Chapter 12: The Primary Assessment Flashcards
Primary Assessment
- the first element in pt assessment
- steps taken for the purpose of discovering and dealing with any life-threatening problems
6 parts of a primary assessment
- forming a general impression
- assessing mental status
- assessing airway
- assessing breathing
- assessing circulation
- determining the priority of the pt for treatment and transport to the hospital
Intervention
actions taken to correct or manage a pt’s problems
General Impression
impression of the pt’s condition that is formed on first approaching the pt, based on the pt’s environment, chief complaint, and appearance
Key Decision: General Impression: Chief Complaint & AVPU
- How does the pt look?
- If pt is apparently lifeless, go directly to pulse check and the CAB approach
- may perform the ABCs in any order
- ^ dependent on the pt’s presentation and emergent needs.
- multiple parts of the PA can be performed simultaneously if there is more than 1 EMT present
Key Decision: Airway
- open the airway
- suction if necessary
- place an oral or nasal airway if indicated
Key Decision: Breathing
- is the pt breathing?
- is the pt breathing adequately?
- is the pt hypoxic
Key Decision: Circulation
- does the pt have a pulse?
- does the pt have signs of shock?
- does the pt have life-threatening bleeding?
Key decision: priority determination
- how do I handle the pt from this point on?
Priority Determination (3)
stable, potentially unstable, unstable
Stable
slower pace, more detailed secondary examination
Potentially unstable
expedite transport, fewer assessments and interventions on scene
unstable
rapid transport, only life-saving assessment and interventions on scene
The “Look Test”
a feeling about the pt’s condition based on conclusions made from environmental observations and first look at the pt
Pts who appear lifeless
- pts w/ no mvmt or apparent evidence will be resuscitated by CPR and preparing defib
Pts who have an obvious altered mental status
- can indicate many underlying conditions (hypoxia, shock, diabetes, overdose, seizure, etc.)
- your concern is not the cause, it is the impact it will have on the pt and your assessment and care decisions
- PA will be aggressive b/c of high potential for life-threatening problems
- Subsequent assessment will likely be done quickly to expedite transport
Pts who appear unusually anxious and those who appear pale and sweaty
- indicators of possible shock
- recognizing these signs at the earliest possible moment will help you identify this potentially serious condition early
Obvious trauma to the head, chest, abdomen, or pelvis
-EMTs identify serious trauma to these areas as injuries the can cause airway problems, profound shock, or death
Specific positions indicate distress
- tripod indicates significant trouble breathing
- levine’s indicates significant chest pain pr discomfort
Chief Complaint
in emergency medicine, the reason EMS was called, usually in the pt’s own words
How you form a general impression
looking, listening, smelling
- look for the pt’s age and sex; look at the pt’s position
- listen for sounds such as moaning, snoring, or gurgling respirations
- sniff the air to detect any smells such as hazardous fumes, urine, feces, vomitus, or decay
Clinical judgement
judgement based on experience in observing and treating pts
Mental Status
level of responsiveness
AVPU
levels of responsiveness
- alert
- verbal response
- painful response
- unresponsive
How to assess airway
- is the airway open/patent?
- will the airway stay open/patent?
How to assess breathing
rate, depth, quality
How to assess circulation
pulse (radial, carotid), skin (color, temperature, condition), major bleeding
4 general situations that call for assistance w/ breathing
- If the pt is in respiratory arrest w/ a pulse
- If the pt is not alert and his breathing is inadequate (w/ an insufficient minute volume b/c of decreased rate or depth or both)
- If the pt has some level of alertness and his breathing is inadequate
- If the pt’s breathing is adequate but there are signs or symptoms suggesting respiratory distress or hypoxia
If the pt is in respiratory arrest w/ a pulse…
perform rescue breathing
If the pt is not alert and his breathing is inadequate (w/ an insufficient minute volume b/c of decreased rate or depth or both)…
provide positive pressure ventilations with 100% O2
If the pt has some level of alertness and his breathing is inadequate…
assist his ventilations w/ 100% O2; synchronize your ventilations w/ the pt’s own respirations so they are working together, not against each other
If the pt’s breathing is adequate but there are signs or symptoms suggesting respiratory distress or hypoxia…
provide O2 base on the pt’s need as determined by your examination, the pt’s complaint and level of distress, and the pulse ox readings
PA if pt is apparently lifeless
- look for signs of life aka “look, listen, feel”
- check the pulse for no longer than 10 seconds
- if no pulse, begin CPR compressions while the AED is being readied
- clear the pt, apply AED pads and follow voice prompts
- continue resuscitation
PA if pt has a pulse
- develop a general impression and obtain a chief complaint; take spinal precautions if trauma is suspected
- open the airway
- suction if necessary
- insert an oral or nasal airway if required to maintain a patent airway
- evaluate breathing for rate, depth, and quality
- apply positive pressure vent to pts who are not breathing or breathing inadequately
- provide O2 based on pt complaint, condition, and pulse ox reading
- identify and control life-threatening bleeding
- evaluate circulation; check the pulse
- evaluate circulation; check skin color, temperature, and conditions
- make a status/transport priority decision
- request ALS or other assistance as necessary
A few hard-and-fast rules for how to determine stability
- To be stable, a pt needs to have vital signs that are in the normal range or just slightly abnormal
- A threat to the airway, breathing, or circulation, either actual or imminent, rules out stable
- There are many times when it is not crystal clear what a pt’s problem is, so there will be many possible diagnoses, some more serious than others
- A pt’s priority can change
Rule: To be stable, a pt needs to have vital signs that are in the normal range or just slightly abnormal
- If they are abnormal, they must be small deviations from normal or easily explained by factors other than injury and illness (ex. sweating on a hot day).
- Stable vital signs are not the only requirement for a stable classification, but they are necessary
Rule: A threat to the airway, breathing, or circulation, either actual or imminent, rules out stable
This puts a pt in either the unstable or potentially unstable category, depending on the severity of the pt’s condition
Rule: There are many times when it is not crystal clear what a pt’s problem is, so there will be many possible diagnoses, some more serious than others
- When a pt doesn’t have any immediate threats to life but you believe he may deteriorate b/c of the nature of the problem, you should consider the potentially unstable category for the pt
- this means you will not delay transport, but it does not necessarily mean you will use lights and siren to transport the pt to the hospital
Rule: A pt’s priority can change
- ex. an unconscious diabetic pt w/ low blood sugar would initially be unstable b/c of the threat to the airway. If the pt became awake enough to swallow oral glucose then became alert and oriented, it would be appropriate to change this pt’s priority to stable.
High-priority conditions
- poor general impression
- unresponsive
- responsive, but not following commands
- difficulty breathing
- shock
- complicated childbirth
- chest pain consistent w/ cardiac problems
- uncontrolled bleeding
- severe pain anywhere
Pt assessment takes different forms depending on:
- whether the pt has a medical problem pr trauma
- whether the pt does or does not have an altered mental status
- whether the pt is an adult, a child, or an infant
Assessing ADULT mental status
AVPU; if alert, is pt oriented to person, place, and time?
Assessing CHILD 1-5 y.o. mental status
AVPU; if alert, is pt oriented to person, place, and time?
Assessing INFANT-1 y.o. mental status
If no alert, shout as a verbal stimulus, flick feet as a painful stimulus. (crying would be infant’s expected response)
Assessing ADULT airway
- Trauma: jaw-thrust maneuver
- Medical: head-tilt chin-lift
- Both: consider OPA or NPA airway and suctioning
Assessing CHILD 1-5 y.o. airway
-same as adult, but when performing head-tilt chin-lift, do not hyperextend the neck
Assessing INFANT - 1 y.o. airway
- same as children, but see airway management to review for special infant airway techniques
Assessing ADULT breathing
- if respiratory arrest, perform rescue breathing
- if depressed mental status and inadequate breathing (slower than 8 bpm), give positive pressure vents w/ 100% O2.
- admin O2 when indicated, according to the pt’s complaint, level of respiratory distress, and the pulse ox readings
Assessing CHILD 1-5 y.o. breathing
- Same as adults, but normal rates for children are faster
Assessing INFANT - 1 y.o. breathing
- Same as children, but normal rates for infants are faster
Assessing ADULT circulation
- assess skin, radial pulse, and bleeding
- of pt is in cardiac arrest, perform CPR
- see “bleeding and shock” on how to treat for bleeding and shock
Assessing CHILD 1-5 y.o. circulation
- assess skin, radial pulse, bleeding, and capillary refill
- if pt is in cardiac arrest, perform CPR
- see “bleeding and shock” on how to treat for bleeding and shock
Assessing Infant - 1 y.o. circulation
- assess skin, brachial pulse, bleeding, and capillary refill
- if pt is in cardiac arrest, perform CPR
- see “bleeding and shock” on how to treat for bleeding and shock
