patient care Flashcards
Patient Assessment
Two primary components
1. Information gathering:
MOI for trauma patients
NOI for medical patients
Ascertain the Hx of the events leading up to EMS activation, gather a SAMPLE Hx, etc
2. Physical examination
ABC or CAB, followed by appropriate examination medical or trauma
Patient Assessment fundamental components
Identify problems- done during primary and secondary survey
Set priorities- determine immediate threats to life/limb (during primary and RTA/RMA)
Develop a care plan- how will you intervene
Execute the plan- perform your interventions and reassess, ALWAYS REASSESS
elements of patient assessment
Gather information
Primary source of information is usually the patient
Other sources include the patient’s family, friends or eyewitnesses to the emergency event
Be observant, it may be necessary to gather information from the scene itself
Primary Survey C-EMCA-P
- Confirm the call information with dispatch
- Environmental hazard check
- Mechanism of injury
- Casualty numbers
- Additional resources required
- Personal protection required
Primary Survey
LOA - Level Of Awareness (AVPU)
Manual C-spine Control (as required)
Airway or Circulation
Breathing or Airway
Circulation or Breathing
Critical Injuries And Gross Bleed Check
Critical Interventions
Primary Survey General impression
The Paramedic will immediately form a “general impression” of the patient. This is also referred to as the Look Test
What do you see?
Focuses on identification and management of life-threatening problems
Medical
Is my patient sick?
If so, how sick are they?
Trauma
Is my patient hurt?
If so, how badly hurt are they?
General impression signs of distress
Altered mental status
Anxiousness
Laboured breathing
Difficulty speaking
Diaphoresis
Poor colour
Obvious pain
Obvious deformity, guarding or splinting
Gross external hemorrhage
Mental Status and Neurological Function
Mental status
One of the prime indicators of how sick the patient really is
Are there changes in the state of consciousness? (do they present with AMS or is this normal for patient?)
Establish a baseline as soon as you encounter a patient.
The Chief complaint
The “Chief Complaint” is determined at the outset of patient contact. It often comes prior to the Primary Survey, as you approach the patient. Or it can be elicited very quickly as you begin to communicate about why the patient called for an ambulance.
C-spine
Evaluate
First for the MOI- is there reason to suspect this pt requires SMR
Altered mental status?
Presence of pain
Distracting injury?
THE BASIC ABCDE’S
AIRWAY
- Open the airway
- Clear the airway
- Insert an oral/nasal airway prn
BREATHING
- Assess breathing
- BVM Ventilations prn
- Supplemental oxygen prn
CIRCULATION
- Assess pulses
- CPR prn (if pt is unconscious CAB)
DISABILITY
-pupillary response
-neuro deficits
EXPOSE- inspect the patient, cut away clothing prn
Airway Status
Focuses primarily on two questions:
1. Is the airway open and patent?
how is the pt positioned? foreign body?
2. Is it likely to remain so?
Are there Sonorous sounds?
Are there Gurgling or bubbling sounds ?
Work from Simple to Complex
Easiest problem to solve is position- requires no special equipment
Possibility of spine injury drives the decision of which technique to use to open the airway.
Head tilt-chin lift or jaw thrust
If Obstruction is present or suspected utilize BLS procedures to clear the obstruction.
BASIC AIRWAY what to do to open
Open And Clear The Airway:
Chin lift and/or modified jaw thrust maneuver.
Visualize the oro-pharynx
Suction and/or remove foreign bodies.
Insert an oral airway if the patient has a decreased LOC and NO gag reflex.
Insert a nasal airway if the patient has a decreased LOC and a gag reflex.
V-Vac
Suction only as far
as you can see…
Measure from
corner of mouth to
tragus
Adult setting=380mmHg
No more than 10 sec
intervals
oropharyngeal airway
An oropharyngeal airway holds back the tongue. Insert an oral airway if the patient has a decreased LOC and NO gag reflex.
Nasopharyngeal Airway
A nasopharyngeal airway runs behind the tongue. Insert a nasal airway if the patient has a decreased LOC and a gag reflex. Note that one (1), nasal airway is sufficient. Two (2) nasal airways can be inserted
King LT Airway
The King LT airway comes in three (3) different sizes for use in adults.
The choice of which size to use is based on the estimated height of the patient. Each size is differentiated by the colour of the tip:
. YELLOW – 4 to 5 feet (122-155 cm)
#4. RED – 5 to 6 feet (155-180 cm)
#5. PURPLE – Over 6 feet (> 180 cm)
Supraglottic Airway Directive indications
Indications
Need for ventilatory assistance or airway control
AND Other airway management is ineffective
patient must be in cardiac arrest
maximum 2 attempts
Supraglottic Airway Directive contraindications
Inability to clear the airway
Stridor
Active vomiting
Airway edema
Caustic ingestion
Breathing minute volume
Respiratory rate multiplied by the tidal volume
Resp Rate x tidal volume
Amount of air actually moved in to and out of the lungs each minute
Basic breathing, assess for adequacy
Look – for rise and fall of the chest. Listen – for the sound of moving air. Feel – for breath on your hand or cheek. Determine whether the patient is breathing, and then whether
the patient is breathing adequately. Determine the approximate rate, rhythm and quality
Basic breathing inadquate level and what to do
8-10 rpm = assist ventilations>
28 rpm with a decreased LOC = assist ventilations.
Claps
Look for CLAPS to ascertain injuries to the thorax and the lungs
C-ontusions
L-acerations
A-brasions
P-enetrations
S-ubcutaneous Emphysema
TICS-D
Look for TICS-D to ascertain injuries to the ribs, sternum and clavicles
T-enderness
I-nstability
C-repitus
S-welling
D-eformity
Circulation Pulse
Provides a rapid check of the patient’s cardiovascular status,
Information about the rate, strength, and regularity of heartbeat
Note the force and rhythm of the pulse- compare central & peripheral
Circulation Skin Colour
Skin colour, temperature, and condition
Collectively provide insight into the patient’s overall perfusion
Use the back of your hand to assess the warmth and moisture of the patient’s skin.
Colour of the skin reflects the status of the circulation immediately underlying the skin.
Normal skin is moderately warm and dry.
Adequate Circulation rate rhytm quality
Rate - normal = 60 – 100 bpm
- too fast = > 160 bpm
- too slow = < 50 bpm
Rhythm - regular
- irregular
Quality - strong
- weak
Capillary Refill
Blanch the skin and wait for the colour to return
< than 2 seconds = normal
> than 2 seconds = delayed
RAPID TRAUMA ASSESSMENT
Typically done between the Primary Survey (initial assessment) and the Secondary Survey (focused physical examination) of a trauma patient
It is an organized, systematic and rapid head to toe exam used to identify any potential threats to life/limb that may not have been apparent during the initial primary survey
RAPID TRAUMA ASSESSMENT Indications
There was a significant mechanism of injury (ex. a high-speed car accident) OR
The patient has analtered mental status OR
The paramedic suspects that the patient hasmulti-system trauma
CRITICAL INJURIES CHECK
The Critical Injuries Check is a rapid “Neck-to-Knees” assessment for gross bleeding as well as findings more specific to their location: RTA
Head – AMS, CLAPS/TICS-D,
Neck – JVD, tracheal deviation, CLAPS/TICS-D.
Chest – auscultation, CLAPS/TICS-D.
Abdomen – observe and palpate all four (4) quadrants for tenderness, distension, rigidity, penetrations.
Pelvis – palpate and compress for TICS-D.
Femurs – palpate for CLAPS/TICS-D
CRITICAL INTERVENTIONS
Critical Interventions are procedures that MUST be completed prior to transport, even with a critical patient:
Oro/nasal airway (decreased LOC).
100% oxygen +/- positive pressure ventilations (hypoxia).
Chest compressions (VSA).
Defibrillation (Cardiac Arrest Protocol –Trauma/Medical).
Hemorrhage control (gross bleed).
Cervical collar (suspected spinal injury).
Spinal board + head immobilization (suspected spinal injury).
Occlusive dressing - open neck wound (4-sided)
- open abdominal wound (4-sided)
- open chest wound (3-sided)
DEFIBRILLATION
It is important to apply the monitor/defibrillator without delay to any patient who is suspected to be in cardiac arrest.
For all other patients, the monitor should be applied as a “bridge” device between the Primary Survey and the Secondary Survey.
Therefore, if you do NOT believe it may be necessary to immediately defibrillate your patient, the cardiac monitor should be applied AFTER the Critical Injuries Check, and AFTER any Critical Interventions.
