PCT 1 Patient Assessment - Intro to asses Flashcards
What do you do for every call?
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
What is environment in EMCA - PIE? what do you look for at the scene every time?
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
What is Mechanism of Injury/Illness?
What caused the injury/illness?
Motor Vehicle Collision (MVC) Exposure (weather, bee sting) Chest Pain Trauma (fall, assault) Psychiatric Drug overdose
What do you do for casualties? Who can go in the same ambulance?
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
What are additional resources you may need?
What assistance do you need? Resources Police Fire More Ambulances ACP crew Supervisor Air Ambulance Hydro Animal rescue CAS
What is PPE and what do you need? Why is it required for every call?
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)
How do you approach a patient? what do you say to them?
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
what is controlling c-spine?
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
What are the different levels of contentiousness? (LOC)?
- 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
What do you do if you think your patient has an acute altered level of consciousness?
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
what is the chief complaint?
The main reason an ambulance was called
whatever the patient is complaining of
What is the definition of primary problem?
PRIMARY PROBLEM- actual reason why they have the complaint, could be the same reason
How do you figure out what the patient was doing proior to the event?
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)
When does physical examination begin?
Although patient assessment formally starts with the history, the physical examination actually begins when you first set eyes on your patient.
whats the purpose of the physical exam?
The purpose of the physical exam is to investigate areas that you suspect are involved in your patient’s primary problem.
What is the foundation of physical assessment based upon?
- Inspection- look at person/body
- Palpation- press into quadrants for discomfort
- Auscultation- listening to heart sounds and blood pressure sounds
- Percussion- determine if area is full of air or water
What do you always check on every patient first for their physical assessment?
ABC (airways, breathing, circulation
How do you assess the airway?
- 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
How do you assess breathing?
-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)
What do you do for feeling? (in breathing assessment)
-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.
What are you trying to determine while listening? (breathing asses)
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
what is crackles (rales)?
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
Whats wheezes?
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
whats rhonci?
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
whats stridor?
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
whats a silent chest?
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
what do the following mean:
- badypnea
- tachypnea
- eupnea
- hypo/hypernea
- hypo/hyperventilation
- orthopnea
- dyspnea
- paroxysmal noctural dyspnea
- apnea
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
what vital signs do you measure?
*obtain, at minimum, x2 sets of vital signs on each patient, whether they are transported to ER or not
- Heart Rate (pulse)
- Respiratory Rate
- Blood pressure
- Body temperature
- SpO2
- Skin
- Pupils
- Level of Awareness (GCS)
Additionally:
Cardiac Monitor
Blood Glucose
H R B T O S P L C B
what do you measure for heart rate?
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
what is a normal, bradycardia, and tachycardia heart rate?
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
what do you measure for respirations?
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
what is fast breathing and slow breathing called?
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
what is blood pressure?
The force of blood against the arteries’ walls as the heart contracts and relaxes
what is systolic and diastolic ?
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)
whats hypertension, hypotension, and normotension?
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
what is pulse pressure, perfusion, and korotkoff sounds?
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
what is the blood pressure assessment?
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
how do you take temperature? what is the bodies regular temperature?
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
what are abnormal skin colours?
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
what is normal skin condition? what is not normal skin? what is skin turgor?
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
what is hyperthermia and hypothermia?
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
what is pupils perla?
P - PUPILS E - EQUAL R – REACTIVE L – (T0) LIGHT A - ACCOMMODATING
what do dilated, constricted, ipsilateral dilation, and slow reactivity mean when assesing pupils?
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
what is the general survey for a comprehensive examination?
- Appearance
- Vital signs
- Additional assessments
- Cardiac monitoring
- Blood glucose determination
- Neurological assessment
what is appearance in the general survey for comp exam?
- 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
what is LOA and GCS?
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
what should normal skin be, what effect does sympathetic response have, and what is hypogycemic?
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
what is normal temperature, what happens at 39 degrees, 41 degrees, 34 degrees, and 31 degrees?
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
PEDIATRIC VITALS
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
what is the general rules for pediatric vitals calculations?
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)
BP, CAP REFILL & SPO2
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)
additional assesment techniques, SKIN
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
the head
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
the abdomen
-what is cullens sign, grey-turners sign, ascites, and borborygmi?
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
what can an asymmetrical abdomen be due to?
Asymmetrical distension due to: Hernias Tumours Cysts Bowel obstruction Enlarged abdominal organs Distended bladder
Pulsatile masses – leaking or ruptured AAA
Mono - enlarged spleen
what is rectal bleeding caused by?
Rectal bleeding Trauma Hemorrhoids Anal fissures Crohn’s/Colitis Cancer
Inflamed hemorrhoids are common in elderly and pregnant women
what do you observe, inspect, and palpate the joints and structures for?
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
what does a complete examination of the extremities include?
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)
what does the peripheral vascular system do, what are abnormal findings?
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
what does a neurological exam attempt to answer?
Are the findings symmetricalor unilateral?
If unilateral, where do theyoriginate?
Is there weakness or full paralysis?
Is there numbness or pain?
what are the 5 areas of neuro exam?
5 Areas of Neuro exam: Mental status and speech Cranial nerves Motor system (grips, pedals) Sensory system Reflexes
what do you assess for mental status and speech?
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
what do you remember when you are examining infants and children?
- 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
age related exams - 0-6 months
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
age related exams - 7 months to 3 years
Usually less cooperative Unreliable history Separation anxiety Injury may be viewed as punishment Approach quietly Use simple direct questions
age related exams - 4-10 years
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
age related exams - 11-18 years
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
age related exams - elderly patients
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)
changes to assessment with infants and children
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
what is a fontanelle in infant skulls?
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)
infant/children vitals asssessment
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
secondary assessment - pediatrics
- 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
recording examination findings
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
