Patient Assessment Flashcards
patient assessment
- focus now on the patient as an individual
- golden hour is critical
- prioritizes patient and their critical functions
- create a method that is systematic:
- scene assessment
- general impression
- primary survey
- secondary survey
golden hour
- trauma patients are time critical
- R Adams Cowely, MD
- found that if bleeding is not controlled and tissue oxygenation is not restored within 1 hour of the injury the patients survival rate plummets
- THE CLOCK WHEN THE EVENT OCCURS
- 90% of trauma patients are simple injuries
- for those 10%, definitive care is the ultimate goal for the patient
primary concern
- prioritize patients in the following order
- conditions that may result in loss of life
- conditions that may result in loss of limb
- all others that do not fall into the above two categories
- this will maximize the golden hour for the patients that are more time sensitive!
- systems are prioritized when assessing the patient in order to get the most people treated the fastest
handling primary concerns
- hemorrhage control perfusion- stopping arterial bleeding
- airway
- ventilation
- oxygenation
- neurologic function
- following this path of assessment will protect the patients ability to oxygenate and deliver RBC to the bodies tissue
scene assessment
- safety- fire, contamination, combat
- pre-arrival information
- arrival on scene
- mechanism of injury
- patients
- taught individually
- wind shield survey -> what can you see/information from outside the scene
- performed simultaneously
- personal and personnel safety is paramount
safety: pre-incident
- prophylaxis (recommended vaccinations)
- training
safety: incident: situational awareness
- do not enter scene unless it is safe
- crime scene
- bad guys still in the area
safety measures
- PPE
- incident specific
- patient specific
- blood, body fluids, sharps
safety: post-incident
-exposures (TB, body substances, etc.)
Pre-arrival information
- dispatch information
- location of incident
- nature of incident
- reported situational issues
- safety
- number of patients
- co-responders
- weather conditions
- traffic conditions
- time of day
arrival on scene
- global view- before you get out of the vehicle
- what do you see, feel, hear, smell?
- is the scene safe?
- what happened?
- who, what, and how many are involved?
- are there any access issues?
- what additional resources may be needed
general impression
- part of the primary survey
- occurs as a bridge between scene and patients assessment
- it is a quick global observation of the patients respiratory, circulatory, and neurologic systems
- it identifies obvious, significant external problems with primary functions
- flow directly into the primary survey
primary survey
- dont be distracted by visually dramatic, non-life threatening injuries
- primary survey and management take precedence over the secondary survey
XABCDE: primary survey
- X- identify severe external bleeding
- A- identify airway compromise or potential for this to develop
- B- identify breathing inadequacy or potential for this to develop
- C- identify hypoperfusion; control mild to moderate bleeding
- D- identify neurologic dysfunction
- E- identify significant injuries
airway and cervical spine
- stabilize the cervical spine
- trauma patients with significant mechanism for injury are suspected to have a spinal injury until it is conclusively ruled out
- ensure the patients neck is manually maintained in the neutral position during the opening of the airway and the administration of necessary ventilation
- airway patency- open and clear
- remove and assess for obstruction
- consider advanced techniques to secure airway
breathing
- make sure patient is breathing
- look, listen, feel for 5-10 sec
- assess rate in value of breaths per minute
- ventilate the patient if they are not breathing
- ensure a patient airway and compliance with ventilation
- ensure oxygen delivered is 85% or greater
- make sure you are having mechanical compliance -> chest rise
- depth is just as important
- if the patients is breathing you must think about the quality/efficacy of that patients efforts
I PASS O2
- I- inspection
- P- palpation
- A- auscultation - 4 places- aortic, pulmonic, tricuspid, and mitral valves
- S- seal holes
- S- stabilize flail segments- two or more ribs broken in two or more places
- O- oxygen/ventilation
apnea
-not breathing, no effort
bradypnea
- guppy breathing
- less than 10 RR
eupnea
- between 12-20 RR
- healthy
tachypnea
- between 20-30 RR
- closely monitor
severe tachypnea
- greater than 30 RR
- indication of hypoxia
- anaerobic metabolism
ronchi
-course bubbling sound indicating sever fluid
rales
- fine crackling
- indicating fluid build up
wheezing
- high pitch sounds
- indication bronchi constriction
stridor
- high pitch wheeze
- indicates obstruction
absent breathing
- due to trapped air
- pneumothorax
- hemothorax (blood in chest)
circulation
assess for circulatory compromise or failure
- check radial, femoral, or carotid pulse for 10 secs
- control hemorrhages
types of hemorrhages
- BLOOD SWEEP
- capillary- from abrasion or mild laceration that have open capillaries just below skin; usually stops on own
- venous- from deeper areas, usually controlled with direct pressure, blood is dark, blueish
- arterial- cause by compromised artery, most important and difficult to control, bright red in color and usually spurting
controlling hemorrhage
- direct pressure with dressing
- redressing if saturation occurs
- tourniquet
perfusion
- assessed by:
- pulse- palpable, strength, regularity
- skin- color, temperature, moisture, capillary refill
disability
- assessment of cerebral function
- primary concern is the patients level of consciousness
- glasgow coma scale is a tool use to measure consciousness/mental status
- patient can have other causes that can cause decrease neurological function
- medical issues can cause trauma
- pupillary response is also a good indication of internal head injury
- extremity function, sensation will also be good indicators of injury
- measures GSC, pupil response, extremity function
- factors that can contribute to decreased LOC:
- CNS injury
- decreased oxygenations
- metabolic
- drug/alcohol
causes of decrease LOC
- A- alcohol/drugs
- E- epilepsy
- I- insulin/diabetes
- O- opiates
- U- uremia
- T- trauma
- I- infection
- P- psychosis
- S- stroke/seizure/shock
expose/environment
- although not in the mnemonic, exposure is a critical part of assessment for LOC
- expose anything that you think could possibly be injured
- address any factors environmentally that could contribute to patient deterioration
- prevent loss of body heat
rapid assessment
- rapid regional exam of the body
- quickly sweep from head to toe looking for injuries
- focuses on outward signs of trauma
- looking for signs of DCAP-BTLS
DCAP-BTLS
- D- deformities
- C- contusion
- A- abrasions
- P- punctures
- B- burns
- T- tenderness- pain only when you touch it
- L- lacerations
- S- Swelling
trauma is time critical
- only critical life threatening injuries/airway complications should be addressed on scene
- all other treatments should be done enroute to the receiving facility
scene size up
-what scene safety concerns or consideration are present
capillary bleeding
- caused by abrasions that have scraped open the tiny capillaries beneath the skin
- controlled with direct pressure
venous bleeding
- trauma to a vein
- originates from deeper in the tissue
- usually controlled with direct pressure
arterial bleeding
- trauma to an artery
- difficult to control
- characterized by spurting blood
- can quickly result in life threatening hypovolemia
secondary assessment
-After the General Impression, and Primary Survey are Done,
The Secondary Survey is completed
-It is a head to toe evaluation of the patient
-SAMPLE and OPQRST History
-Signs and Symptoms, Allergies, Medicines, Pertinent
Medical History, Last oral intake, Events leading to Event.
-Onset, Provocation, quality, radiation, severity, Time
-Detailed Physical Exam
-Primary survey finds life threatening conditions
-Secondary survey finds all other injuries,
-A regional Investigation looking for any sign of injury
secondary assessment by region
-Head: Search Through Hair, Check Pupil, Palpate bones
-Neck: Anatomical placement, SQ (subcutaneous) Emphysema, tracheal
Alignment (is it midline?)
-Thoracic: Pain, Paradoxical movement, symmetry
-Back: Log Roll, Expose!, Palpate, Step offs, Subluxation
-Abdomen: Guarding, Tenderness, Distention, Pulsing mass
-Pelvic Girdle: Palpate Pubis, Iliac Crests, Crepitus.
-THIS IS DONE ONLY ONCE!
-Extremities: Palpate Girdle Through Fingers or toes
summary
- scene safety of prehospital care providers and the patient is the priority
- all life threats are to be managed as soon as discovered
- maintain a high index of suspicion for subtle life threatening injuries
who needs a full secondary assessment
- people who cant communicate to you
- perform a rapid full body scan
- focused assessment of pain
- assessment of vital signs
- techniques of physical examination
- respiratory system
- presence of breath sounds
5 main parts in an incident
- scene size up
- primary assessment
- history taking
- secondary assessment
- reassessment
symptoms and signs
- rarely does one sign or symptom show you the patients status or underlying problem
- symptom- subjective condition the patient feels and tell you about
- sign- objective condition you can observe about the patient
secondary assessment
- may be performed on scene in the back of the ambulance en route to the hospital or not at all
- purpose is to perform a systematic physical exam on the pt
- may be a systematic head to toe survey or an assessment that focuses on a certain area or system of the body
- compare one side of the body to the other
- goal is to identify hidden injuries or identify causes missed during 60-90 sec exam during primary assessment
how and what to assess in a secondary assessment
- inspection- look at the patient for abnormalities
- palpation- touch or feel the pt for abnormalities
- auscultation- listen to the sounds a body makes by using a stethoscope
focused assessment
- performed on patients who have sustained nonsignificant MOIs or on responsive medical pts
- typically based on the CC
- goal is to focus your attention on the body part or systems affected by the priority problems
respiratory system
- expose the pts chest
- look for signs of airway obstruction
- inspect symmetry
- listen to breath sounds
- measure RR
- look for retraction and increased work of breathing
respiratory rate
- normal is 12-20 breaths/min for adults
- children breathe at even faster rates
- count the number of breaths in a 30 sec period and multiply by 2
respiratory rhythm
- regular- the time from one peak chest rise to the next is fairly consistent
- irregular- respirations vary or the rate changes frequently
quality of breathing
- normal breathing is silent
- breathing accompanied by other sounds may indicate a significant respiratory problem
upper air sounds
-usually inspiration
lower airway sounds
-usually expiration
depth of breathing
-amount of air the pt exchanges depends on the rate and tidal volume
breath sounds
-you can almost always hear breath sounds better from the pts back
what are you listening for?
- normal breath sounds
- snoring breath sounds
- wheezing breath sounds
- crackles
- rhonchi
- stridor
cardiovascular system
- look from trauma to the chest and listen for breath sounds
- consider the pulse, respiratory rate, and BP
- pay attention to rate, quality, and rhythm
- consider your finding when assessing skin
- check and compare distal pulses
- consider auscultation for abnormal heart sounds
pulse rate
- normal resting for an adult is 60-100 beats/min
- the younger the pt the faster the pulse
pulse quality
- describe a stronger than normal pulse as bounding
- a pulse that is weak and difficult to feel is described as weak or thready
pulse rhythm
- regular- interval between each contraction should be the same; the pulse should occur at a constant regular rhythm
- irregular- heart perdiocally has an early or late beat; if a pulse beat is missed
blood pressure
- pressure of circulating blood against the walls of the arteries
- a drop in BP may indicate:
- loss of blood or fluid components
- a loss of vascular tone and sufficient arterial constriction
- cardiac pumping problem
- decreased blood pressure is a late sign of shock
- abnormally high blood pressure may result in a rupture or other critical damage in the arterial system
blood pressure cuff
- blood pressure cuff with gauge contains:
- wide outer cuff
- inflatable wide bladder
- ball pump with one way valve
- pressure gauge
auscultation: BP
-most common means of measuring blood pressure
palpation
-does not depend on the ability to hear sounds
normal blood pressure
- hypotension- blood pressure is lower than normal
- hypertension- blood pressure is higher than normal
neurologic assessment
- should be performed with any pt who has:
- changes in mental status
- possible head injury
- stupor
- dizziness/drowsiness
- syncope
- evaluate the LOC and orientation
- use the AVPU scale if appropriate
- glasgow coma scale (GCS) can be helpful in providing additional info
pupils
- the black center portion of the eye
- pupils are normally round and of approx equal size
- in the absence of any light the pupils will become fully relaxed and dilated
anisocoria
- unequal pupils
- small number of population exhibit this
causes of depressed brain function
- injury of the brain or brain stem
- trauma or stroke
- brain tumor
- inadequate oxygenation or perfusion
- drugs or toxins
PEARRL: pupil
- pupils
- equal
- and
- round
- regular in size
- react to light
neurovascular status
- check for bilateral muscle strength and weakness
- complete a thorough sensory assessment
- test for pain, sensations, and position
- compare distal and proximal sensory and motor responses and one side with the other
head, neck, and cervical spine
- palpate the scalp and skull
- check the pts eyes
- check the color of the sclera
- assess the pts cheekbones
- check the pts ears and nose for fluid
- check the upper (maxillae) and lower (mandible) jaw
- open the pts mouth and look for any broken or missing teeth
- note any unusual odors in the mouth
chest
- inspect, visualize, and palpate
- watch for both sides of the chest to rise and fall together with normal breathing
- observe for abnormal breathing signs
abdomen
- palpate for tenderness, rigidity, and pt gaurding
- start palpating away from the pain and work your may closer
- four quadrants:
- left upper quadrant (LUQ)
- left lower quadrant (LLQ)
- right upper quadrant (RUG)
- right lower quadrant (RLQ)
pelvis
-inspect for symmetry and any obvious signs of injury, bleeding and deformity
extremities
- inspect for symmetry, cuts, bruises, swelling, obvious injuries, and bleeding
- palpate for deformities
- check for pulses and motor and sensory functions
posterior body
- inspect the back for DCAP-BTLDS, symmetry and open wounds
- palpate the spine from the neck to the pelvic for tenderness and deformity
pulse oximetry
- used to evaluate oxygenations effectiveness
- measures the oxygen saturation of hemoglobin in the capillary beds
- patients with difficulty breathing should receive oxygen regardless of their pulse oximetry value
monitoring devices
-never replace you comprehensive assessment of the pt
capnography
-can quickly provide information on a pts ventilation, circulation, and metabolism
blood glucometry
-measures the level of glucose in the bloodstream
sphygmomanometer
-blood pressure cuff
reassessment
- perform at regular intervals during the assessment process
- repeat the primary assessment
- reassess vital signs
- compare with the baseline vital signs obtained during the primary assessment
- look for trends
reassess the chief complaint
- ask and answer the following questions
- is the current treatment improving the pts condition
- has an already identified problem gotten better
- has an already identified problem gotten worse
- what is the nature of any newly identified problems
recheck interventions
- check all interventions
- most important are the pts ABCs
- ensure management of bleeding
- ensure adequacy of other interventions, and consider the need for new interventions
identify and treat changes in the pts condition
-document any changes, whether positive or negative
reassess the patient
- unstable pts- approx every 5 minutes
- stable patients- approx every 15 minutes
stabilization of spine is the first step of assessing disability
- false
- LOC and cerebral function is the first step
