in relation to the patient’s last oral intake?
When the last time they ate or drink something was and how much/what did they consume
If they had any abdominal pain
What should you ask in relation to the events leading up to the injury or illness?
What they were doing before and when the signs and symptoms of this event began
If they noticed anything unusual in the hours before the event
What does the OPQRST acronym stand for?
O: onset
P: provocation/palliation
Q: quality
R: radiation/referred
S: severity
T: time
What does onset refer to?
If the pain of injury/illness happened suddenly, gradual, intermittently, etc.
What does provocation/palliation refer to?
Provocation- does anything make the condition worse
Palliation- does anything make the condition better
What does quality refer to?
How the patient describes their condition
What does radiation/referred refer to?
Radiation- is there any pain radiating throughout the body
Referred- is there any pain that stays in associated parts of the body of injury/illness
What does severity refer to?
How bad the patient’s condition is on a scale of 1-10 (they rate it themselves)
What does time refer to?
When the pain/incident started in that specific moment that made them call for help
What does the ASPN acronym stand for?
A: associated
S: signs/symptoms
P: pertinent
N: negatives
What are associated signs and symptoms?
Signs and symptoms that you expect to find based on the complaint and are actually present
What are pertinent negatives?
Signs and symptoms that you should expect the patient to have based on the complaint but they are not present
What are the 2 parts of the secondary assessment?
- Systematically assess the patient
- Assess vital signs
What is the purpose of the secondary assessment?
To perform a physical examination of the patient head to toe to assess non-life-threatening conditions
What is a sign?
Something you can observe in a patient (bleeding, temperature, etc.)
What is a symptom?
A condition the patient tells you
What do the acronyms DOTS and DCAP-BTLS help with in relation to the secondary assessment?
Looking and feeling for signs of injury
What does the acronym DOTS stand for?
D: deformities
O: open injuries
T: tenderness
S: swelling
What does the acronym DCAP-BTLS stand for?
D: deformities
C: contusions (bruises)
A: abrasions
P: punctures or penetrations
B: burns
T: tenderness
L: lacerations
S: swelling
What should you assume all unconscious, injured patients have?
Spinal injuries that need to be stabilized while the assessment is being performed
What is the backboard used for?
Stabilizing unconscious, injured patients before transportation
How should upper extremities be examined?
- Start by observing one extremity at a time and see if it is positioned abnormally or looks broken
- Examine for tenderness from the shoulder down while firmly squeezing to check for fractures
- Check for movement and see if the patient can squeeze your hand
- Check for sensation by asking if the patient can feel tingling or numbness in the extremity and if they can feel you touch it
- Check the radial pulse, fingers for capillary refill, and the hand’s temp, color, and moisture
If you find any tenderness or deformities on an extremity during the exam, what should you never do?
Ask the patient to move that extremity
How should lower extremities be examined?
- Observe extremity for deformities in its position and shape including if it’s rotated
- Examine for tenderness from the groin down using firm but gentle pressure to identify tender/injured areas
- Check if the patient can move their foot or toes
- Check if they can feel your touch and if there’s tingling or numbness
- Check the posterior tibial pulse, toes for capillary refill, and the skin’s color, temp, and moisture
If you do not feel a radial (upper extremity) or posterior tibial pulse (lower extremity), what does that indicate?
Blood vessel damage
Where is the posterior tibial pulse on the lower extremities?
Behind the ankle bone on the inner side of the ankle
If a patient can’t move their extremity by squeezing your hand or moving their foot and toes, what does that indicate?
The extremity is seriously injured or paralyzed
What does tenderness indicate?
Injury
What does a tingling feeling or numbness indicate?
Potential injury
When is an exam of a specific area of the body done?
When the patient is responsive or when they have sustained nonsignificant MOIs
What do the vital signs consist of?
- Respiration
- Pulse
- Blood pressure
- Skin condition
What is the respiratory rate?
Indicates how fast the patient is breathing; normally 12-20 breaths per minute in adults (inhaling and exhaling together)
What can rapid and shallow respirations indicate?
Shock
What can slow respirations indicate?
Stroke or drug overdose
How can respirations be described?
Rapid, slow, shallow, deep, wheezing, gasping, panting, snoring, labored, or noisy
What does pulse indicate?
The speed and force of the heartbeat
What are the 4 common pulse points?
- Radial: thumb side of wrist (most common)
- Carotid: neck
- Brachial: inside of arm
- Posterior tibial: inner ankle behind ankle bone
Where should you check for a pulse on a conscious patient?
Radial pulse
Where should you check for a pulse on an unconscious patient?
Carotid pulse
Where should you check for a pulse on an infant?
Brachial pulse
Where do you assess the circulatory status of a leg?
Posterior tibial pulse
How do you determine pulse rate?
- Find the pulse
- Count the beats for 30 seconds
- Multiply by 2
What is the normal resting pulse rate for adults?
60-100 bpm
What is the normal pulse rate for children?
70-150 bpm
What can a very slow pulse rate indicate?
Serious illness
What can a very fast pulse rate indicate?
Shock
What is a bounding pulse?
A strong pulse
What is a thready pulse?
A weak pulse
Which is more dangerous, a bounding pulse or a thready pulse?
Thready pulse
What is capillary refill?
The ability pf the circulatory system to return blood to the capillary vessels after the blood has been squeezed out
How do you perform a capillary refill test?
- Squeeze the patient’s nailbed firmly
- Release pressure once the nailbed looks pale
- Wait 2 seconds and the nailbed should turn pink normally
What can a delayed or absent capillary refill be related to?
A patient losing a lot of blood and experiencing shock or blood vessel damage in that limb
In cold environments, should a capillary refill test be used to assess the circulatory status of an extremity?
No
What can a high blood pressure indicate?
The patient is susceptible to stroke
What can a low blood pressure indicate?
One of the several possible types of shock
What is the systolic blood pressure?
The top number on the BP measurement; the force exerted on the walls of the arteries as the heart contracts
What is the diastolic blood pressure?
The bottom number on the BP measurement; the arterial pressure during relaxation phase of the heart
What is hypertension?
High blood pressure; higher than 130/90 mm Hg
What is hypotension?
Low blood pressure; systolic BP is lower than 90 mm Hg
How do you find a patient’s BP by palpation?
- Apply the BP cuff to the uninjured or less injured arm
- Locate the radial pulse
- Pump the cuff until you can no longer feel the radial pulse +30 mm Hg
- Slowly release the pressure in the cuff
- When you feel the radial pulse come back, that is the systolic BP
How do you find a patient’s BP by auscultation?
- Apply the BP cuff to the uninjured or less injured arm
- Place the diaphragm of the stethoscope over the brachial pulse
- Pump the cuff until you can no longer hear the pulse +30 mm Hg
- Slowly release pressure in the cuff
- When you hear the pulse again, that is the systolic BP
- When you no longer hear the pulse, that is the diastolic BP
What is the normal skin condition described as?
Warm, pink, and dry
How do you check the pupil size after vital signs have been completed?
Shining a light into the patient’s eyes
What do pupils of unequal size indicate?
Stroke or injury to the brain
What do pupils that remain constricted indicate?
The patient may be taking narcotics or has central nervous system diseases
What do pupils that remain dilated indicate?
A relaxed or unconscious state; head injuries or drug use (barbiturates or sleeping pills)
How should you assess the level of responsiveness during the secondary assessment?
Observe and note any changes if any occur after the first level of consciousness assessment which was done in the primary assessment based on the AVPU scale
What are the 7 parts of the reassessment?
- Repeat the primary assessment
- Reassess vital signs
- Reassess the chief complaint
- Recheck the effectiveness of the treatment
- Identify and treat changes in the patient’s condition
- Reassess the patient
- Provide a handoff report
How should you repeat the primary assessment?
- Recheck their level of responsiveness
- Recheck their airway, breathing, and circulation
- Continue maintaining an open airway and monitor breathing and pulse rate (rate, rhythm, quality)
How often should you reassess unstable patients?
Every 5 minutes
How often should you reassess stable patients?
Every 15 patients
What information should be included in the handoff report?
- Age and sex of patient
- History of the incident
- Patient’s primary or chief complaint
- Patient’s level of responsiveness
- How you found the patient (their condition and position)
- Status of vital signs (ABC) and if severe bleeding is present
- Results of the secondary assessment
- Pertinent medical conditions (SAMPLE)
- Interventions provided and how patient responded to them
How long should the patient assessment take to complete?
2 minutes
What adjustment should you make to the patient assessment sequence when dealing with a trauma patient?
Perform the secondary assessment before taking the patient’s medical history to gain info on the patient’s injuries
