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8: Patient Assessment

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8: Patient Assessment

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    1. 8: Patient Assessment

    2. Cognitive 3-1.1 Recognize hazards/potential hazards. 3-1.2 Describe common hazards found at the scene of a trauma and a medical patient. 3-1.3 Determine if the scene is safe to enter. 3-1.4 Discuss common mechanisms of injury/nature of illness. 3-1.5 Discuss the reason for identifying the total number of patients at the scene. 3-1.6 Explain the reason for identifying the need for additional help or assistance. Scene Size-up Objectives (1 of 2)

    3. Scene Size-up Objectives (2 of 2) Affective 3-1.7 Explain the rationale for crew members to evaluate scene safety prior to entering. 3-1.8 Serve as a model for others explaining how patient situations affect your evaluation of mechanism of injury or illness. Psychomotor 3-1.9 Observe various scenarios and identify potential hazards.

    4. Cognitive 3-2.1 Summarize the reasons for forming a general impression of the patient. 3-2.2 Discuss methods of assessing altered mental status. 3-2.3 Differentiate between assessing the altered mental status in the adult, child, and infant patient. 3-2.4 Discuss methods of assessing the airway in the adult, child, and infant patient. 3-2.5 State reasons for management of the cervical spine once the patient has been determined to be a trauma patient. Initial Assessment Objectives (1 of 7)

    5. Initial Assessment Objectives (2 of 7) 3-2.6 Describe methods used for assessing if a patient is breathing. 3-2.7 State what care should be provided to the adult, child, and infant patient with adequate breathing. 3-2.8 State what care should be provided to the adult, child, and infant patient without adequate breathing. 3-2.9 Differentiate between a patient with adequate and inadequate breathing. 3-2.10 Distinguish between methods of assessing breathing in the adult, child, and infant patient.

    6. Initial Assessment Objectives (3 of 7) 3-2.11 Compare the methods of providing airway care to the adult, child, and infant patient. 3-2.12 Describe the methods used to obtain a pulse. 3-2.13 Differentiate between obtaining a pulse in an adult, child, and infant patient. 3-2.14 Discuss the need for assessing the patient for external bleeding. 3-2.15 Describe normal and abnormal findings when assessing skin color. 3-2.16 Describe normal and abnormal findings when assessing skin temperature.

    7. Initial Assessment Objectives (4 of 7) 3-2.17 Describe normal and abnormal findings when assessing skin condition. 3-2.18 Describe normal and abnormal findings when assessing skin capillary refill in the infant and child patient. 3-2.19 Explain the reason for prioritizing a patient for care and transport.

    8. Initial Assessment Objectives (5 of 7) Affective 3-2.20 Explain the importance of forming a general impression of the patient. 3-2.21 Explain the value of performing an initial assessment.

    9. Initial Assessment Objectives (6 of 7) Psychomotor 3-2.22 Demonstrate the techniques for assessing mental status. 3-2.23 Demonstrate the techniques for assessing the airway. 3-2.24 Demonstrate the techniques for assessing if the patient is breathing. 3-2.25 Demonstrate the techniques for assessing if the patient has a pulse.

    10. Initial Assessment Objectives (7 of 7) 3-2.26 Demonstrate the techniques for assessing the patient for external bleeding. 3-2.27 Demonstrate the techniques for assessing the patient's skin color, temperature, condition, and capillary refill (infants and children only). 3-2.28 Demonstrate the ability to prioritize patients.

    11. Cognitive 3-3.1 Discuss the reasons for reconsideration concerning the mechanism of injury. 3-3.2 State the reasons for performing a rapid trauma assessment. 3-3.3 Recite examples and explain why patients should receive a rapid trauma assessment. 3-3.4 Describe the areas included in the rapid trauma assessment and discuss what should be evaluated. Focused History and Physical Exam: Trauma Objectives (1 of 3)

    12. 3-3.5 Differentiate when the rapid assessment may be altered in order to provide patient care. 3-3.6 Discuss the reason for performing a focused history and physical exam. Affective 3-3.7 Recognize and respect the feelings that patients might experience during assessment. Focused History and Physical Exam: Trauma Objectives (2 of 3)

    13. Psychomotor 3-3.8 Demonstrate the rapid trauma assessment that should be used to assess a patient based on mechanism of injury. Focused History and Physical Exam: Trauma Objectives (3 of 3)

    14. Cognitive 3-4.1 Describe the unique needs for assessing an individual with a specific chief complaint with no known prior history. 3-4.2 Differentiate between the history and physical exam that are performed for responsive patients with no known prior history and responsive patients with a known prior history. 3-4.3 Describe the needs for assessing an individual who is unresponsive. Focused History and Physical Exam: Medical Patients Objectives (1 of 3)

    15. 3-4.4 Differentiate between the assessment that is performed for a patient who is unresponsive or has an altered mental status and other medical patients requiring assessment. Affective 3-4.5 Attend to the feelings that these patients might be experiencing. Focused History and Physical Exam: Medical Patients Objectives (2 of 3)

    16. Psychomotor 3-4.6 Demonstrate the patient care skills that should be used to assist a patient who is responsive with no known history. 3-4.7 Demonstrate the patient care skills that should be used to assist a patient who is unresponsive or has an altered mental status. Focused History and Physical Exam: Medical Patients Objectives (3 of 3)

    17. Cognitive 3-5.1 Discuss the components of the detailed physical exam. 3-5.2 State the areas of the body that are evaluated during the detailed physical exam. 3-5.3 Explain what additional care should be provided while performing the detailed physical exam. 3-5.4 Distinguish between the detailed physical exam that is performed on a trauma patient and that of the medical patient. Detailed Physical Exam Objectives (1 of 2)

    18. Affective 3-5.5 Explain the rationale for the feelings that these patients might be experiencing. Psychomotor 3-5.6 Demonstrate the skills involved in performing the detailed physical exam. Detailed Physical Exam Objectives (2 of 2)

    19. Cognitive 3-6.1 Discuss the reason for repeating the initial assessment as part of the ongoing assessment. 3-6.2 Describe the components of the ongoing assessment. 3-6.3 Describe trending of assessment components. Affective 3-6.4 Explain the value of performing an ongoing assessment. Ongoing Assessment Objectives (1 of 2)

    20. Ongoing Assessment Objectives (2 of 2) 3-6.5 Recognize and respect the feelings that patients might experience during assessment. 3-6.6 Explain the value of trending assessment components to other health professionals who assume care of the patient. Psychomotor 3-6.7 Demonstrate the skills involved in performing the ongoing assessment.

    21. Patient Assessment Scene size-up Initial assessment Focused history and physical exam Vital signs History Detailed physical exam Ongoing assessment

    22. Patient Assessment Process

    23. Scene Size-up Dispatch information Inspection of scene Scene hazards Safety concerns Mechanism of injury Nature of illness/chief complaint Number of patients Additional resources needed

    24. Body Substance Isolation Assumes all body fluids present a possible risk for infection Protective equipment Latex or vinyl gloves should always be worn Eye protection Mask Gown Turnout gear

    25. Scene Safety: Potential Hazards Oncoming traffic Unstable surfaces Leaking gasoline Downed electrical lines Potential for violence Fire or smoke Hazardous materials Other dangers at crash or rescue scenes Crime scenes

    26. Scene Safety Park in a safe area. Speak with law enforcement first if present. The safety of you and your partner comes first! Next concern is the safety of patient(s) and bystanders. Request additional resources if needed to make scene safe.

    27. Mechanism of Injury Helps determine the possible extent of injuries on trauma patients Evaluate: Amount of force applied to body Length of time force was applied Area of the body involved

    28. Nature of Illness Search for clues to determine the nature of illness. Often described by the patient’s chief complaint Gather information from the patient and people on scene. Observe the scene.

    29. The Importance of MOI/NOI Guides preparation for care to patient Suggests equipment that will be needed Prepares for further assessment Fundamentals of assessment are same whether emergency appears to be related to trauma or medical cause.

    30. Number of Patients Determine the number of patients and their condition. Assess what additional resources will be needed. Triage to identify severity of each patient’s condition.

    31. Additional Resources Medical resources Additional units Advanced life support Nonmedical resources Fire suppression Rescue Law enforcement

    32. C-Spine Immobilization Consider early during assessment. Do not move without immobilization. Err on the side of caution.

    33. Patient Assessment Process

    34. Initial Assessment Develop a general impression. Assess mental status. Assess airway. Assess the adequacy of breathing. Assess circulation. Identify patient priority.

    35. Develop a General Impression Occurs as you approach the scene and the patient Assessment of the environment Patient’s chief complaint Presenting signs and symptoms of patient

    36. Obtaining Consent Introduce self. Ask patient’s name. Obtain consent.

    37. Chief Complaint Most serious problem voiced by the patient May not be the most significant problem present

    38. Assessing Mental Status Responsiveness How the patient responds to external stimuli Orientation Mental status and thinking ability

    39. Testing Responsiveness A Alert V Responsive to Verbal stimulus P Responsive to Pain U Unresponsive

    40. Testing Orientation Person Place Time Event

    41. Caring for Abnormal Mental Status Complete initial assessment. Provide high-flow oxygen. Consider spinal immobilization. Initiate transport. Support ABCs. Reassess.

    42. Assessing the Airway Look for signs of airway compromise: Two- to three-word dyspnea Use of accessory muscles Nasal flaring and use of accessory muscles in children Labored breathing

    43. Signs of Airway Obstruction in the Unconscious Patient Obvious trauma, blood, or other obstruction Noisy breathing such as bubbling, gurgling, crowing, or other abnormal sounds Extremely shallow or absent breathing

    44. Assessing Breathing Choking Rate Depth Cyanosis Lung sounds Air movement

    45. Assessing Breath Sounds

    46. High-Flow Oxygen Administration Breathing faster than 20 breaths/min Breathing slower than 12 breaths/min Breathing too shallow Decreased level of consciousness Respiratory distress Poor skin color

    47. Positioning the Patient Position of comfort Sitting up with feet dangling High Fowler’s position Spinal precautions if possible spinal injury

    48. Assessing the Pulse Presence Rate Rhythm Strength

    49. Normal Pulse Rates in Infants and Children

    50. Assessing and Controlling External Bleeding Assess after clearing the airway and stabilizing breathing. Look for blood flow or blood on floor/clothes. Controlling bleeding Direct pressure Elevation Pressure points

    51. Assessing Perfusion Color Temperature Skin condition Capillary refill

    52. Priority Patients Difficulty breathing Poor general impression Unresponsive with no gag reflex Severe chest pain Signs of poor perfusion

    53. Transport Decision Patient condition Availability of advanced care Distance to transport Local protocols

    54. Patient Assessment Process

    55. Goals of the Focused History and Physical Exam Understand the circumstances surrounding the chief complaint. Obtain objective measurements. Perform physical exam.

    56. Components of Focused History and Physical Exam Medical history Baseline vital signs Physical exam

    57. Rapid Physical Exam 60-90 second head-to-toe exam Performed on: Significant trauma patients Unresponsive medical patients Identifies undiscovered conditions

    58. DCAP-BTLS D Deformities C Contusions A Abrasions P Punctures/ Penetrations B Burns T Tenderness L Lacerations S Swelling

    59. Components of a Rapid Physical Exam (1 of 3) Maintain spinal immobilization while checking patient’s ABCs. Assess the head. Assess the neck. Apply a cervical spine immobilization collar.

    60. Components of a Rapid Physical Exam (2 of 3) Assess the chest. Assess the abdomen. Assess the pelvis.

    61. Components of a Rapid Physical Exam (3 of 3) Assess all four extremities. Roll the patient with spinal precautions.

    62. Focused Physical Exam Used to evaluate patient’s chief complaint Performed on: Trauma patients without significant MOI Responsive medical patients

    63. Head, Neck, and Cervical Spine Feel head and neck for deformity, tenderness, or crepitation. Check for bleeding. Ask about pain or tenderness.

    64. Chest Watch chest rise and fall with breathing. Feel for grating bones as patient breathes. Listen to breath sounds.

    65. Abdomen Look for obvious injury, bruises, or bleeding. Evaluate for tenderness and any bleeding. Do not palpate too hard.

    66. Pelvis Look for any signs of obvious injury, bleeding, or deformity. Press gently inward and downward on pelvic bones.

    67. Extremities Look for obvious injuries. Feel for deformities. Assess Pulse Motor function Sensory function

    68. Posterior Body Feel for tenderness, deformity, and open wounds. Carefully palpate from neck to pelvis. Look for obvious injuries.

    69. Specific Chief Complaints Chest pain Shortness of breath Abdominal pain Pain associated with bones or joints Dizziness

    70. Significant Mechanism of Injury Ejection from vehicle Death in passenger compartment Fall greater than 15'-20' Vehicle rollover High-speed collision

    71. Assessment Steps for Significant MOI Rapid trauma assessment Baseline vital signs SAMPLE history Reevaluate transport decision

    72. Assessment Steps for Trauma Patients Without Significant MOI Focused assessment Baseline vital signs SAMPLE history Reevaluate transport decision

    73. Responsive Medical Patients History of illness SAMPLE history Focused assessment Vital signs Reevaluate transport decision

    74. Unresponsive Medical Patients Rapid medical assessment Baseline vital signs SAMPLE history Reevaluate transport decision

    75. Patient Assessment Process

    76. Detailed Physical Exam More in-depth exam based on focused physical exam Should only be performed if time and patient’s condition allows Usually performed en route to the hospital

    77. Performing the Detailed Physical Exam (1 of 10) Visualize and palpate using DCAP-BTLS. Look at the face. Inspect the area around the eyes and eyelids. Examine the eyes.

    78. Performing the Detailed Physical Exam (2 of 10) Pull the patient’s ear forward to assess for bruising. Use the penlight to look for drainage or blood in the ears.

    79. Performing the Detailed Physical Exam (3 of 10) Look for bruising and lacerations about the head. Palpate the zygomas.

    80. Performing the Detailed Physical Exam (4 of 10) Palpate the maxillae. Palpate the mandible.

    81. Performing the Detailed Physical Exam (5 of 10) Assess the mouth and nose for obstructions and cyanosis. Check for unusual odors.

    82. Performing the Detailed Physical Exam (6 of 10) Look at the neck. Palpate the front and the back of the neck. Look for distended jugular veins.

    83. Performing the Detailed Physical Exam (7 of 10) Look at the chest. Gently palpate over the ribs.

    84. Performing the Detailed Physical Exam (8 of 10) Listen for breath sounds. Listen also at the bases and apices of the lungs.

    85. Performing the Detailed Physical Exam (9 of 10) Look at the abdomen and pelvis. Gently palpate the abdomen. Gently compress the pelvis.

    86. Performing the Detailed Physical Exam (10 of 10) Gently press the iliac crests. Inspect all four extremities. Assess the back for tenderness or deformities.

    87. Patient Assessment Process

    88. Ongoing Assessment Is treatment improving the patient’s condition? Has an already identified problem gotten better? Worse? What is the nature of any newly identified problems?

    89. Steps of the Ongoing Assessment Repeat the initial assessment. Reassess and record vital signs. Repeat focused assessment. Check interventions.

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