Chapter 13 - Patient Assessment Flashcards
Components of primary assessment
Form general impression of pt Assess level of consciousness Assess the airway Assess breathing Assess oxygenation Assess circulation Establish patient priorities
The main purpose of the primary assessment is to:
Identify and manage immediately life threatening conditions to the airway, breathing, oxygenation, or circulation.
Chief complaint
What the patient tells you is wrong with him
Forming general impression:
Estimate pt age Note pt sex Determine trauma/medical Chief complaint Identify and manage immediate life threats
There are two types of trauma:
Blunt and penetrating
Type of force that pierces the skin and body tissues.
Penetrating
Steps of scene size-up:
Standard precautions Scene hazards/scene safety Moi Noi # of patients Need for additional resources
Bringing the patients head into a neutral in-line position and holding it there.
In-line stabilization
In-line stabilization procedure:
Place one hand on each side of the patient’s head.
Gently bring the head into a position in which the nose is in line with the patient’s navel.
Position the head neutrally so the head is not extended (tipped backward) or flexed (tipped forward).
AVPU
Alert
Voice
Pain
Unresponsive
Central painful stimulus:
Trapezius pinch Supraorbital pressure Sternal rub Earlobe pinch Armpit pinch
Peripheral painful stimuli:
Nail bed pressure
Pinch to the web between thumb and index finger
Pinch to the finger, toe, hand or foot
Purposeful movements
Attempts made by the patient to remove the painful stimulus or avoid the pain. Documented as “withdraws the stimulus” or “withdraws from pain”
Nonpurposeful movements:
Flexion posturing and extension posturing. Both signs of a serious head injury.
Flexion posturing
(Decorticate posturing) The patient arches the back and flexes the arms inward toward the chest.
Extension posturing
(Decerebrate posturing) Patient arches back and extends the arms straight out parallel to the body.
Occluded
Closed or blocked
Patent
Open
Sounds that may indicate partial airway obstruction:
Snoring-a rough, snoring-type sound on inspiration and/or exhalation
Gurgling-a sound similar to air rushing through water on inspiration and/or exhalation
Crowing-a sound like a cawing crow on inspiration
Stridor-harsh, high pitched sound on inspiration
Airway sound heard that is an indication that the tongue and likely the epiglottis are partially blocking the airway.
Snoring
Airway sound that is an indication that a liquid substance is in the airway.
Gurgling
High-pitched sounds produced on inspiration. Commonly associated with the swelling or muscle spasms that can result from conditions such as airway infections, allergic reactions, or burns to the upper airway.
Crowing/Stridor
Breathing assessment:
Determine if breathing is adequate or inadequate
Determine the need for early oxygen therapy if breathing is adequate
Provide positive pressure ventilation with supplemental oxygen for inadequate breathing
Amount of air breathed in and out.
Tidal volume
Best method to assess breathing:
Looking
Listening
Feeling
Poor movement (rise) of the chest wall. Typically described as shallow respiration.
Inadequate tidal volume
Breathing that is either too fast or too slow (outside the ranges of 8-24 per min for an adult, 15-30 per min for a child, 25-50 per min for an infant)
Abnormal respiratory rate
Abnormally slow breathing. Respiratory rate that is too slow.
Bradypnea
Conditions that may cause bradypnea:
Hypoxia (especially in young children and infants), drug O/D on depressant drugs, head injury, stroke, hypothermia (cold emergency), and toxic inhalation.
A respiratory rate that is too fast
Tachypnea
Conditions that may lead to tachypnea:
Hypoxia, fever, pain, drug overdose, stimulant drug use, shock, head injury, chest injury, stroke, and other medical conditions.
Identified by a sunken-in appearance of tissues that are pulled inward on inhalation.
Retractions at:
The suprasternal notch (above the sternum)
Intercostal spaces (between ribs)
Supraclavicular spaces (above the clavicles)
Identified by no chest wall movement and no sensation or sound of air moving in and out of the nose or mouth
Absence of breathing (apnea)
A bluish or blue-grey tone of the skin seen early around the lips, nose, and fingernail beds indicating inadequate oxygenation.
Cyanosis
Dyspnea
Difficulty breathing
An assessment of circulation includes:
Pulse
Possible major bleeding
Skin color, temp, and condition
Capillary refill
Bradycardia
Heart rate les than 60bpm
Tachycardia
Heart rate greater than 100bpm
Skin that is _____ or ______ typically indicates a decrease in perfusion and the onset of shock (hypoperfusion).
Suspect that the patient is losing blood internally or externally or suffering another cause of shock.
Pale/Mottled
Blue-gray, skin may indicate reduced oxygenation from chest injuries, blood loss, or conditions like pneumonia or pulmonary edema that disrupt gas exchange in the lungs. It is a late sign of poor perfusion.
Cyanotic
______ refers to the amount of moisture found on the skin surface.
Skin condition
Critical finding making the patient unstable :
Obvious blood, vomitus, secretions, or other obstructions to the airway
Immediately suction or clear the obstruction from the airway
Critical finding making the patient unstable :
Obvious open would to the anterior, lateral, or posterior chest
Immediately cover the open wound with a nonporous or occlusive dressing taped on three sides
Critical finding making the patient unstable :
Paradoxical movement of the chest
Stabilize the segment with your hand, or provide bag-valve-mask ventilation, if necessary for inadequate breathing.
Critical finding making the patient unstable :
Major bleeding that is spurting or flowing steadily
Apply direct pressure to the site of bleeding
Critical finding making the patient unstable :
Mechanism of injury that might produce spinal injury
Establish and hold manual in-line stabilization of the head and neck
Critical finding making the patient unstable :
Altered mental status to include a patient who is confused, responds only to verb or painful stimuli, or one who does not respond
Closely assess airway, breathing, and oxygenation status. Administer supplemental oxygen.
Critical finding making the patient unstable :
Blood, secretions, vomitus, or other substance in mouth and airway (gurgling, stridor, or crowing sounds)
Immediately suction the airway and clear any other obstructions
Critical finding making the patient unstable :
Occluded from the tongue (sonorous sounds)
Immediately perform a head-tilt, chin-lift, or jaw-thrust maneuver if a spine injury is suspected.
Critical finding making the patient unstable :
Inadequate respiratory rate (too slow or too fast, with other signs of inadequate breathing)
Immediately begin positive pressure ventilation with supplemental oxygen connected to the ventilation device
Critical finding making the patient unstable :
Rapid and weak pulses
Stop any major bleeding. Administer supplemental oxygen
Critical finding making the patient unstable :
Carotid pulse present, but absent peripheral pulses
Stop any major bleeding administer supplemental oxygen
Critical finding making the patient unstable :
Pale, cool, clammy skin
Stop any major bleeding. Administer supplemental oxygen
Critical finding making the patient unstable :
Capillary refill greater than 2 seconds with other signs of poor perfusion
Stop any major bleeding. Administer supplemental oxygen.
Critical finding making the patient unstable :
Major bleeding that is spurting or flowing steadily
Immediately stop the bleeding by applying direct pressure
Critical finding making the patient unstable :
Absent carotid pulse in the adult or child; absent brachial pulse in the infant
Immediately initiate CPR, beginning with chest compressions, and apply AED.
Three major steps to the secondary assessment:
Conduct physical exam
Take baseline vital signs
Obtain history
A clear fluid that surrounds and cushions the brain and the spinal cord.
Cerebrospinal fluid (CSF)
Ecchymosis
Black and blue discoloration
The white portion of the eye.
Sclera
Hematoma
Collection of blood
Subcutaneous emphysema
Air under the skin
Tension pneumothorax
Air trapped in the chest cavity as a result of chest or lung injury
Pericardial tamponade
Blood filling the sac around the heart - congestive heart failure.
Segments of the chest that are moving inward during inspiration and outward during exhalation, the opposite to the direction of the rest of the chest.
Paradoxical movement
Peritonitis
Inflammation or irritation of the lining of the abdomen
Priapism
Persistent erection of the penis - sign of a possible spinal cord injury
Paraplegia
Paralysis involving both legs only
Conjuctiva
Mucous membrane that covers the covers the front of the eye and lines the inside of the eyelids
Quadriplegia
Paralysis involving both arms and both legs
Hemiplegia
Paralysis of an arm or leg on one side of the body
the major body systems assessment includes the:
respiratory (pulmonary)
cardiovascular
neurological
musculoskeletal
body system assessment of respiratory (pulmonary) system:
chest shape and symmetry
accessory muscle use (retractions)
auscultation (normal and abnormal breath sounds)
body system assessment of cardiovascular system:
peripheral and central pulse (rate, rhythm, strength, location) blood pressure (systolic, diastolic, pulse pressure)
body system assessment of neurological system:
mental status (AVPU, orientation)
posture and motor activity appropriateness of posture and movement, arm drift)
facial expression (anxiety, depression, anger, fear, sadness, pain, facial asymmetry or droop)
speech ad language (slurred, garbled, aphasia)
mood (nature, intensity, suicidal ideation)
memory and attention (orientation to person, place, time, purpose)
body system assessment of musculoskeletal system:
pelvic region (symmetry, tenderness)
lower extremities (symmetry, superficial findings, range of motion, sensory, motor function)
upper extremities (symmetry, superficial findings, range of motion, sensory, motor function, arm drift)
peripheral vascular system (tenderness, temp., distal pulses)
perfusion (distal pulses, skin color, temp., condition)
posterior body (symmetry, contour, superficial findings, flank tenderness, spinal column tenderness)
components of the SAMPLE history:
Signs and Symptoms Allergies Medications Past medical history Last oral intake Events prior to the incident
secondary assessment sequence for trauma patient:
physical exam
baseline vital signs
history
potentially deadly side effect of very high intracranial pressure that occurs when a part of the brain is squeezed across structures within the skull.
Brain herniation
secondary assessment for a medical patient who is responsive:
rapid secondary assessment (head to toe)
baseline vital signs
history
secondary assessment for a medical patient who is unresponsive:
history
modified secondary assessment (focused on the chief complaint, signs, and symptoms)
baseline vital signs
Two or more adjacent ribs that are fractured in two or more places
Flail segment
The patient arches the back and flexes the arms inward toward the chest. A sign of serious head injury. Also called Decorticate posturing.
Flexion posturing
Breathing a substance into the lungs
Aspiration
The patients answer to the question “why did you call the ambulance?”
Chief complaint
Black-and-blue discoloration to the mastoid area behind the ear, a late sign of skull or head injury.
Battle sign
The movement of a section of the chest in the opposite direction of the rest of the chest during respiration.
Paradoxical movement
Open; not blocked
Patent
The absence of breathing
Apnea
Fluid that surrounds the brain and spinal cord
Cerebrospinal fluid
Following inspection and palpating f extremities in the rapid secondary assessment of the trauma patient, the EMT should check for PMS. “PMS” refers to:
Pulses
Motor function
Sensation
Baseline vital signs:
Respiration Pulse Skin Blood pressure Pulse oximetry Pupils
History for medical patient who IS alert and oriented - OPQRST questions:
Onset Provocation Quality Radiation Severity Time
during rapid trauma assessment - DCAP-BTLS:
deformities contusions abrasions punctures burns tenderness lacerations swelling
crepitation
crackling, or rattling sound
