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Secondary Assessment, Reporting Documentation
Firefighter Prehospital Care Program Module 7 & 8 Secondary Patient Assessment Reporting & Documentation Document 1.3 Secondary Assessment Objectives • Conduct a more thorough examination than in the primary assessment • Head to toe examination • Identify and treat any missed life threatening conditions (treat as soon as found) • Identify and treat non-life threatening conditions after the secondary assessment is complete • Obtain vital signs • Establish dialogue with patient and family, collect information and reassure • Verify chief complaint, obtain list of allergies, medications, and medical history • Report to paramedics Overview • Complete history, vital signs, and head to toe examination • Reassess ABCs and look again for life threats • Treat life threats as soon as found • Treat other problems after the secondary survey • Report to paramedics Patient Interview h Name h Age h Chief Complaint (CC) h Incident History h S.A.M.P.L.E. S.A.M.P.L.E. S - Signs and symptoms A - Allergies M - Medications P - Previous medical history L - Last oral intake E - Events leading up to incident Pain Assessment O - Onset P - Provocation Q - Quality R - Radiation S - Severity T - Time Baseline Assessment Level of Consciousness (LOC) hA.V.P.U hPatient Alert to surroundings hResponsive to Verbal stimulation hResponsive to Painful stimulation hUnresponsive to painful stimulation hGlasgow Coma Scale (GCS) Level of Awareness (LOA) h Person / Place / Time Baseline Vital Signs Pulse: h Rate (measure beats for 30 seconds and X 2) hRhythm - regular or irregular hVolume – weak or full Normal Values: hAdult 60 - 90 bpm hChild 80 - 150 bpm hInfant 120 - 150 bpm Baseline Vital Signs Respirations: Rate (measure beats for 30 seconds and X 2) Rhythm – regular or irregular Volume – shallow or full Normal Values: hAdult 12 - 20 hChild 15 - 30 hInfant 25 - 50 Baseline Vital Signs Skin: h Colour h Temperature h Condition Blood Pressure (BP) h 2 main techniques: Palpation & auscultation h Systolic reading (when heart is contracting) diastolic reading (between heartbeats) h Follow along with the slides… Blood Pressure Cuff Parts Cuff Pressure gauge Inflation bulb Air bladder (hidden inside cuff) Step 1: Choose an appropriately sized cuff • The cuff air bladder should go about 80% of the way around the arm • A wrong sized cuff will give a wrong reading; you may omit taking a BP if you don’t have the right cuff size The bladder takes up only part of the cuff! Step 2: Apply the cuff • Find the brachial artery (between the tendon of the biceps and the humerus) • Wrap the cuff securely around the upper arm with the “artery” marking pointing to the brachial artery pulse • Make sure clothing is not caught under the cuff Step 3: Inflate the cuff • Find the radial or brachial pulse • Inflate the cuff until you can no longer feel the pulse (this occurs at about the systolic blood pressure level) • Inflate the cuff another 20 mmHg above that Step 4: Apply the Stethoscope • Place the diaphragm of the stethoscope over where the brachial pulse had been palpated Step 5: Deflate the cuff • Deflate the cuff slowly (2 mmHg/second) • Record the systolic pressure when you first hear a “thud-thud-thud” • Record the diastolic pressure when you lose the sounds or they become very quiet Blood Pressure by Palpation h Find the radial pulse h Apply the cuff as before h Inflate the cuff until the radial pulse is lost; then inflate it another 20 mmHg h Deflate cuff slowly h Systolic pressure is when radial pulse returns h Diastolic pressure is not obtained h Record only systolic reading Normal Blood Pressure Values Systolic: Adult: age + 100 (up to 150 mmHg) Child : 2 x age + 80 Diastolic: Adult: 65 - 90 mmHg Child: 50 - 80 mmHg Low or High Blood Pressures • Low blood pressures (below 90/60 in adults) suggest shock (lack of blood flow to vital organs) • Long term high blood pressures (above 160/100) can damage organs (heart, kidneys, brain); Sometimes this takes years • Short term high blood pressures also occur with pain, fright, emotional upset • Patients who ask about their blood pressure should be encouraged to ask their physicians about any concerns they may have Pupils h Are the Pupils Equal And Reactive to Light (PEARL) ? h Pupils may be dilated, constricted, or mid-size Assess the head hObserve for discharge (blood or fluid) hAssess pupil size hObserve for “Battle’s Sign” hCLAPS-D and TICS-D hReassess airway Assess the neck hCLAPS-D hTICS-D hDistended neck veins (JVD) hTracheal Deviation Assess the chest & back hCLAPS-D hTICS-D hAuscultation * Reassess Critical Interventions Assess the abdomen hPulsating Masses hPalpate 4 quadrants hCLAPS-D and TICS-D hRigidity hTenderness Assess the pelvis hCLAPS-D and TICS-D hObserve for incontinence and / or blood hStability in 3 planes If any instability or crepitus is found, there should be no further assessment of the pelvis at any point • Priapism? Assess the lower extremities h CLAPS-D h TICS-D h Circulation (skin colour and pulse in foot) h Sensation to touch h Movement Assess the upper extremities h CLAPS-D h TICS-D h Circulation (skin colour and pulse) h Sensation h Movement Medical Report What Whatwe wefound found What Whatwe wedid did What Whatwe wehave havenow now • Patient’s name hPatient’s age hChief complaint hIncident history hTreatment hVitals hAssessment findings hResponse to treatment Pocket Medical Report • • • • No patient name to be recorded on this form Available to assist crews with assessment and reporting skills PMR Given to TEMS crew with no copy required by TFS Use PMR as a guide – not a mandatory TFS form TORONTO FIRE SERVICES & SOCPC POCKET MEDICAL REPORT Incident address Age Please read important information on the back of this form M F Chief Complaint Important Instructions Incident History Primary/Secondary Survey Airway/Breathing/Circulation Level of consciousness (A V P U) Details Head/Neck Chest/Abdomen Pelvis/Extremities Past Medical History Cardiac Respiratory Details Stroke Diabetes Seizures Medications List (use reverse side) or collect medications & send with patient ASA Codeine Sulpha Penicillin Other? Time Pulse Blood Pressure Respirations 1st set / hr / ---------------------------------------------------------------------------------------------2nd set / hr / Treatment CPR and defibrillation Oxygen C-spine support Splinting Wound dressing Allergies Document 1.13 Due to patient confidentiality issues DO NOT include the patient’s name on the Pocket Medical Report. The patient’s name, if available, should be collected as it will be required for completion of the TFS ‘A’ form. Summary In this module we have discussed and/or practiced: • A head to toe examination • Identified and treated any life threatening conditions missed during the primary survey • Identified and treated non-life threatening conditions after completion of the secondary survey • Obtained and recorded vital signs, including blood pressure • Establishing a dialogue with patient and family to collect information, confirm the chief complaint, and identify any other medical issues • Organizing and delivering a patient report Any Questions ? Photography credits: Michael Feldman Kirk Fudge Uri Rateneks Bill Sault Natasha Skvorets
