Chapter 13: Patient Assessment Flashcards
primary assessment
after scene is safe and controlled, conducted on every patient regardless of the MOI or NOI
the overall purposes of patient assessment served during primary assessment
1) determine whether the patient is injured or ill
2) identify and manage immediately life-threatening conditions
3) determine priorities for further assessment and care on the scene versus immediate transport
the main purpose of the primary assessment
identify and manage immediately life-threatening conditions to the airway, breathing, oxygenation, or circulation
components of primary assessment
1) form a general impression of the patient
2) assess the level of consciousness (mental status)
3) assess the airway
4) assess breathing
5) assess oxygenation
6) assess circulation
7) establish patient priorities
spine motion restriction (SMR)
performed if you suspect spinal cord or vertebral injury (patient has sever MOI) or if patient complains or neck/back pain, loss of motor/sensory functions, or abnormal sensations in extremities
self-restriction
patient instructed to bring head and neck in line with umbilicus and not move it
penetrating trauma
a force that pierces skin and body tissues, e.g. gunshots, knives, other sharp objects
blunt trauma
caused by a force that impacts or is applied to the body but is not sharp enough to penetrate, e.g. blows or crushing
chief complaint
the patient’s answer to “why did you call EMS today?” and if patient cannot answer, it may be the response of a family member/bystander or what you infer from observation if no one can answer
immediate life threats that require immediate managements
1) an airway compromised by blood, vomit, tongue, etc…
2) obvious open wounds to chest
3) paradoxical movement of chest (moves in on inhalation and out on exhalation)
4) major bleeding
5) unresponsive with no breathing or no normal breathing (agonal or gasping breaths)
performing manual SMR
1) place one hand on either side of patient’s head
2) gently bring head into a position in which the nose is aligned with the patients naval
3) position the head neutrally so the head is not extended or flexed
performing self-restriction
1) instruct patient to bring his head and neck in line with his navel
2) instruct the patient to bring his legs and feet also in line with his body and to keep his toes in line with his nose and naval
3) instruct the patient not to move his head or neck by extending, flexing, or making any lateral movements until further instructed, a cervical collar is often put in place as a reminder
AVPU mnemonic
Alert, responds to Verbal stimulus, responds to Painful stimulus, Unresponsive
trapezius pinch
painful stimulus, pinch the trapezius muscle that extends from along the base of the neck to the shoulder, grasp 1-2 inches of the muscle and squeeze
supraorbital pressure
slide fingers under the upper ridge of the eye socket and apply upward pressure
sternal rub
apply hard downward pressure to center of sternum with knuckles
earlobe pinch
pinch the soft tissue portion of the earlobe
armpit pinch
pinch the skin and underlying tissue along the margin of the armpit
nail bed pressure
apply point pressure to the cuticle area of the nail bed
other peripheral painful stimuli
1) pinch the web between thumb and index finger
2) pinch the finger, toe, hand, or foot
flexion posturing
aka decorticate posturing, a non-purposeful movement, patient arches back and flexes arms inward towards chest, sign of serious head injury
extension posturing
aka decerebrate posturing, a non-purposeful movement, patient arches back and extends arm straight out parallel to the body, sign of serious head injury
occluded airway
closed or blocked airway, immediate life-threatening condition
patent airway
open airway
assess breathing to:
1) determine whether breathing is inadequate or adequate
2) determine need for early oxygen therapy if breathing is adequate
3) provide positive pressure ventilation with supplemental oxygen for inadequate breathing
inadequate tidal volume
poor movement (rise) of chest wall (shallow respiration)
abnormal respiratory rate
breathing that is either too fast or too slow
bradypnea
a respiratory rate that is too slow, causes inadequate minute ventilation leading to hypoxia. can be caused by hypoxia, drug overdose (depressant drugs), head injury, stroke, hypothermia, toxic inhalation
tachypnea
respiratory rate that is too fast, can lead to hypoxia. can be caused by hypoxia, fever, pain, drug overdose, stimulant drug use, shock, head injury, chest injury, stroke, other medical conditions
retraction
sunken-in appearance, tissues pulled in on inhalation
tracheal tugging
pendulum motions of the trachea in the anterior neck during inhalatoin
apnea
absence of breathing, no chest wall movement and no sensation/sound of air moving in and out of nose/mouth
dyspnea
difficulty breathing
when to administer oxygen treatment
SpO2 reading below 94%, signs of hypoxia, hypoxemia, poor perfusion, heart failure, respiratory distress
circulation assessment
check the:
1) pulse (presence, absence, approx. HR, regularity and strength)
2) possible major bleeding
3) skin color (mucous membranes), temperature, condition
4) capillary refill
major bleeding
bright red, spurting bleeding (arterial) OR dark red, steady, rapid bleeding (venous)
abnormal skin
1) pale/mottled
2) cyanotic
3) red
4) yellow
pale/mottled skin
decrease in perfusion, onset of shock (hypoperfusion), suspect blood loss or other shock cause
cyanotic skin
blue-grey skin, indicate reduced oxygenation from chest injuries, blood loss, conditions that disrupt gas exchange in lungs, late sign of poor perfusion
red skin
increase in the amount of blood circulating in blood vessels in skin, can indicate anaphylactic or vasogenic shock, poisonings, overdose, diabetic.other medical conditions, alcohol, local inflammation, cold exposure, heat emergency
yellow skin
jaundice, indicates liver dysfunction
hot skin
from a hot environment or a very elevated body core temperature
cool skin
decreased perfusion as seen in shock, exposure to cold temperatures, fright, anxiety, drug overdose, medical conditions that may interfere with body’s ability to regulate temperature
cold skin
frostbite, significant cold exposure, immersion in cold water, severe hypothermia
cool and clammy skin
cool and moist, from blood loss, fright, nervousness, anxiety, pain, other medical conditions, THE MOST common sign of shock (hypoperfusion)
dry skin
dehydrated or suffering from severe heat exposure or from some medical emergencies
moist skin
sweating (in a hot environment), exercise or exertion, fever…from heart attack, hypoglycemia, shock, many other conditions
secondary assessment
to identify any additional injuries or conditions that may be life threatening
1) conduct a physical exam
2) take vital signs
3) obtain a history
NOT necessarily in this order
cerebrospinal fluid (CSF)
clear fluid that surrounds and cushions the spinal cord, CSF leakage usually indicates a skull fracture
consensual reflex
when both pupils react simultaneously and equally to light being shined in either eye
fixed and dilated pupil
pupil that is large and not responding to light
visual acuity
clarity of vision
conjugate movement
eyes should move together
nystagmus
jerky eye movements
fixed gaze
singular eye that is fixed
dysconjugate gaze
eyes do not move together
sclera
white portion of eye
icterus
yellow sclera, possible liver damage/failure
hematoma
collection of blood
subcutaneous emphysema
air under the skin, evidence of trauma to the airway
tension pneumothorax
air trapped in the chest cavity because of chest or lung injury
pericardial tamponade
blood filling the sac around the heart
productive cough
mucus produced with cough
peritonitis
inflammation or irritation of the abdomen lining
priapism
a persistent erection of the penis, sign of a possible spine injury
paraplegia
paralysis involving both legs only
quadriplegia
paralysis involving both arms and both legs
hemiplegia
paralysis of an arm and leg on one side of the body
vital signs that need to be assessed during the secondary assessment and reassessed throughout the entire call
breathing (rate and tidal volume), pulse (location, rate, strength, regularity), skin (temperature, color, condition), capillary refill, blood pressure (systolic and diastolic), pupils (equality, size, rate of reactivity), SpO2
SAMPLE history
S: Signs and Symptoms
A: Allergies
M: Medications
P: Past medical history
L: Last oral intake
E: Events prior to the incident
secondary assessment order for a trauma patient
- physical exam
- vital signs
.3. history
rapid secondary assessment
a rapid head-to-toe exam, followed by prompt transport or on-scene emergency care
modified secondary assessment
an exam focused on a specific injury site, followed by on-scene emergency care
when to do a rapid secondary assessment followed by rapid emergency care and transport
if the mechanism of injury is significant enough to cause critical injuries, if multiple injuries exist, if the patient has an altered mental status, or if any other critical finding identified in the primary assessment makes the patient unstable,
when to do a rapid secondary assessment followed by rapid emergency care and transport
if the mechanism of injury is significant enough to cause critical injuries, if multiple injuries exist, if the patient has an altered mental status, or if any other critical finding identified in the primary assessment makes the patient unstable
when to do a rapid secondary assessment followed by on-scene emergency care
the mechanism of injury is not significant enough to produce critical injuries but you suspect the patient could be suffering from multiple or serious injuries anywhere on the body, or if the patient has altered mental status
when to do a modified secondary assessment followed by appropriate on-scene emergency care
if the patient is suffering from an isolated injury that is not critical, the mechanism of injury is minor, there is no evidence of multiple injuries, and the patient is alert and oriented
significant mechanisms of injury
- ejection (partial or complete) of the patient from a vehicle in an automobile crash
- a crash that causes death to a person in the same passenger compartment in which the patient is found
- a fall of greater than 20 feet
- rollover of the vehicle the patient was in
- a vehicle collision that has occurred at a high speed
- an intrusion of greater than 12 inches into the passenger compartment or greater than 18 inches at any site on the vehicle
- a pedestrian/bicyclist struck by a vehicle
- a motorcycle crash greater than 20mph with separation of rider from motorcycle
- blunt or penetrating trauma that results in an altered mental status from confusion to unresponsiveness
- penetrating injuries to the head, neck, torso, or extremities above the knee or elbow
- blast injuries from an explosion
- seat-belt injuries
- collisions in which seat belts are not worn, even if air bags have been deployed
- impact causing deformity to the steering wheel
- collision that results in prolonged extrication
special considerations for infants and children for MOIs
- a fall of greater than 10 feet or 2-3 times the height of the child
- a bicycle collision with a motor vehicle
- a pedestrian or occupant in a vehicle collision at a medium speed
- any vehicle collision where the infant or child was unrestrained
- all other adult significant MOIs
secondary assessment: trauma patient with significant MOI, multiple injuries, or altered mental status
1) continue in-line stabilization
2) consider ALS request
3) reconsider transport decision
4) reassess mental status
5) perform rapid secondary assessment
6) assess vital
7) obtain history
8) transport
9) perform reassessment
secondary assessment: trauma with NO significant MOI, NO multiple injuries, and NO altered mental status
1) perform modified secondary assessment
2) assess vitals
3) obtain history
4) transport
5) perform reassessment
AVPU
A: alert
V: responds to verbal stimulus
P: responds to painful stimulus
U: unresponsive
Glascow Coma Scale
GCS, to rank the patients level of conciousness between 3-15. A score of 8 or less means that there is a severe alteration in brain function. A score of 13 or less means that there needs to be limited (less than 10 minutes) of on-scene time and rapid transport
brain herniation
significant swelling and/or bleeding to or around the brain creates excessive pressure within the skull and causes the brain to be compressed and pushed downward toward the brain stem, when the brain is pushed out of the foramen magnum (the opening where the spinal cord exits the brain) or the fibrous tentorium (divides the upper and lower brain).
aspiration
the patient breaths a substance into the lungs
aniscoria
unequal pupils (normally)
subcutaneous emphysema
air trapped under the lower layer of the skin, good indicator of significant neck or chest injury
tension pneumothorax
trachea shifted to one side due to air in the chest cavity, the result of severe lung or chest injury (trachea deviates away from the injured side), when a lung is completely collapsed from air trapped in pleural space
tracheal tugging
pendulum motion of the trachea, indicates airway obstruction
paradoxical movement
a section of the chest sinks inward on inhalation while the rest of the chest moves outward
flail segment
two or more adjacent ribs fractured in two or more places, alters negative chest pressure, life threatening injury (reduces breathing and oxygenation adequacy), CPAP can be good here
tenderness
a pain response elicited upon palpation
markle test/heel jar test
strike bottom of heel sharply with fist while patient is supine, tests for rebound tenderness and possible internal injury to abdominal organs
DCAP-BTLS
for rapid secondary assessment (trauma)
D: Deformities
C: Contusions
A: Abrasions
B: Burns
T: Tenderness
L: Lacerations
S: Swelling
PMS
for rapid secondary assessment of the extremities
P: Pulses (distal pulses)
M: Motor function
S: Sensation
breathing assessment: rapid secondary assessment (trauma patient)
rate, tidal volume, quality of breathing (normal, shallow, labored, deep, noisy)
pulse assessment: rapid secondary assessment (trauma patient)
radial pulse (adult and child patient), brachial pulse (infant less than 1 year), if radial not present, assess carotid
skin assessment: rapid secondary assessment (trauma patient)
pale or cyanotic nail beds, pale skin, pale oral mucosa, pale conjunctiva, feel skin w/ back of hand for temperature and condition, capillary refill
pupil assessment: rapid secondary assessment (trauma patient)
size and reactivity
blood pressure assessment: rapid secondary assessment (trauma patient)
via auscultation, determine systolic and diastolic, narrow pulse pressure and hypotension = signs of serious blood loss and shock
pulse oximeter assessment: rapid secondary assessment (trauma patient)
apply to determine oxygen level, any reading less than 94% is suspicious
revised trauma score
includes Glasgow Coma Scale, has 3 major components (respiratory rate, systolic blood pressure, GCS score)
secondary assessment: medical patient who is responsive, alert, and oriented
1) assess complaints plus signs and symptoms (OPQRST)
2) obtain history
3) perform a modified secondary assessment
4) assess vital signs
5) make transport decision
6) reassessment
secondary assessment: medical patient who is unresponsive, not responsive to verbal or painful stimuli, not alert or oriented
1) perform a rapid secondary assessment
2) assess vital signs
3) position patient
4) obtain history
5) transport
6) reassessment
orthopnea
inability to breathe/shortness of breath while lying flat
crackles/rales
fine crackling noises on inhalation similar to hair being rubbed together close to your ear, indication of fluid in/around alveoli and terminal end of bronchioles
wheezing
a musical sound on inhalation and exhalation, indicates higher resistance in bronchioles with restricted airflow, usually from bronchiole constriction or swelling/inflammation
peritonitis
irritation of the abdomen lining (peritoneum)
peripheral edema
swelling around the hands, feet, ankles
recovery/coma position
left lateral recumbent position (modified), avoids the potential for aspiration
reassessment
conducted following the secondary assessment, reassess vital signs every 5 minutes for unstable patient or every 15 minutes in the stable patient
three basic reasons to perform a reassessment
- to detect any change in the patient’s condition
- to identify any missed injuries or conditions, especially those that are life-threatening
- to adjust the emergency care as needed
breathing assessment for an unresponsive medical patient
tachypnea, abnormal respiratory patterns
pulse assessment for an unresponsive medical patient
radial pulse, then carotid pulse if radial pulse is not present, determine rate and quality
pupil assessment for an unresponsive medical patient
document size, equality, reactivity to light
skin assessment for an unresponsive medical patient
assess temperature, color, condition (pale cool and clammy may indicate vasoconstriction)
blood pressure assessment for an unresponsive medical patient
get both systolic and diastolic, pay attention to pulse pressure
pulse oximeter
determine SpO2 on room air
general steps of reassessment
1) repeat primary assessment
2) reassess and record vital signs
3) repeat secondary assessment for other complaints, injuries, or a change in the chief complaint
4) check interventions
5) note trends in the patient’s condition
