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Scene Size-Up

Patient Assessment Beginning the Physical Examination: Scene Size-Up, General Survey, Vital Signs, and Pain. Scene Size-Up. 1. Scene Safety 2. BSI 3. MOI/NOI 4. # Patients 5. Additional Help? 6. C-Spine?. Initial Assessment. Initial /Primary Assessment. 1. General Impression

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Scene Size-Up

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  1. Patient AssessmentBeginning the Physical Examination: Scene Size-Up, General Survey, Vital Signs, and Pain

  2. Scene Size-Up • 1. Scene Safety • 2. BSI • 3. MOI/NOI • 4. # Patients • 5. Additional Help? • 6. C-Spine?

  3. Initial Assessment

  4. Initial /Primary Assessment • 1. General Impression • Age, Sex, Race, CC, Environment • 2. Mental Status • AVPU • 3. Airway (C-Spine) • 4. Breathing • 5. Circulation • Pulse – Skin - Bleeds • 6. Determine Priority

  5. Components of General Survey • General Appearance/Impression • Height and Weight

  6. Apparent state of health Acute or chronically ill, frail Level of consciousness Awake, alert, responsive or lethargic, obtunded, comatose Signs of distress Cardiac or respiratory; pain; anxiety/depression Skin color and obvious lesions Dress, grooming, and personal hygiene Appropriate to weather and temperature Clean, properly buttoned/zipped Facial expression Eye contact, appropriate changes in facial expression Odors of body and breath Posture, gait, and motor activity General Appearance - Description

  7. Mental Status and Behavior Terminology • To appreciate the differences in mental status and behavior, you must learn the terminology • Level of consciousness: how aware the person is of his environment • Attention: the ability to focus or concentrate • Alert: the patient is awake and aware • Lethargic: you must speak to the patient in a loud forceful manner to get a response • Obtunded: you must shake a patient to get a response • Stuporous: the patient is unarousable except by painful stimuli (sternal rub) • Coma: the patient is completely unarousable

  8. Height and Weight • Height • Short or tall • Build: slender and lanky, muscular, or stocky • Body symmetry • Note general body proportions and any deformities • Weight • Emaciated, slender, plump, obese • If obese, is fat distributed evenly or concentrated over trunk, upper torso, or around the hips? • small – medium – large?

  9. Initial Assessment?

  10. What next • Health form • History • http://videos.med.wisc.edu/videos/33744 • Secondary Assessment: • Detailed exam • Focused exam • Ongoing exam

  11. Health History: subjective • Changes in weight • Rapid or gradual • Rapid changes over a few days suggest changes in fluid, not tissue • Weight gain: nutrition vs. medical causes • Weight loss: medical vs. psychosocial causes • Fatigue and weakness • Fatigue: a sense of weariness or loss of energy • Weakness: a demonstrable loss of muscle power • Medical vs. psychosocial causes • Fever, chills, and night sweats • Ask about exposure to illness or any recent travel • Some medications may cause elevated temperature

  12. Question A patient presents with a 6-day history of rapid weight gain, and increasing fatigue. The most likely explanation is: • Dysphagia • Excessive absorption of nutrients • Diabetes mellitus • Accumulation of body fluids

  13. Answer • Accumulation of body fluids Rapid changes over a few days suggest changes in fluid.

  14. Vital Signs • Blood pressure • Heart rate and rhythm • Respiratory rate and rhythm • Temperature • Pain • SaO2

  15. Question A patient’s vital signs are recorded as follows: T 98.4 F, HR 74, R 18, BP 180/98 What would be the MOST appropriate action related to this patient’s vital signs? • The blood pressure should not be repeated • Repeat the blood pressure and verify in contralateral arm • Check the heart rate again to see if it is regular • Listen to the patient’s lungs for adventitious sounds

  16. Answer • Repeat the blood pressure measurement and verify in the contralateral arm

  17. Pain • Assess • OPQRST

  18. Pain • Types of pain • Nociceptive or somatic – related to tissue damage • Neuropathic – resulting from direct trauma to the peripheral or central nervous system • Psychogenic – relates to factors that influence the patient’s report of pain • Psychiatric conditions • Personality and coping style • Cultural norms • Social support systems • Idiopathic – no identifiable etiology

  19. Examination Techniques • Inspection • Palpation • Percussion • Auscultation • System with cc: function / physiology • System above and below

  20. Thoracic Landmarks—Anterior Chest

  21. Shoulders and Related Structures

  22. Percussion and Auscultation of Chest

  23. Thoracic Landmarks—Posterior Chest

  24. Spine • Inspection • Cervical, thoracic, and lumbar curves • Lordosis (swayback) • Kyphosis (hunchback) • Scoliosis (razorback) • Height differences of shoulders • Height differences of iliac crest

  25. Breath Sounds Fig. 11-26

  26. Pulse • Auscultate for: • Frequency (pitch) • Intensity (loudness) • Duration • Timing in cardiac cycle

  27. Abdomen • four quadrants • Inspect • Auscultate • Percuss • Palpate

  28. Abdomen—Inspection • Skin • Umbilicus • Contour • Abdominal movement

  29. Pelvis • Pelvic structural integrity • Hands on anterior iliac crests • Press down and out • Heel of hand on symphysis pubis • Press down

  30. Ankles and Feet • Range of motion • Dorsiflexion • Plantar flexion • Inversion • Eversion

  31. Ongoing Assessment • Components • Repeat initial assessment • Stable patient: every 15 minutes • Unstable patient: every 5 minutes (minimum) • Reassess mental status • Reassess airway • Monitor breathing for rate and quality • Reassess circulation • Reestablish patient priorities

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