PCT 1 Patient Assessment - Intro to asses

Question 1

What do you do for every call?

Answer 1

AEMCA
A – Apply PPE
E – Environment
M – Mechanism of Injury/Illness
C – Casualties (#)
A – Additional Resources 

EMCA -PIE
Environment
Mechanism of Injury
Casualties (Number of)
Assistance Required
Personnel Protective Equipment 
Interview
Events Prior

Question 2

What is environment in EMCA - PIE? what do you look for at the scene every time?

Answer 2

Are there dangers to yourself or the patient?
No Fire, Wire, Gas, or Glass
No needles or weapons
No Violence - domestic dispute or aggressive patient

Know your exits and plan a strategy for leaving as you enter

Question 3

What is Mechanism of Injury/Illness?

Answer 3

What caused the injury/illness?

Motor Vehicle Collision (MVC)
Exposure (weather, bee sting)
Chest Pain
Trauma (fall, assault)
Psychiatric 
Drug overdose

Question 4

What do you do for casualties? Who can go in the same ambulance?

Answer 4

What are the number of casualties on scene?

If more than one you may need a second ambulance
If one or both are ambulatory (and are friends/family of each other), both can be transported in one vehicle
Some ambulances have double stretchers – able to transport two patients who require a stretcher at the same time
Helpful for isolated areas where another crew is far away

Question 5

What are additional resources you may need?

Answer 5

What assistance do you need?
Resources
Police
Fire
More Ambulances 
ACP crew 
Supervisor
Air Ambulance
Hydro
Animal rescue
CAS

Question 6

What is PPE and what do you need? Why is it required for every call?

Answer 6

Protect yourself and others:

Helmet (MVC, fallen structures, etc)
Goggles (i.e. Risk of spray of body substances and/or droplets)
Mask (i.e. Risk of spray of body substances, and/or droplets)
Gloves (to be worn on every call)
Gown/Isolation Suits (exposure to contagious diseases)

Question 7

How do you approach a patient? what do you say to them?

Answer 7

Always approach from the front of the patient if possible
Introduce yourself:
“Hello my name is ___ and I’m a paramedic.”
“Can you tell me what happened?”
“What’s going on today?”
“If you can hear me please do not move.”
Obtain Consent
Avoid using demeaning terms such as “hun”, “dear”, or “sweetie”
-WRITE DOWN EVERYTHING
Inquire about the patient’s feelings
Be sensitive to the patient’s feelings and experience(s)
Avoid entering the patient’s personal space (if possible)
Use language that is appropriate and easily understood
-Note level of consciousness
Drowsy (tired, not necessarily confused)
Stupor – unaware of surroundings
Obtunded – unresponsive to stimuli
Coma – patient cannot be aroused, no eye movements (unresponsive)
Note posture, gait(walking), and motor activity
Ataxia (uncoordinated movements – the inability to control muscle movement)
Note dress, grooming, hygiene and breath or body odours
Is it appropriate for the environment?
Medic alert bracelets
Facial expressions
Mood
Speech
Thoughts and perceptions
Memory and attention

Question 8

what is controlling c-spine?

Answer 8

Ensure that your partner (or a trained resource) controls c-spine until you have ruled out any potential spinal injuries.
This is important only for those patients who may have sustained a traumatic M.O.I
Not necessary for medical patients with no traumatic mechanism

Question 9

What are the different levels of contentiousness? (LOC)?

Answer 9

• Alert
• Verbal- have to talk to them for them to open their eyes
• Pain/Physical- have to touch or move them for them to open their eyes
• Unresponsive

Question 10

What do you do if you think your patient has an acute altered level of consciousness?

Answer 10

if unprotected airway, determine airway is clear and insert an oro/naso airway
if patient is apneic or respirations are inadequate, assist ventilations
attempt to determine a specific cause for the altered level of consciousness (AEIOU TIPS) and provide further assessment and management
perform a secondary survey to assess the patient from head-to-toe
perform trauma assessments if trauma is obvious, suspected or cannot be ruled out

Question 11

what is the chief complaint?

Answer 11

The main reason an ambulance was called

whatever the patient is complaining of

Question 12

What is the definition of primary problem?

Answer 12

PRIMARY PROBLEM- actual reason why they have the complaint, could be the same reason

Question 13

How do you figure out what the patient was doing proior to the event?

Answer 13

O.P.Q.R.S.T – questioning about pain (only if they are in pain)
S.A.M.P.L.E – questioning about medical history and current medical events (use on EVERY SINGLE PATIENT)

Question 14

When does physical examination begin?

Answer 14

Although patient assessment formally starts with the history, the physical examination actually begins when you first set eyes on your patient.

Question 15

whats the purpose of the physical exam?

Answer 15

The purpose of the physical exam is to investigate areas that you suspect are involved in your patient’s primary problem.

Question 16

What is the foundation of physical assessment based upon?

Answer 16

1. Inspection- look at person/body
2. Palpation- press into quadrants for discomfort
3. Auscultation- listening to heart sounds and blood pressure sounds
4. Percussion- determine if area is full of air or water

Question 17

What do you always check on every patient first for their physical assessment?

Answer 17

ABC (airways, breathing, circulation

Question 18

How do you assess the airway?

Answer 18

• Is the airway patent (clear of obstruction)?
• If not, reposition (if possible) the patient or the patient’s head/jaw to ensure airway patency
• If the patient has a foreign body obstruction, remove the foreign body to clear the airway
• If patient has a decreased LOC or is unresponsive with no gag reflex or mandible trauma insert an oropharyngeal airway to maintain airway patency
• head tilt, chin lift to see if airway is clear
• oral airway best bet for unconscious patient
• If the patient does not accept an oropharyngeal airway due to an intact gag reflex, or trismus (locked jaw), and has decreasing LOC or mandible trauma, insert a nasopharyngeal airway
• Nasopharyngeal airways should NOT be inserted into patients with head trauma
• Once you have secured a patent airway you may proceed with the remainder of the Primary Survey

Question 19

How do you assess breathing?

Answer 19

-Look for chest rise and fall
-Listen for air movement in and out of the patient’s mouth and nose
-Determine if the patient’s breathing seems regular, laboured, shallow, deep, etc
-Feel air movement on your ear/cheek while you are looking for chest rise and fall
-You do not check an actual respiratory rate at this stage
-Observe if any accessory muscles are being used
(LOOK, LISTEN, FEEL, OBSERVE)

Question 20

What do you do for feeling? (in breathing assessment)

Answer 20

-Feel the patient’s chest movement to ensure symmetry. (chest trauma)
-Chest moving as one segment
-This assessment is important in ruling out flail chest and/or a pneumothorax
-Fractured ribs or collapsed/punctured lung
-Note any in-drawing of the intercostal muscles (accessory muscle use) using other muscles to breathe
-Muscles between ribs, around base of neck, abdomen, etc
-Flail chest
-Two or more ribs fractured in two or more places
-The chest wall moves upon inspiration, but the
fractured segments will not move with the rest of the
rib cage upon inspirations
-Pneumothorax
-Punctured/collapsed lung
-Can be spontaneous or traumatic in nature
-The chest wall will not move symmetrically as the lung
is not filling up with air due to rupture within the lung.

Question 21

What are you trying to determine while listening? (breathing asses)

Answer 21

Auscultate upper and lower lobes for breath sounds:

• Clear
• Crackles – loose fluid or congestion
  
  • Pneumonia, CHF
• Wheezes – bronchoconstriction
  
  • Asthma, Anaphylaxis
• Rhonchi – low pitched rattle
  
  • Cystic Fibrosis, COPD
• Rub – harsh, grating noise
  
  • Infection, Pulmonary Embolism
• Stridor – high-pitched wheeze
  
  • Croup, Airway Obstruction
• Silent chest – inability to hear any lung sounds – uni/bilaterally
• Pneumothorax , Asthma Exacerbation

Question 22

what is crackles (rales)?

Answer 22

A fine bubbling sound produced by air entering the distal airways and the alveoli that contain serous secretions (fluid) – can be considered “fine” or “coarse”
The most typical cause of crackles is pulmonary edema
-Congestive Heart Failure (CHF)
-Pneumonia
-Chest congestion

Question 23

Whats wheezes?

Answer 23

High pitched musical noises that are usually louder during expiration
Wheezes are caused by high-velocity air traveling through narrowed airways
Wheezes may occur because of (most commonly):
Asthma
Anaphylaxis
COPD

Question 24

whats rhonci?

Answer 24

Low –pitch rumbling sounds usually heard on expiration
Similar to wheezes but doesn’t involve small airways
Ronchi are less discrete than crackles and are easily auscultated
Ronchi are caused by the passage of air through thick secretions, muscular spasm, new tissue growth or external pressure collapsing the airway lumen
May result by any condition that increases secretion
Pneumonia
Aspiration
Cystic Fibrosis
COPD

Question 25

whats stridor?

Answer 25

``` Stridor Indicates a life threatening problem Usually heard upon inspiration and sounds like a crowing type sound. That can be heard without a stethoscope Caused by significant narrowing (~90%) or obstruction of the larynx or trachea May be caused by: Epiglottitis Croup Aspiration/Airway obstruction ```

Question 26

whats a silent chest?

Answer 26

``` When no breath sounds can be heard but the patient is attempting to breathe Indicates a life threatening problem May occur with: Severe asthma Anaphylaxis Pulmonary trauma Pneumothorax ```

Question 27

what do the following mean: - badypnea - tachypnea - eupnea - hypo/hypernea - hypo/hyperventilation - orthopnea - dyspnea - paroxysmal noctural dyspnea - apnea

Answer 27

Bradypnea - <12 breaths/min (slow) Tachypnea - >28 breaths/min for treatment (fast) Eupnea – normal for the patient’s age (12-20 breaths/min for adults) Hypo/Hyperpnea – decreased/increased depth Hypo/Hyperventilation – decreased/increased rate and depth Orthopnea – SOB when patient lies down Dyspnea – difficulty/laboured breathing Paroxysmal nocturnal dyspnea – sudden onset of SOB while sleeping Apnea – absence of breathing

Question 28

what vital signs do you measure?

Answer 28

*obtain, at minimum, x2 sets of vital signs on each patient, whether they are transported to ER or not 1. Heart Rate (pulse) 2. Respiratory Rate 3. Blood pressure 4. Body temperature 5. SpO2 6. Skin 7. Pupils 8. Level of Awareness (GCS) Additionally: Cardiac Monitor Blood Glucose H R B T O S P L C B

Question 29

what do you measure for heart rate?

Answer 29

Rate The number of pulses felt in one minute Rhythm The pattern and regularity of the intervals between beats Quality The strength, which can be weak, thready, strong, or bounding

Question 30

what is a normal, bradycardia, and tachycardia heart rate?

Answer 30

``` Normal Heart rate between 60-100 beats per minute (bpm) Bradycardia Heart rate of 59 bpm or lower Tachycardia Heart rate of 100 bpm or higher ```

Question 31

what do you measure for respirations?

Answer 31

``` Rate The number of times a patient breathes in one minute Rhythm Affected by speech, emotions, etc. Abnormal respirations in a patient with altered mental status is a serious concern Effort How hard a person works to breathe Quality The depth and pattern of breathing ```

Question 32

what is fast breathing and slow breathing called?

Answer 32

Bradypnea Slow breathing Tachypnea Fast breathing Comparisons: A conscious and alert patient breathing at 10 times per minute may be normal VS. An unresponsive patient breathing at 10 time per minute may indicate compromise

Question 33

what is blood pressure?

Answer 33

The force of blood against the arteries’ walls as the heart contracts and relaxes

Question 34

what is systolic and diastolic ?

Answer 34

Systolic -Maximum force of blood against the arteries when the ventricles contract Diastolic - Force of blood against the vessel walls when the ventricles relax - Measure of systemic vascular resistance (correlates well to blood vessel size)

Question 35

whats hypertension, hypotension, and normotension?

Answer 35

Hypertension* Blood pressure higher than normal A relative amount but usually >140/90 Hypotension* Blood pressure lower than normal Based on patient’s normal BP status Normotension Blood pressure 90-100 systolic, and less than approx. 140 systolic Treat the patient’s symptoms – organ perfusion is the most important

Question 36

what is pulse pressure, perfusion, and korotkoff sounds?

Answer 36

Pulse Pressure Difference between systolic and diastolic pressures Wide or narrow pulse pressures may be a concern Perfusion Passage of blood through an organ or tissue Korotkoff Sounds Sound of blood hitting the arterial walls The sounds heard while taking a blood pressure

Question 37

what is the blood pressure assessment?

Answer 37

Patient Variables Anxiety, position, previous activities, movement Equipment May be done by palpation, auscultation, doppler Non-invasive blood pressure assessment Context Must be correlated to other vital signs and patient condition to be of value

Question 38

how do you take temperature? what is the bodies regular temperature?

Answer 38

The body works hard to maintain a temperature approximately 37° C Generally done with a thermometer but if using your hand, the dorsal surface of your hand is more sensitive than the plantar surface Sites - Tympanic – used by EMS - Oral - used by ER - Rectal – used often for patients who are hypothermic - Axillary – used often for infants/children

Question 39

what are abnormal skin colours?

Answer 39

Pale = vasoconstriction, blood loss or both Cyanosis = inadequate oxygenation or poor perfusion due to suffocation or hypopnea Flush = heat exhaustion, vasodilation, fever, or late CO poisoning Jaundice = may indicate liver disease Bruises, rashes, scars Ashen = greyish colour often seen with cardiac patient

Question 40

what is normal skin condition? what is not normal skin? what is skin turgor?

Answer 40

Normal is warm, pink, and dry Moist, clammy skin can indicate shock, hyperthermia or cardiac emergencies Dry skin may indicate dehydration or spinal injuries Skin turgor – elasticity; poor skin turgor indicates fluid loss or dehydration – skin will stay tented for an extended amount of time

Question 41

what is hyperthermia and hypothermia?

Answer 41

Hyperthermia Increased body core temperature >37 degrees Celsius Can lead to heat cramps, exhaustion, or stroke Hypothermia Decreased body core temperature <35 degrees Celsius Leads to organ shut down

Question 42

what is pupils perla?

Answer 42

``` P - PUPILS E - EQUAL R – REACTIVE L – (T0) LIGHT A - ACCOMMODATING ```

Question 43

what do dilated, constricted, ipsilateral dilation, and slow reactivity mean when assesing pupils?

Answer 43

Dilated (mydriasis) may indicate stimulant use, hypoxia, cardiac arrest Constricted (miosis) may indicate opiate use Ipsilateral pupil dilation may indicate CVA, glass eye, post cataract removal or eye drops Slow reactivity may indicate hypoxia or ↓perfusion MI, cardiac arrest , and severe shock will cause fixed pupil dilation

Question 44

what is the general survey for a comprehensive examination?

Answer 44

1. Appearance 2. Vital signs 3. Additional assessments - Cardiac monitoring - Blood glucose determination - Neurological assessment

Question 45

what is appearance in the general survey for comp exam?

Answer 45

- Level of consciousness - The first step in determining the presence of a life-threatening condition is to assess the patient's level of consciousness - Signs of distress - Apparent state of health - Vital statistics - Skin color and obvious lesions - Posture, gait, and motor activity - Dress, grooming, and personal hygiene - Odours of breath or body - Facial expression

Question 46

what is LOA and GCS?

Answer 46

LEVEL OF AWARENESS (LOA) Altered refers to a GCS that is less than normal for that person Unaltered refers to a GCS that is normal for that person (glasgow coma scale, level of conciousness, highest is 15 (fully awake), lowest is 3 *deep coma/death), eye verbal and motor response

Question 47

what should normal skin be, what effect does sympathetic response have, and what is hypogycemic?

Answer 47

SKIN Skin should be warm, pink, and dry Sympathetic response will make skin pale, cool, and clammy BLOOD GLUCOSE Considered hypoglycemic: <2 years BG=<3.0mmol/L >2 years BG=<4.0mmol/L

Question 48

what is normal temperature, what happens at 39 degrees, 41 degrees, 34 degrees, and 31 degrees?

Answer 48

Normal is 37ºC Above 39ºC neurons of the brain begin to denature At 41ºC brain cells die and seizures may occur Below 34ºC the body’s warming mechanisms begin to fail Below 31ºC heart sounds diminish and cardiac irritability increases

Question 49

PEDIATRIC VITALS

Answer 49

AGE, RESP RATE, HEART RATE ``` 0-3 months, 30-60, 90-180 3-6 months, 30-60, 80-160 6-12 months, 25-45, 80-140 1-3 years, 20-30, 75-130 6 years, 16-24, 70-110 10 years, 14-20, 60-90 adult: 12-20, 60-100 ```

Question 50

what is the general rules for pediatric vitals calculations?

Answer 50

As a general rule: The upper limit for a child’s pulse can be 150 - (5 times the age) Normotension (age 1‐10 years) > 90mmHg+ (2 x age in years) Hypotension (age 1‐10 years) < 70mmHg+ (2 x age in years)

Question 51

BP, CAP REFILL & SPO2

Answer 51

``` BP (normal) Adults 120/80 Normotension SBP >100 mmHg (ALS pg. 12) BETWEEN 90-100 Hypotension SBP <90 mmHg Hypertension SBP – depends on pt past hx, typically >140mmHg Cap refill - <2 seconds ``` O2 Sats – titrate to 92-96% (BLS Oxygen Therapy Standard)

Question 52

additional assesment techniques, SKIN

Answer 52

The largest organ in the humanbody Makes up approx. 15% of our total bodyweight Consists of 2 layers that lie atop thesubcutaneous fat Dermis Epidermis

Question 53

the head

Answer 53

The scalp consists of 5 layers of tissue: Skin Connective Tissue Aponeurosis – membrane connecting muscles Loose Tissue Periosteum – tissue around bones Exophthalmos – abnormal protrusion of the eyeball Ptosisis – drooping of the upper eyelid

Question 54

the abdomen | -what is cullens sign, grey-turners sign, ascites, and borborygmi?

Answer 54

Cullen’s sign Discoloration around the umbilicus suggestive of intra-abdominal hemorrhage Grey-Turner’s sign Discoloration over the flanks suggesting intra-abdominal bleeding Ascites Fluid accumulation in abdomen - from liver cirrhosis Borborygmi Loud, prolonged, gurgling bowel sounds (stomach growling) – an hour glass stomach

Question 55

what can an asymmetrical abdomen be due to?

Answer 55

``` Asymmetrical distension due to: Hernias Tumours Cysts Bowel obstruction Enlarged abdominal organs Distended bladder ``` Pulsatile masses – leaking or ruptured AAA Mono - enlarged spleen

Question 56

what is rectal bleeding caused by?

Answer 56

``` Rectal bleeding Trauma Hemorrhoids Anal fissures Crohn’s/Colitis Cancer ``` Inflamed hemorrhoids are common in elderly and pregnant women

Question 57

what do you observe, inspect, and palpate the joints and structures for?

Answer 57

``` Observe, inspect, and palpate the joints and structures for: Pain Swelling Deformity Symmetry Tissue changes Crepitus (snap, crackle, pop) Compare strength and range of motion ```

Question 58

what does a complete examination of the extremities include?

Answer 58

``` A complete examination of the extremities includes: Wrists and hands Elbows Shoulders Ankles and feet Knees Hips ``` Check for swelling, tenderness, ↑heat, redness, ↓function, and stability (for hips, squeeze once)

Question 59

what does the peripheral vascular system do, what are abnormal findings?

Answer 59

``` The peripheral vascular system delivers oxygenated blood to the tissues of the extremities Abnormal findings: Swollen or asymmetrical extremities Pale or cyanosis Weak or diminished pulses Skin cold to touch Absence of hair growth Pitting edema ```

Question 60

what does a neurological exam attempt to answer?

Answer 60

Are the findings symmetricalor unilateral? If unilateral, where do theyoriginate? Is there weakness or full paralysis? Is there numbness or pain?

Question 61

what are the 5 areas of neuro exam?

Answer 61

``` 5 Areas of Neuro exam: Mental status and speech Cranial nerves Motor system (grips, pedals) Sensory system Reflexes ```

Question 62

what do you assess for mental status and speech?

Answer 62

Level of responsivness - AVPU Appearance and behavior – Clean? Aggressvie? Speech and language – Slurred? Erratic? Mood – Unusual happiness/sadness Thought and perceptions – Paranoia or fear Insight and judgment – Disregard/denial Memory and attention – Retrograde amnesia? - Unable to focus

Question 63

what do you remember when you are examining infants and children?

Answer 63

- Children are not just small adults and you cannot treat them as if they are - Different age groups have specific fears and characteristics - Position yourself at the child’s level, use a soft voice, and smile often - Regular explanations may not be sufficient

Question 64

age related exams - 0-6 months

Answer 64

``` Easy to perform assessment Keep warm Poor head control Belly breathers Observe fontanelles – indicated hydration level or any risk of increased intracranial pressure ``` Skin colour and nasal flaring indicate dyspnea

Question 65

age related exams - 7 months to 3 years

Answer 65

``` Usually less cooperative Unreliable history Separation anxiety Injury may be viewed as punishment Approach quietly Use simple direct questions ```

Question 66

age related exams - 4-10 years

Answer 66

``` Usually cooperative Can provide limited Hx of event Separation anxiety Injury may be viewed as punishment Approach quietly Allow child to “help” with examination Reluctant to discuss pain/discomfort in “private parts” Advise child of any unexpected pain ```

Question 67

age related exams - 11-18 years

Answer 67

Generally calm and helpful Concerned about modesty, pain, disfigurement, disability, and death Require reassurances during examination Privacy If possible separate from family and friends Consider the possibility of alcohol, drugs, and pregnancy

Question 68

age related exams - elderly patients

Answer 68

``` Allow extra time Stay close to the pt Repetition may be required Be careful no to patronize or offend Multiple health problems Decreased sensory function May fail to mention changes in daily activities as they attribute it to aging so ask them Be alert to chronic pain (grimacing/wincing) ```

Question 69

changes to assessment with infants and children

Answer 69

Scene assessment is the same, except for observing the “big picture” Consider how best to involve the parents or caregivers in emergency care, if appropriate, and finding out if the patient has been moved Remember, kids don’t have as much blood – they compensate well for a while but then crash fast The primary assessment is basically the same as for an adult Check with the caregiver to find out what is the “normal” level of consciousness for the infant or child Remember the anatomical differences of an infant or child. Pay particular attention to the airway and breathing Know the early signs of respiratory distress Be prepared to suction and assist ventilations if needed Constantly monitor vital signs in pediatric patients due to compensation factor

Question 70

what is a fontanelle in infant skulls?

Answer 70

Allows the skull to flex during childbirth Sphenoidal and Posterior fontanelles close during first few months Anterior fontanelles close between 9-18 months If a fontanelle is bulging, there may be increased pressure inside the skull If the fontanelle is concave or sunken, the infant may be dehydrated and in shock (pic in slideshow)

Question 71

infant/children vitals asssessment

Answer 71

Take the vital signs of infants and children more frequently than you would for an adult (if needed) Pay attention to your overall impression of how the patient looks and acts Use the brachial pulse in an infant and the radial or brachial pulse in a child Monitor respirations frequently to determine breathing rate Remember that blood pressure readings are not essential for children under the age of three When assessing the infant’s or child’s skin, cold hands and feet may indicate shock Be alert for any signs of discoloration of the skin Assess capillary refill in children under six years of age

Question 72

secondary assessment - pediatrics

Answer 72

- Assess the child while he or she is on the parent’s lap - Radiate confidence, competence, and friendliness - Get at eye level with the patient; conduct a toe-to-head exam - Explain what you are doing in terms a child can understand, while maintaining eye contact and speaking in a calm, quiet voice - Watch your phrasing because small children tend to take what people say literally - Be honest, truthful, and candid even when a procedure will hurt - Keep the most painful parts of the assessment for the end

Question 73

recording examination findings

Answer 73

After you perform the history andphysical examination, it is time torecord the findings on your patient’schart or permanent medical record The patient record is only as goodas the accuracy, depth, and detailyou provide