Ch10: Patient Assessment Flashcards
A 29-year-old male with a head injury opens his eyes when you speak to him, is confused as to the time and date, and is able to move all of his extremities on command. His Glasgow Coma Scale (GCS) score is:
A. 13.
B. 10.
C. 12.
D. 14
A. 13
Which of the following would the EMT likely NOT perform on a responsive patient with a headache and no apparent life-threatening conditions?
A. Noninvasive blood pressure monitoring
B. Systemic head-to-toe examination
C. Assessment of O2 saturation
D. Focused secondary assessment
B. Systemic head-to-toe examination
The goal of the systematic head-to-toe exam that is performed during the secondary assessment is to:
A. locate injuries not found in the primary assessment.
B. definitively rule out significant internal injuries.
C. assess only the parts of the body that are injured.
D. detect and treat all non-life-threatening injuries.
A. locate injuries not found in the primary assessment.
The systematic head-to-toe assessment should be performed on:
A. responsive medical patients and patients without a significant MOI.
B. stable patients who are able to tell you exactly what happened.
C. patients with a significant MOI and unresponsive medical patients.
D. all patients with traumatic injuries who will require EMS transport.
C. patients with a significant MOI and unresponsive medical patients.
A blood pressure cuff that is too small for a patient’s arm will give a:
A. falsely low systolic and diastolic reading.
B. falsely high systolic and diastolic reading.
C. falsely low systolic but high diastolic reading.
D. falsely high systolic but low diastolic reading.
B. falsely high systolic and diastolic reading.
A patient’s short-term memory is MOST likely intact if they correctly answer questions regarding:
A. day and event
B. person and place
C. time and place
D. event and person
A. day and event
5 Stages of Patient Assessment
- Scene size up
- Primary assessment
- History taking
- Secondary assessment
- Reassessment
5 Stages of Scene Size-Up
- Ensure scene safety
- Determine MOI and NOI
- Take standard precautions
- Determine no. of patients
- Consider add’l resources
2 Types of Trauma
- Blunt: force applied over a large area, sometimes skin isn’t broken
- Penetrating: piercing skin, open wounds
How do energy transfers apply to MOI?
Blunt trauma or force to one area of the body can transfer and cause injury in other places because of energy transfers.
E.g. trauma on foot can transfer up to pelvis and spinal cord
Triage
Sorting patients based on severity of condition
Incident command system
system to manage disasters & mass-casualty events
7 Stages of Primary Assessment
- Form general impression (by talking to patient, noting any observations/bleeding)
- Assess LOC
- Airway
- Breathing
- Circulation (ABCs)
- Identify & treat life-threatening conditions
- Determine priority of patient care
What are not included in primary assessments?
In-depth physical examination, vital signs
How to assess LOC? (2 steps)
1) AVPU scale
Awake & alert
Verbal stimuli
Pain stimuli - pinching tissue in sternum, lower jaw, trapezius (muscle above collarbone)
Unresponsive
2) PPTE (for orientation)
Person
Place
Time
Event
–> all yes = “awake and fully oriented”
–> deviation from normal mental status = “altered mental status”
When do patients need spinal immobilization?
Blunt/Penetrating Trauma with any of:
- tenderness on neck or spine palpation
- reported neck/back pain
- paralysis or neurologic complaint
Blunt trauma with any of:
- intoxication
- altered mental status
- difficulty in communicating
OR distracting injury
(may distract from any neck/back pain)
What happens if airway is obstructed
blocks air movement
not enough perfusion
How do you tell if a responsive patient has unobstructed airways?
If they can talk and cry.
How do you tell if a responsive patient has an obstructed airway?
If they cannot talk or cry.
How do you tell if an unresponsive patient has an obstructed airway?
trauma –> jaw thrust movement
noisy breathing
shallow respirations
Conditions that cause sudden death
respiratory arrest
respiratory failure
airway obstruction
cardiac arrest
shock
severe bleeding
What’s the diff between respiratory arrest and failure
arrest: complete cessation of BREATHING
failure: ventilation failure; inadequate O2 getting into blood
How do you document a patient breathing on his/her own in a PCR?
spontaneous breathing
What are examples of positive pressure ventilation as breathing support?
endotracheal tube, oxygen mask
Signs of inadequate breathing
shallow respirations; little chest movement, poor chest excursion
tripod or sniffing (infants) position
use of accessory muscles (abdomen, neck)
two to three-word dyspnea
Difference between respiratory distress, arrest, and failure
distress: difficulty breathing
arrest: complete cessation of BREATHING
failure: ventilation failure; inadequate O2 getting into blood
signs of respiratory distress
increased breathing rate (tachypnea)
increased HR (tachycardia)
use of accessory muscles
seesaw breathing, nasal flaring, head bobbing
stridor, wheezing
anxiety
signs of respiratory failure
increased breathing rate (tachypnea)
low O2 sats
bradycardia
gasping for air with gurgling or snoring sounds
lethargy
diminished of muscle tone
inadequate chest rise
3 Steps of Assessing Circulation
1) mental status 🗣️
2) pulse
3) skin condition
Where to find pulse in infant?
brachial artery (inside of upper arm)
Where to find the pulse of an unresponsive child/adult (1+ years)?
carotid artery
Where to find the pulse of a responsive child/adult (1+ years)?
radial artery (wrist)
What do you do if there is a pulse but no breathing?
provide ventilations
- for adult: 10-12 breaths per min
- for infants/children: 12-20 breaths per min
What do you do if there is no pulse?
start CPR, apply AED
What does pale, ashen, grey or white skin indicate?
poor circulation
or abnormally cold skin
What does cyanosis indicate?
poor perfusion (cells not getting O2)
What does flushed & red skin condition tell us?
High bp
What does jaundice tell us?
liver disease
What is normal vs. abnormal skin temp?
normal: warm to the touch
abnormal: cold, hot or clammy (slightly moist) to the touch
What can HOT skin temp be caused by?
sunburn
fever
hyperthermia
What can COLD skin temp be caused by?
hypothermia
early shock
hypoperfusion
What is the medical term for skin being very wet and moist?
diaphoretic
3 Important Aspects when Documenting Circulation Assessment
- Color
- Temp
- Moisture
“Skin: pale, cool, clammy”
What is Capillary refill time?
Time it takes for blood to flow back into the tip of a finger/toe (warm, pink color) after being blanched
Should be ~2 seconds, as long as it takes to say “capillary refill”
How to document CRT
“CRT > 2 seconds”
“CRT is delayed”
How to control bleeding
1) Use gloves
2) Put direct pressure on wound
3) Apply sterile bandage
If it’s still bleeding or a major hemorrhage: apply tourniquet
7 Components of Rapid Head-to-toe patient assessment during primary assessment
- head
- neck
- chest (+ breathing sounds)
- abdomen
- pelvis
- extremities
- back & buttocks (double B’s)
What signs and symptoms render a patient “High Priority” and that they need immediate transport?
Hint: many to do with resp and cardiovascular systems
unresponsive
difficulty breathing
severe chest pain
severe pain anywhere
uncontrolled bleeding
altered LOC
pale skin, signs of poor perfusion
complicated childbirth
What is the Golden Hour
the one hour after an injury happens where survival potential is best if treatment occurs
20 mins: discovery & EMS activation
10 mins: “platinum 10 minutes” (patient assessment, intervention, packaging)
30 mins: transport and hospital stabilization
What is decompensated shock?
when the body’s vitals such as HR and bp suddenly fall after a period of being stable as the body can no longer compensate for any failures/compromises
Outline for documenting information in a PCR
CHART
Chief Complaint
History
Assessment
Rx Treatment
Transport
Mnemonic for investigating a chief complaint and pain assessment during History-Taking
OPQRST
Onset
Provocation
Quality
Region/Radiation
Severity
Time
Mnemonic for investigating patient history
SAMPLE
Signs & symptoms
Allergies
Medications
Past medical history
Last oral intake
Event leading up to illness
Critical thinking process during Assessment and History Taking (3 steps)
Gather (info)
Evaluate
Synthesize (form deduction and drafting a plan of action based on gathered info)
What sensitive topics may need to be talked about during History taking?
Alcohol & drugs
Abuse & violence
Sexual History
When do you start the secondary assessment (systematic physical examination)?
- After ALL life-threatening conditions have been taken care of in primary assessment
- if patient is stable
- complaint is isolated (significant MOI)
8 Specific Things to look for in both rapid and systematic head-to-toe examinations
DCAP - BTLS
Deformities
Contusions (bruise)
Abrasions
Punctures
Burns
Tenderness
Lacerations
Swelling
Systematic head-to-toe assessment drill (14 steps)
- Eyes (around the eyes, redness, pupil reaction)
- Ears (Battle sign behind ears, any drainage/blood inside)
- Palpate head, zygomas and maxillae
- Nose (drainage/blood)
- Palpate mandible
- Mouth (blood, unusual odors)
- Neck (jugular vein distention)
- Chest & ribs
- Anterior breathing (observe & auscultate)
- Back & posterior breathing (observe & auscultate)
- Abdomen (palpate)
- Pelvis (gently press sides, and then down on iliac crest)
- Extremities (circulation, motor & sensory function)
- Back (tenderness, deformities)
7 Steps in Focused Respiratory Exam (secondary assessment)
- Expose patient’s chest
- Airway obstruction?
- Trauma?
- Left vs right the same?
- Breath sounds - normal?
- RRDQ (Resp rate, rhythm, depth, quality)
- Retractions?
Patient is coughing up thick yellow/green mucus. What does it mean?
Respiratory infection
Patient is coughing up blood or frothy white/pink sputum. What does it mean?
Blood and fluids are mixing with air in the lungs producing froth
Could be chest injury or congestive heart failure (fluid building up in lungs)
Normal RR for infants
30 - 60 breaths/min
Normal RR for toddlers
24 - 40 breaths/min
Normal RR for pre-schoolers
22 - 34 breaths/min
Normal RR for school-age children
18 - 30 breaths/min
Normal RR for adolescents
12 - 16 breaths/min
Normal RR for adults
12 - 20 breaths/min
Cardiac arrest vs congestive heart failure
Cardiac arrest = abrupt loss of heart function because of irregular heart rhythm e.g. ventricular fibrillation
Congestive heart failure = heart loses ability to effectively pump blood, e.g. damage to heart muscle
What does a wheezing breathing sound like and what does it mean?
Musical, whistling, squeaky sound
Lower airway obstruction
What does stridor sound like and what does it mean?
high-pitch crowing sound
upper airway obstruction
What does a snoring breathing sound mean?
upper airway obstruction
What does crackling breathing sound like and what do they mean?
They are wet, short and high-pitch.
They mean that there is fluid in the lungs
What does rhonchi sound like and what do they mean?
Low, bubbly, rumbling sound (like underwater)
Mucus, fluid in the lungs
6 Steps in Focused Circulatory Exam (secondary assessment)
- trauma?
- breath sounds
- RQR (rate, quality, rhythm)
- skin condition
- Lefts vs. right distal pulses
- auscultation
How would you describe pulse quality during documentation
normal = “strong”
stronger than normal = “bounding”
weak or difficult to find = “weak” or “thready”
How would you describe pulse rhythm during documentation
Regular or irregular
What does an irregular pulse rhythm suggest?
there is a cardiovascular problem, might need to call for ALS back up and paramedics
What can low bp indicate?
Loss of blood
Loss of fluid component of the blood
Loss of vascular tone
Cardiac pumping problem
How do you measure bp with a manual ball-pump sphygmomanometer?
- Secure cuff on arm (2 fingers above the elbow bend)
- Stethoscope on brachial artery (between cuff and elbow bend)
- Close valve and increase pressure to 200 mmHg.
- Open valve slightly and let pressure decrease slowly.
- Systolic: note down pressure when you first start hearing a pulse
- Diastolic: note down pressure when you stop hearing the pulse
Document as: “BP 120/80”
When to avoid measuring blood pressure on an arm
When a medical device or equipment has been inserted like IV
Avoid measuring blood pressure on the side of a mastectomy
If patient has a fistula (if they have chronic kidney disease or are on dialysis)
Injury to that arm
How do you measure bp with using palpation instead of a stethoscope (in noisy situations)?
- Secure cuff on arm (2 fingers above the elbow bend)
- Put two fingers at radial artery (wrist)
- Close valve and increase pressure to 200 mmHg.
- Open valve slightly and let pressure decrease slowly.
- Systolic ONLY: note down pressure when you first feel a pulse again
Document as: “BP 120/P”, verbalize as “200, palpated”
*It cannot determine diastolic pressure
Normal blood pressure for a neonate
67 - 84 mmHg
Normal blood pressure for a 2 year old
86 - 106 mmHg
Normal blood pressure for a 7 yo
97 - 115 mmHg
Normal blood pressure for an infant
72 - 104 mmHg
Normal blood pressure for an adolescent
110 - 130 mmHg
Normal blood pressure for an adult
90 - 120 mmHg
8 Steps in Focused Neurologicno Exam (secondary assessment)
- AVPU scale
- activity level
- mood & thought content
- incomprehensible/understandable statements?
- memory?
- Glasgow Coma Scale (out of 15)
- Pupillary reaction
- Neurovascular status
What is the criteria for GCS?
Eye opening (1-4 points)
4: spontaneous
3: to sound/verbal stimuli
2: to pressure
1: none
Best verbal response (1-5 points)
5: orientation
4: confusion
3: words
2: sounds
1: none
Best motor response (1-6 points)
6: obey commands
5: localizing
4: normal flexion
3: abnormal flexion
2: extension
1: none
What is a normal pupil reaction?
PEARRL
Pupils
Equal
And
Round
Regular in Size
and respond to Light
4 Steps of assessing neurovascular status
- pulse
- CRT
- check sensations (A. tip of finger and toe, B. side of foot)
- check motor function (A. open hand and make a fist, B. point and flex foot)
How to assess blood glucose level
- Clean tip of finger with antiseptic
- Prick finger with lancet
- Dispose needle into the sharps bin
- Add drop of blood to a test strip and insert it into a glucometer
- Bandage it up!
6 Stages for Reassessment
- Repeat primary assessment
- Reasses vitals
- Reasses chief complaint
- Reasses interventions
- Identify & treat any changes in patient condition
- Reasses every 5/15 mins (for unstable and stable patients respectively)
What position is preferred when transporting a person who is unconscious from a non trauma emergency?
? Trendelenburg
? Prone
? Supine
? Recovery
Recovery, to maintain a patent airway
What are the 3 factors of the pediatric assessment triangle (PAT)
PAT is for assessment without patient contact = SAW
Skin Circulation
Appearance
Work of Breathing,
