section 2 - Hatzalah of Miami-Dade

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section 2 - Hatzalah of Miami-Dade
8: Patient Assessment
Scene Size-up
Objectives (1 of 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 (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.
Initial Assessment
Objectives (1 of 7)
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 (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.
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.
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.
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.
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.
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.
Focused History and Physical
Exam: Trauma
Objectives (1 of 3)
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 (2 of 3)
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 (3 of 3)
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: Medical Patients
Objectives (1 of 3)
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 (2 of 3)
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 (3 of 3)
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.
Detailed Physical Exam
Objectives (1 of 2)
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 (2 of 2)
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.
Ongoing Assessment
Objectives (1 of 2)
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 (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.
Patient Assessment
• Scene size-up
• Initial assessment
• Focused history and physical exam
– Vital signs
– History
• Detailed physical exam
• Ongoing assessment
Patient Assessment Process
Scene Size-up
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Dispatch information
Inspection of scene
Scene hazards
Safety concerns
Mechanism of injury
Nature of illness/chief complaint
Number of patients
Additional resources needed
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
Scene Safety:
Potential Hazards
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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
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.
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
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.
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.
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.
Additional Resources
• Medical resources
– Additional units
– Advanced life support
• Nonmedical resources
– Fire suppression
– Rescue
– Law enforcement
C-Spine Immobilization
• Consider early during assessment.
• Do not move without immobilization.
• Err on the side of caution.
Patient Assessment Process
Initial Assessment
• Develop a general
impression.
• Assess mental status.
• Assess airway.
• Assess the adequacy of
breathing.
• Assess circulation.
• Identify patient priority.
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
Obtaining Consent
• Introduce self.
• Ask patient’s name.
• Obtain consent.
Chief Complaint
• Most serious problem
voiced by the patient
• May not be the most
significant problem
present
Assessing Mental Status
• Responsiveness
– How the patient
responds to external
stimuli
• Orientation
– Mental status and
thinking ability
Testing Responsiveness
• A
Alert
• V
Responsive to Verbal stimulus
• P
Responsive to Pain
• U
Unresponsive
Testing Orientation
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Person
Place
Time
Event
Caring for Abnormal Mental Status
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Complete initial assessment.
Provide high-flow oxygen.
Consider spinal immobilization.
Initiate transport.
Support ABCs.
Reassess.
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
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
Assessing Breathing
• Choking
• Rate
• Depth
• Cyanosis
• Lung sounds
• Air movement
Assessing Breath Sounds
High-Flow Oxygen Administration
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Breathing faster than 20 breaths/min
Breathing slower than 12 breaths/min
Breathing too shallow
Decreased level of consciousness
Respiratory distress
Poor skin color
Positioning the Patient
• Position of comfort
– Sitting up with feet dangling
– High Fowler’s position
• Spinal precautions if possible spinal injury
Assessing the Pulse
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Presence
Rate
Rhythm
Strength
Normal Pulse Rates in Infants and
Children
Age
Infant: 1 month to 1 year
Range
(beats/min)
100 to 160
Toddler: 1 to 3 years
90 to 150
Preschool-age: 3 to 6 years
80 to 140
School-age: 6 to 12 years
70 to 120
Adolescent: 12 to 18 years
60 to 100
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
Assessing Perfusion
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Color
Temperature
Skin condition
Capillary refill
Priority Patients
• Difficulty breathing
• Poor general
impression
• Unresponsive with no
gag reflex
• Severe chest pain
• Signs of poor perfusion
• Complicated childbirth
• Uncontrolled bleeding
• Responsive but unable
to follow commands
• Severe pain
• Inability to move any
part of the body
Transport Decision
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Patient condition
Availability of advanced care
Distance to transport
Local protocols
Patient Assessment Process
Goals of the Focused History and Physical Exam
• Understand the circumstances surrounding
the chief complaint.
• Obtain objective measurements.
• Perform physical exam.
Components of Focused History
and Physical Exam
• Medical history
• Baseline vital signs
• Physical exam
Rapid Physical Exam
• 60-90 second head-totoe exam
• Performed on:
– Significant trauma
patients
– Unresponsive
medical patients
• Identifies undiscovered
conditions
DCAP-BTLS
• D Deformities
• B Burns
• C Contusions
• T Tenderness
• A Abrasions
• L Lacerations
• P Punctures/
Penetrations
• S Swelling
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.
Components of a Rapid Physical
Exam (2 of 3)
• Assess the chest.
• Assess the abdomen.
• Assess the pelvis.
Components of a Rapid Physical
Exam (3 of 3)
• Assess all four extremities.
• Roll the patient with spinal precautions.
Focused Physical Exam
• Used to evaluate patient’s chief complaint
• Performed on:
– Trauma patients without significant MOI
– Responsive medical patients
Head, Neck, and Cervical Spine
• Feel head and neck for deformity,
tenderness, or crepitation.
• Check for bleeding.
• Ask about pain or tenderness.
Chest
• Watch chest rise and fall with
breathing.
• Feel for grating bones as
patient breathes.
• Listen to breath sounds.
Abdomen
• Look for obvious injury, bruises, or
bleeding.
• Evaluate for tenderness and any
bleeding.
• Do not palpate too hard.
Pelvis
• Look for any signs of obvious injury,
bleeding, or deformity.
• Press gently inward and downward
on pelvic bones.
Extremities
• Look for obvious injuries.
• Feel for deformities.
• Assess
– Pulse
– Motor function
– Sensory function
Posterior Body
• Feel for tenderness, deformity, and
open wounds.
• Carefully palpate from neck to pelvis.
• Look for obvious injuries.
Specific Chief Complaints
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Chest pain
Shortness of breath
Abdominal pain
Pain associated with
bones or joints
• Dizziness
Significant Mechanism of Injury
• Ejection from vehicle
• Death in passenger
compartment
• Fall greater than 15'-20'
• Vehicle rollover
• High-speed collision
• Vehicle-pedestrian
collision
• Motorcycle crash
• Unresponsiveness or
altered mental status
• Penetrating trauma to the
head, chest, or abdomen
Assessment Steps for
Significant MOI
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Rapid trauma assessment
Baseline vital signs
SAMPLE history
Reevaluate transport decision
Assessment Steps for Trauma
Patients Without Significant MOI
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Focused assessment
Baseline vital signs
SAMPLE history
Reevaluate transport decision
Responsive Medical Patients
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History of illness
SAMPLE history
Focused assessment
Vital signs
Reevaluate transport decision
Unresponsive Medical Patients
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Rapid medical assessment
Baseline vital signs
SAMPLE history
Reevaluate transport decision
Patient Assessment Process
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
Performing the Detailed
Physical Exam (1 of 10)
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•
Visualize and palpate using DCAP-BTLS.
Look at the face.
Inspect the area around the eyes and eyelids.
Examine the eyes.
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.
Performing the Detailed
Physical Exam (3 of 10)
• Look for bruising and lacerations about the head.
• Palpate the zygomas.
Performing the Detailed
Physical Exam (4 of 10)
• Palpate the maxillae.
• Palpate the mandible.
Performing the Detailed
Physical Exam (5 of 10)
• Assess the mouth and nose for
obstructions and cyanosis.
• Check for unusual odors.
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.
Performing the Detailed
Physical Exam (7 of 10)
• Look at the chest.
• Gently palpate over the ribs.
Performing the Detailed
Physical Exam (8 of 10)
• Listen for breath sounds.
• Listen also at the bases and
apices of the lungs.
Performing the Detailed
Physical Exam (9 of 10)
• Look at the abdomen and pelvis.
• Gently palpate the abdomen.
• Gently compress the pelvis.
Performing the Detailed
Physical Exam (10 of 10)
• Gently press the iliac crests.
• Inspect all four extremities.
• Assess the back for tenderness or deformities.
Patient Assessment Process
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?
Steps of the Ongoing Assessment
• Repeat the initial assessment.
• Reassess and record vital signs.
• Repeat focused assessment.
• Check interventions.

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