Patient Assessment

Created by mkmecm 

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Chapter 8

five parts of assessment

scene size up
primary assessment
history taking
secondary assessment
reassessment

steps of scene size up

ensure scene safety
ensure your safety
wear a public safety vest
look for dangerous as approach - difficult terrain, environmental conditions, traffic,
forms of hazards - chemical and biological, electrical, water, fires, toxic, MVC

MOI

mechanism of injury

NOI

nature of illness

evaluate these three factors in MOI

amount of force applied to body
length of time force applied
areas of the body involved

blunt trauma

occurs over a broad area, skin is usually not broken, tissues and organs below the area of impact may be damaged

penetrating trauma

the force is a small point of contact between the skin and the object, open wound,

severity of injury depends on

characteristics of the object
the amount of force
the part of the body effected.

triage

the process of sorting patients based on the severity of each patient's condition

primary assessment

LOC - AVPU, GCS, PERRL
ABCs -
identify life threats
assessment of vital functions
initial general impression - stay and play / load and go
begin interventions needed to preserve life
and integration of treatment to preserve life

assess the airway

check for patent airway
unresponsive - check for signs of obstructions

assess breathing

Rate
Rhythm - regular or irregular
Quality
depth - rise and fall of chest

normal range respiration

adult 12-20
children 15-30
infants 25-50

assess circulation

Pulse Rate
Pulse Rhythm
Pulse Quality
Skin color
skin temperature
skin moisture
capillary refill
control external bleeding

normal pulse rate range

adult/adolescents 60-100
school age 70-120
preschool 80-140
toddler 90-150
infant 100-160

First three steps of patient assessment

BSI/Scene Safe
ABC
SAMPLE
OPQRST

AVPU

used to access the LOC
- Awake and alert
- Responsive to Verbal stimuli
- Responsive to Pain
- Unresponsive

PERRL

- Pupils
- Equal
- Round
- Regular in size
- React to Light

Golden Period/ Golden Hour

is the time from injury to definitive care
- Treatment of shock and traumatic injuries should occur

Platinum 10

Aim to assess, stabilize, package, and begin transport of trauma patients within 10 minutes

SAMPLE

- Signs and symptoms
- Allergies
- Medications
- Past Pertinent medical history
- Last oral intake
- Events leading up to the injury/illness

OPQRST

to evaluate a patient's pain
Onset - when did it start
- Provocation or palliation (pr v-k sh n) (pal li a tion) anything makes it worse or better
- Quality - what does it feel like, dull, sharp, describe it
- Region/radiation - where is it does it radiate anywhere
- Severity 0-10
- Timing - how long

pertinent negatives.

- Negative findings that warrant no care or intervention - what the patient denies -

Special Challenges in Obtaining Patient History

• Silence
• Overly talkative
• Multiple symptoms
• Anxiety
• Anger and hostility
• Intoxication
• Crying
• Depression
• Confusing behavior or history
• Limited cognitive abilities
• Language barriers
• Hearing problems
• Visual impairments

Secondary Assessment

Purpose is to perform a systematic physical examination of the patient. May be a full-body scan or an assessment that focuses on a certain area of the body
• Inspection—Look at the patient for abnormalities.
• Palpation—Touch or feel the patient for abnormalities.
• Auscultation—Listen to the sounds a body makes by using a stethoscope

DCAP-BTLS

evaluate the body
• Deformities
• Contusions
• Abrasions
• Punctures/penetration
• Burns
• Tenderness
• Lacerations
• Swelling

Full-Body Scan

• Systematic head-to-toe examination
• Goal is to identify injuries or causes missed during the primary assessment's rapid scan.
it is performed during secondary assessment on patients who have sustained a significant MOI, is unconscious or in critical condition

Focused Assessment

•Performed on patients who have sustained nonsignificant MOIs or on responsive medical patients
• Based on the chief complaint
• Goal is to focus your attention on the immediate problem

Focused Assessment Respiratory system

• Expose the patient's chest.
• Look for signs of airway obstruction.
• Inspect for symmetry.
• Listen to breath sounds.
• Measure the respiratory rate.
• Reevalute pulse rate and skin and blood pressure.

Focused Assessment Cardiovascular system

• Look for trauma to the chest.
• Reevaluate pulse, respiratory rate, and blood pressure.
• Reevaluate the skin.
• Check and compare distal pulses.
• Consider auscultation for abnormal heart sounds.

Focused Assessment Blood pressure

A drop in blood pressure indicates:
• A loss of blood
• A loss of vascular tone
• A cardiac pumping problem
Decreased blood pressure is a late sign of shock - decompensated shock
High blood pressure may result in a rupture or other critical damage in the arterial system.
adults 90-140
children 80-115
infants 50-90

Focused Assessment Neurologic system

Should be performed with any patient who has:
• Changes in mental status
• A possible head injury
• Stupor
• Dizziness/drowsiness
• Syncope
- Evaluate the level of consciousness and orientation.
- Assess the patient's thought process.
- Inspect the head for trauma.
- Check for bilateral muscle strength and weaknesses.

Focused Assessment Musculoskeletal system

- Assess for posture and look at joints.
- Always compare the right side with the left.
- Look for trauma to the abdomen and for distention.
- Palpate the abdomen for tenderness, rigidity, and patient guarding.

Focused Assessment Pelvis

- Inspect for symmetry and any obvious signs of injury, bleeding, and deformity.

Focused Assessment Extremities

- Inspect for symmetry, cuts, bruises, swelling, obvious injuries, and bleeding.
- Palpate for deformities.
- Check pulse and motor and sensory functions PMS

Focused Assessment Posterior body

- Inspect the back for tenderness, deformity, symmetry, and open wounds.
- Palpate the spine from the neck to the pelvis for tenderness and deformity.

Focused Assessment Anatomic regions
• Head, neck, and cervical spine

- Palpate the scalp and skull.
- Check the patient's eyes.
- Check the color of the sclera - whites of the eyes
- Assess the patient's cheekbones.
- Check the patient's ears and nose for fluid.
- Check the upper (maxillae) and lower (mandible) jaw.
- Open the patient's mouth and look for any broken or missing teeth.
- Note any unusual odors in the mouth - hyperglycemia may have fruity smell

Focused Assessment Abdomen

- Palpate the front and back of the abdomen.

Reassessment

Perform at regular intervals during the assessment process
Repeat the primary assessment.
Reassess vital signs.
Compare the baseline vital signs obtained during the primary assessment.
Look for trends -
Reassess the chief complaint.
Recheck interventions.
Identify and treat changes in the patient's condition.

how often should you Reassess the patient.

- Unstable patients: every 5 minutes
- Stable patients: every 15 minutes

Symptom

subjective condition the patient feels and tells you about - something they say

Sign

objective condition you can observe about the patient - something you see

Stridor

high pitch/whistle sound, crowing sound on inspiration suggest an occluded airway
upper airway

Rhonchi

loud
coarse low-pitched breath sounds heard in patients with chronic mucus in the upper airway

Rales

wet sound / like air bubbling through water
crackling, rattling sign of fluid in the lungs

Wheezing

- expiratory sound - lower airway

accessory muscles

the secondary muscles of respiration. include the neck muscles (sternocleidmastoids), the chest pectoralis major muscles and the abdominal muscles

auscultate

to listen to sounds within an organ with a stethoscope

bradycardia

slow heart less then 60b/m

capnography

a non invasive method that quickly and efficiently provide information on a patient's ventilatory status, ciculation and metabolism

capnometry

the use of a capnometer, a device that measures the amount of expired carbon dioxide

carbon dioxide

a component of air and typically makes up 0.3% of air at sea level. it is a wast product exhaled during expiration by the respiratory systme

coagulate

to form a clot to plug an opening in an injured blood vessel and stop bleeding

colorimetric devices

capnometer or end-tidal carbon dioxide detectors are devices that use a chemical reaction to detect the amount of carbon dioxide present in expired gases by changing colors
yellow = good
purple = bad

conjunctiva

the delicate membrane that lines the eyelids and covers the exposed surface of the eye

crepitus

a grating or grinding sensation caused by fractured bone ends or joints rubbing together also air bubbles under the skin that produce a crackling sound or crinkly feeling (Subcutaneous emphysema)

cyanosis

skin takes on a blue tint

diaphoretic

profuse sweating

end-tidal CO2

the amount of carbon dioxide present in exhaled breath

frostbite

damage to tissue due to exposure to cold

general impression

the overall initial impression that determines the priority for patient care; based on the patient's surroundings, the MOI, signs and symptoms and the chief complaint
load and go or stay and play

guarding

involuntary muscle contractions (spasms) of the abdominal wall in an effort to protect an inflamed abdomen; a sign of peritonitis

hypothermia

a condition in which the internal body temperature falls below 95F (35C) after exposure to a cold environment

incident command system

a system implemented to manage diasters and MCI, in which section chiefs, report to the incident commander asls referred to as teh incident management system

jaundice

yellow skin or sclera that is caused by liver disease or dysfunction

labored breathing

breathing that requires visible increased effort; characterized by grunting, stridor and use of accessory muscles

MOI

mechanism of injury - the way in which a traumatic injuries occur; the force that act on the body to cause damage

nasal flaring

flaring out of the nostrils, indicating that there is an airway obstruction

NOI

nature of illness - the general type of illness a patient is experiencing

orientation

the mental status of a patient as measure by memory - person (patient's name) - place (location of patient)- time (current year/month/date) and event (what happened)

palpate

examine by touch

paradoxical movement

the motion of the chest wall section that is detached in a flail chest; the motion is exactly the opposite of normal motion during breathing
only one section of the chest rises on inspiration while another area falls

perfusion

circulation of the blood within an organ

pertinent negatives

negative findings that warrant no care or intervention (example patient denies pain at a MVC)

responsiveness

the way in which a patient responds to external stimuli, including verbal, tactile, and painful

retractions

movement in which the skin pulls in around the ribs during inspiration

When you shine a light into one pupil, the normal reaction of the other pupil should be to:

constrict - become smaller

While en route to the scene of a shooting, the dispatcher advises you that the caller states that the perpetrator has fled the scene. You should:

confirm this information with law enforcement personnel at the scene.

Reassessment is performed to determine all of the following, EXCEPT:
A. the patient's response to your treatment.
B. whether or not the patient is deteriorating.
C. the reason why the patient called EMS.
D. the nature of any newly identified problems.

C. the reason why the patient called EMS.

You respond to the scene of a motor vehicle collision. Upon arrival, you find the driver, a young female, sitting on the curb. She is confused, is in obvious respiratory distress, and has pale, moist skin. As your partner manually stabilizes her head, you perform a primary assessment. After performing any immediate livesaving treatment, you should:

perform a rapid scan of her entire body and prepare for immediate transport.

Which of the following is an example of a symptom?
A. cyanosis
B. headache
C. tachycardia
D. hypertension

B. headache

What maneuver should be used to open the airway of an unresponsive patient with suspected trauma?

jaw-thrust maneuver

Poor peripheral circulation will cause the skin to appear:

pale, white, ashen, or gray

The MOST effective way to determine whether your patient's problem is medical or traumatic in origin is to:

perform a careful and thorough assessment

When palpating a patient's pulse, you note that there is a short interval between pulsations. This indicates that the pulse is:

rapid

A decrease in the blood pressure may indicate

a loss of vascular tone.

Which of the following would the EMT most likely not perform on a responsive patient with a headache and no apparent life-threatening conditions?
A. systemic head-to-toe examination
B. noninvasive blood pressure monitoring
C. assessment of oxygen saturation
D. focused secondary assessment

A. systemic head-to-toe examination

A 39 year old male sustained a stab wound to the groin during an altercation at a bar. As you approach the patient, you note that he is conscious, is screaming in pain, and is attempting to control the bleeding, which is bright red and spurting from his groin area. You should:

apply direct pressure to the wound.

Pain that moves from its point of origin to another body location is said to be

radiating

An adult patient who is NOT experiencing difficulty breathing will:

be able to speak in complete sentences without unusual pauses

When performing a reassessment of your patient, you should first:

repeat the primary assessment

The goal of the primary assessment is to:

identify and rapidly treat all life-threatening conditions

During the primary assessment, circulation is evaluated by assessing:

pulse quality, external bleeding, and skin condition.

The diastolic pressure represents the:

minimum amount of pressure that is always present in the arteries.

In infants and small children, skin color should be assessed on the:

palms and soles

A patient with high blood pressure would be expected to have skin that is:

flushed and red

You receive a call to a local daycare center for an unresponsive 8-month-old infant. Upon arrival, you perform an assessment and determine that the infant is not breathing. After delivering two rescue breaths, you should:

assess for the presence of a brachial pulse

Which of the following situations or conditions warrants immediate transport?

severe chest pain and cool, pale skin

An unstable patient should be reassessed at least every:

5 minutes

Which of the following questions would you ask a patient to ascertain the "M" in the SAMPLE history?

"How much Tylenol do you take each day?"

When assessing a patient's abdomen, you will typically evaluate for all of the following, EXCEPT:
A. open wounds or eviscerations.
B. subcutaneous emphysema.
C. rigidity and obvious bleeding.
D. gross bleeding and tenderness.

B. subcutaneous emphysema.

As you assess the head of a patient with a suspected spinal injury, your partner should:

maintain stabilization of the head.

When auscultating the blood pressure in a patient's upper extremity, you should place the diaphragm (head) of the stethoscope over the _________ artery.

brachial

After performing a head tilt-chin lift maneuver to open the airway of an unresponsive patient, you should:

suction as needed and insert an airway adjunct.

A crackling sound produced by air bubbles under the skin is called:

subcutaneous emphysema.

End-tidal carbon dioxide (ETCO2) is defined as the:

maximal concentration of CO2 at the end of an exhaled breath.

A patient who does not respond to your questions but moves or cries out when his or her trapezius muscle is pinched, is said to be:

responsive to painful stimuli

Which of the following statements regarding the mechanism of injury (MOI) is correct?

. avoid compressing both carotid arteries simultaneously.

After the first 60 minutes of experiencing a significant injury:

the body's ability to compensate for shock decreases.

Observations made when forming a general impression of a patient would include all of the following, EXCEPT:
A. appearance.
B. race and gender.
C. pulse strength.
D. level of distress.

C. pulse strength.

The chief complaint is MOST accurately defined as the:

most serious thing the patient is concerned about

When using the pulse oximeter as part of your assessment of a patient, it is important to remember that

. any situation that causes vasoconstriction or loss of red blood cells, such as anemia or bleeding, may result in an inaccurate or misleading value

Palliating factors regarding a patient's pain involve those that

alleviate the pain

Which of the following patient responses would establish the "E" in the SAMPLE history?
A. "I am not having any difficulty breathing."
B. "The chest pain started about 45 minutes ago."
C. "I was mowing the lawn when the pain began."
D. "I was in the hospital a week ago.

C. "I was mowing the lawn when the pain began."

You should suspect that a patient is experiencing respiratory failure if he or she:

has bradycardia and diminished muscle tone

Jugular venous distention suggests a problem with blood returning to the heart if the patient is:
A. in a supine position.
B. sitting up at a 45° angle.
C. in a recumbent position.
D. in a full Fowler's position.

B. sitting up at a 45° angle.

When you assess capillary refill time (CRT) in an infant, normal color to the tested area should return within:

2 seconds

A patient with profuse sweating is referred to as being:

. diaphoretic

A 71-year-old female slipped on a rug and fell. She is conscious and alert and complains of severe pelvic pain. Her respirations are 22 breaths/min with adequate depth and her heart rate is 120 beats/min. Which of the following would NOT be appropriate for this patient?
A. 100% supplemental oxygen
B. gentle palpation of the pelvis
C. performing a full-body scan
D. treating her for possible shock

B. gentle palpation of the pelvis

You should gently palpate a patient's pelvis only if:

the patient does not complain of pelvic pain

Typical methods of assessing a patient's breathing include all of the following, EXCEPT:
A. observing the chest for adequate rise and fall.
B. feeling for air movement at the nose and mouth.
C. listening to breath sounds with a stethoscope.
D. observing for nasal flaring during inhalation.

D. observing for nasal flaring during inhalation.

During a 30-minute transport of a stable patient, you should reassess him or her at least ________ times.

2

Which of the following actions would NOT be performed during the scene size-up?
A. asking a neighbor to secure the patient's dog
B. noting the position of a crashed motor vehicle
C. notifying the dispatcher to send fire personnel
D. rapidly assessing a patient's respiratory status

D. rapidly assessing a patient's respiratory status

A properly sized blood pressure cuff should cover:

two thirds the length from the armpit to the crease in the elbow

Clinical signs of labored breathing include all of the following, EXCEPT:
A. use of accessory muscles.
B. shallow chest movement.
C. gasping attempts to breathe.
D. supraclavicular retractions.

B. shallow chest movement.

When a patient's respirations are shallow:

tidal volume is markedly reduced

Which of the following statements regarding the secondary assessment is correct?
A. If your general impression of a patient does not reveal any obvious life threats, you should proceed directly to the secondary assessment.
B. The purpose of the secondary assessment is to systematically examine every patient from head to toe, regardless of the severity of his or her injury.
C. A focused secondary assessment would be the most appropriate approach for a patient who experienced significant trauma to multiple body systems.
D. You may not have time to perform a secondary assessment if you must continually manage life threats that were identified during the primary assessment.

D. You may not have time to perform a secondary assessment if you must continually manage life threats that were identified during the primary assessment.

What part of the patient assessment process focuses on obtaining additional information about the patient's chief complaint and any medical problems he or she may have?

history taking

When approaching a 32-year-old male who is complaining of traumatic neck pain, you should:

ensure that the patient can see you approaching him.

Which of the following scenarios does NOT involve the presence of any symptoms?
A. a 44-year-old male with abdominal pain and severe dizziness
B. a 49-year-old female with blurred vision and ringing in the ears
C. a 61-year-old female who is unconscious with facial cyanosis
D. a 55-year-old male with a severe headache and 2 days of nausea

C. a 61-year-old female who is unconscious with facial cyanosis

The "Golden Period" begins when an injury occurs and ends when:

the patient receives definitive care

A pulse with a consistent pattern is considered to be:

regular

When evaluating a patient with multiple complaints, the EMT's responsibility is to:

determine which complaint poses the greatest threat to the patient's life.

In which of the following situations is a pertinent negative identified?
A. A 53-year-old man with dizziness also tells you that he has vomited three times.
B. A 56-year-old woman states that her chest hurts every time she takes a deep breath.
C. A 50-year-old woman states that nothing makes her chest pain better or worse.
D. A 59-year-old man complains of crushing chest pain but denies shortness of breath.

D. A 59-year-old man complains of crushing chest pain but denies shortness of breath.

Which of the following medical history questions would be of LEAST pertinence in an acute situation?
A. "Does your mother have diabetes?"
B. "Has this ever happened to you before?"
C. "Does the pain stay in your chest?"
D. "Are there medications that you cannot take?

A. "Does your mother have diabetes?"

A 50-year-old male is found unconscious in his car. There were no witnesses to the event. When gathering medical history information for this patient, the EMT should:

determine if the patient has a medical alert bracelet or wallet card

An elderly patient has fallen and hit her head. You assess her level of consciousness as unresponsive using the AVPU scale. Your initial care should focus on

. airway, breathing, and circulation

Cyanosis of the skin is caused by

decreased blood oxygen.

A 40-year-old male presents with pain to the right upper quadrant of his abdomen. He is conscious and alert with stable vital signs. During your assessment, you note that his skin and sclera are jaundiced. You should suspect:

liver dysfunction

With regard to the assessment of a patient's cardiovascular status, capillary refill time is MOST reliable in:
A. patients with decreased peripheral perfusion.
B. children who are older than 6 years of age.
C. children who are younger than 6 years of age.
D. patients who are significantly hypotensive

C. children who are younger than 6 years of age.

Which of the following patients does NOT have an altered mental status?
A. a patient with a head injury who is slow to answer questions
B. a patient who overdosed and moans when he is touched
C. a diabetic who opens his eyes when you ask questions
D. a patient with an acute allergic reaction and dizziness

D. a patient with an acute allergic reaction and dizziness

The full-body scan of a patient that occurs following the primary assessment should take no longer than:

60-90 seconds

Which of the following statements regarding the blood pressure is correct?
A. Blood pressure falls early in patients with hypoperfusion.
B. Blood pressure is the most reliable indicator of perfusion.
C. Blood pressure is usually not measured in children younger than 3 years of age.
D. The systolic pressure represents ventricular relaxation.

C. Blood pressure is usually not measured in children younger than 3 years of age.

Normal skin color, temperature, and condition should be:

pink, warm, and dry

An injured patient is assigned a total score of 9 on the GCS. He is assigned a score of 2 for eye opening, a score of 3 for verbal response, and a score of 4 for motor response. Which of the following clinical findings is consistent with his GCS score?

opens eyes in response to pain, uses inappropriate words, withdraws from pain

Marks: 1/1
When palpating a patient's pulse, you note that it is grossly irregular. You should:

count the pulse rate for a full minute to obtain an accurate reading.

Which of the following conditions would MOST likely cause the pupils to remain significantly constricted?

overdose of an opiate drug

Treatment and transport priorities at the scene of a mass-casualty incident should be determined after:

all the patients have been triaged.

A patient's short-term memory is MOST likely intact if he or she correctly answers questions regarding:

date and event

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