Patient Assessment

paramedic

1. Chapter 11 Patient Assessment

2. National EMS Education Standard Competencies Assessment Integrate scene and patient assessment findings with knowledge of epidemiology and pathophysiology to form a field impression. This includes developing a list of differential diagnoses through clinical reasoning to modify the assessment and formulate a treatment plan.

3. National EMS Education Standard Competencies Scene Size-up Scene safety Scene management Impact of the environment on patient care Addressing hazards Violence Need for additional or specialized resources Standard precautions Multiple patient situations

4. National EMS Education Standard Competencies Primary Survey Primary survey for all patient situations Initial general impression Level of consciousness ABCs Identifying life threats Assessment of vital functions Begin interventions needed to preserve life. Integration of treatment/procedures needed to preserve life

5. National EMS Education Standard Competencies History Taking Determining the chief complaint Investigation of the chief complaint Mechanism of injury/nature of illness Past medical history Associated signs and symptoms Pertinent negatives

6. National EMS Education Standard Competencies History Taking (cont’d) Components of the patient history Interviewing techniques How to integrate therapeutic communication techniques and adapt the line of inquiry based on findings and presentation

7. National EMS Education Standard Competencies Secondary Assessment Performing a rapid full-body exam Focused assessment of pain Assessment of vital signs Techniques of physical examination Respiratory system Presence of breath sounds

8. National EMS Education Standard Competencies Secondary Assessment Cardiovascular system Neurologic system Musculoskeletal system

9. National EMS Education Standard Competencies Secondary Assessment Techniques of physical examination for all major Body systems Anatomic regions Assessment of Lung sounds

10. National EMS Education Standard Competencies Monitoring Devices Obtaining and using information from patient monitoring devices including (but not limited to): Pulse oximetry Noninvasive blood pressure Blood glucose determination Continuous ECG monitoring 12-lead ECG interpretation Carbon dioxide monitoring Basic blood chemistry

11. National EMS Education Standard Competencies Reassessment How and when to reassess patients How and when to perform a reassessment for all patient situations

12. National EMS Education Standard Competencies Medicine Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression and implement a comprehensive treatment/disposition plan for a patient with a medical complaint.

13. National EMS Education Standard Competencies Medical Overview Assessment and management of a Medical complaint Pathophysiology, assessment, and management of medical complaints to include: Transport mode Destination decisions

14. Introduction One of the most important skills you will develop is the ability to assess a patient. Combines a number of steps: Assessing the scene Obtaining chief complaint and medical history Performing a secondary assessment Process leads to: Differential diagnosis Working diagnosis

15. Introduction Your job is to quickly: Identify your patient ’ s problem(s). Set your care priorities. Develop a patient care plan. Execute your plan.

16. Sick Versus Not Sick Determine whether the patient is sick or not sick. If the patient is sick, determine how sick. Every time you assess a patient: Qualify whether your patient is sick or not sick. Quantify how sick the patient is.

17. Establishing the Field Impression A determination of what you think is the patient ’ s current problem You must be able to communicate and ask the right questions. Be a “detective.” Ask increasingly relevant questions. Develop your own style.

18. Is This Medical or Trauma? Medical patients Identify chief complaint and sift through medical history. Trauma patients Medical history may have less impact Requires a modified approach

19. Scene Size-up

20. Scene Size-up Looking around and evaluating the overall safety and stability of the scene Safe and secure access into the scene Ready egress out of the scene Specialty resources needed

21. Scene Safety Ensure the safety and well-being of your EMS team and any other responders. If the scene is not safe, do what is necessary to make it safe. Requires constant reassessment

22. Scene Safety Crash-and-rescue scenes often include multiple risks. Wear a high-visibility public safety vest. Consider specialty reflective gloves, coats, and boots. © Adam Alberti, NJFirePictures.com. © Glen E. Ellman.

23. Scene Safety Ensure that your team can safely gain access to the scene and the patient. Consider a snatch and grab. Establish a safe perimeter to keep bystanders out of harm ’ s way.

24. Scene Safety Be wary of toxic substances and toxic environments. Proper body and respiratory protection is a must. Courtesy of Tempe Fire Department.

25. Scene Safety Potential crime scenes Law enforcement should enter first. Formulate an escape plan. Be aware of violence from bystanders. Patients who abuse methamphetamines can be a large threat. © Paul Chiasson, CP/AP Photo.

26. Scene Safety Environment risks include: Unstable surfaces Snow and ice Rain Consider stability of structures around you. Ensure safety of bystanders next. Courtesy of James Tourtellotte/U.S. Customs & Border Control.

27. Mechanism of Injury or Nature of Illness Mechanism of injury (MOI) Forces that act on the body to cause damage Nature of illness (NOI) General type of illness a patient is experiencing

28. Mechanism of Injury or Nature of Illness Multiple patients or obese patients may warrant additional resources. Multiple patients must be triaged. Be familiar with specialized resources. Assess the need for spinal motion restriction.

29. Standard Precautions Your first priority is your own safety and the safety of other EMS team members.

30. Standard Precautions Treat all patients as potentially infectious. Wear properly sized gloves. Wear eye protection. Wear a HEPA or N95 mask. Wear a gown. Err on side of caution.

31. Standard Precautions Personal protective equipment (PPE) Clothing or equipment that provides protection from substances that pose a health/safety risk Steel-toe boots Helmets Heat-resistant outerwear Self-contained breathing apparatus Leather gloves

32. Primary Survey

33. Primary Survey You may use three exam techniques: Inspection Palpation Auscultation

34. Primary Survey Form a general impression. Based on initial presentation and chief complaint Make conscious, objective, and systematic observations. Is the patient in stable or unstable condition? Is the patient sick or not sick?

35. Primary Survey Observe level of consciousness. Decide whether to implement spinal motion restriction procedures. Determine your priorities of care. Identify age and sex of the patient.

36. Primary Survey Treat life threats as you find them. What additional care is needed? What needs to be done on scene? When to initiate transport? Which facility is most appropriate? Assess mental status by using AVPU process.

37. Assess the Airway Is airway open and patent? Crying or talking indicates airway adequacy. Move from simple to complex: Position Obstruction

38. Assess the Airway P ossibility of spine injury determines how to open airway: Head tilt–chin lift maneuver in medical patients Jaw-thrust maneuver in trauma patients Mechanical means requires an airway adjunct. If patient cannot maintain airway, use more invasive technique.

39. Assess Breathing Is the patient breathing? If not, you must breathe for him or her. If so, is he or she breathing adequately? Expose chest and inspect for injuries. Consider minute volume. Respiratory rate multiplied by the tidal volume inspired with each breath

40. Assess Breathing Also consider: Breathing rate Work of breathing Chest rise and fall Lung sounds

41. Assess Circulation Perform full-body scan. Look for major hemorrhage or life-threatening injury. Check for pulse. Evaluate the skin.

42. Assess Circulation Assess and control external bleeding. Perform rapid exam to identify any major external bleeding. Venous bleeding is characterized by steady blood flow. Arterial bleeding is characterized by a spurting flow of blood. For unresponsive patients, sweep for blood by running gloved hands from head to toe.

43. Assess Circulation Palpate the pulse. Count the number of beats in 30 seconds and multiply by 2. Normal pulse rate for adults is 60 – 100 beats/min. Bradycardia : R ate less than 60 beats/min Tachycardia : R ate higher than 100 beats/min

44. Assess Circulation Quality Normal pulse is easy to feel. Weak pulse is thready . Bounding indicates hypertension. Rhythm Normal rhythm is regular. Irregular: Beats come early or late, or are skipped Report your findings.

45. Assess Circulation Assess the skin to evaluate perfusion. Color Temperature Condition © Jones & Bartlett Learning.

46. Assess Circulation

47. Restoring Circulation If a patient has inadequate circulation: Restore or improve circulation. Control severe bleeding. Improve oxygen delivery to the tissues.

48. Restoring Circulation If you cannot feel a pulse, begin CPR until an AED or manual defibrillator is available. Follow standard precautions. Evaluate cardiac rhythm of any patient in cardiac arrest. Oxygen delivery is improved through the administration of supplemental oxygen.

49. Assess the Patient for Disability Perform a neurologic evaluation. A mini-neurologic exam includes: AVPU scale and pupils (eg, size, equality, reactivity to light) A quick assessment for neurologic deficits Glasgow Coma Scale (GCS)

50. Assess the Patient for Disability Assess for any gross neurologic deficits. Have the patient move all extremities. Assess for motor strength and weakness. Assess grip strength. Assess for loss of sensation.

51. Expose Then Cover Visually inspect areas being examined. You cannot assess what you cannot see! Proper exposure of areas being examined is essential to the physical examination process.

52. Make a Transport Decision Identify priority patients. Do only what is necessary at the scene and handle everything else en route.

53. Priority Patients Include: Patients receiving CPR Hypoperfusion or shock Complicated childbirth Chest pain w/ systolic BP < 100 mm Hg Uncontrolled bleeding Multiple injuries Poor general impression Unresponsive patients Difficulty breathing Hypoxia not corrected in 1 – 2 minutes Suspected AMI w/ ECG showing STEMI Suspected stroke

54. History Taking

55. History Taking Gain information about the patient and the events surrounding the incident. Ask open-ended questions. Avoid leading questions. Ask age-appropriate questions. Be patient.

56. Patient Information Name and chief complaint are the most important pieces. Obtain other information in whatever order is most conducive to good patient care and most convenient.

57. Techniques for History Taking Appearance and demeanor Clean, neat, and professional Project a good attitude © Jones & Bartlett Learning.

58. Techniques for History Taking Note taking Let the patient know that you will be writing information down. Position yourself at eye level. Maintain good eye contact. © Glen E. Ellman.

59. Communication Techniques Introduce yourself and partner. Identify your service and certification level. Be familiar with the cultural groups in your area. Any issues that could lead to misunderstanding Ask about feelings.

60. Communication Techniques Communicate empathy. Offer reassurance. © Jones & Bartlett Learning.

61. Communication Techniques Read nonverbal cues. Encourage dialogue. Avoid medical jargon.

62. Dealing With Sensitive Topics Social history Not typically gathered in prehospital setting However, provides valuable information about overall health and helps to identify risk factors for various disease processes

63. Dealing With Sensitive Topics Alcohol and drug abuse Alcohol can mask signs and symptoms. Patients may give an unreliable history. Keep a professional attitude. © Jack Dagley Photography/Shutterstock.

64. Dealing With Sensitive Topics Sexual history Talk to the patient in private. Keep your questions focused. Do not interject opinions or biases. Treat with compassion and respect.

65. Domestic Violence and Sexual Assault or Rape Physical abuse, domestic abuse, and sexual assault Required to report Look for clues. Always call law enforcement. Maintain evidence per protocol. © Jones & Bartlett Learning.

66. Handling Physical Attraction to Patients It is never appropriate for a clinician to act on feelings of attraction to a patient. If a patient becomes seductive or makes sexual advances, firmly make it clear that your relationship is professional. Keep someone else in the room at all times.

67. Ensuring Confidentiality Maintain confidentiality of the patient’s information. Be familiar with relevant laws: HIPAA State laws

68. Protecting the Patient’s Privacy Interview patients in a private setting. Obtain information that patient may be reluctant to share. Do not hesitate to ask nonessential personnel to leave the room or to step back.

69. Gathering Information From Third Parties If patients can’t provide information, other sources on scene may need to be used. The further from primary source, the greater the chance of inaccuracies. Family and friends often filter information. They may be able to describe the patient’s chief complaint, history, and possibly current health status.

70. Gathering Information From Third Parties Law enforcement personnel and bystanders can also provide information. For routine transfers, take a few moments to review transfer paperwork. Learn about the patient’s medical history. Consider reliability of this paperwork.

71. Cultural Competence Common barriers to communication: Race Ethnicity Age Gender Language Education Religion Geography Economic status

72. Cultural Competence Respect ideas and beliefs. Consider dietary practices. Obtain consent. Provide best possible care for all patients. Research prevalent groups in your area. Remember the importance of manners.

73. Cultural Competence Facilitating cross-cultural communication Identify an interpreter. Consider using closed-ended questions. Remind interpreter that information is confidential. Use a certified medical interpreter if possible. Consider manners, hand gestures, and body language.

74. Special Challenges in History Taking Overly talkative patients Silence Anxious patients Depression Situational Chronic Anger and hostility Don’t take it personally. Be attentive to risks. Retreat and call police if needed.

75. Special Challenges in History Taking Confusing history or bizarre behavior Consider medical causes. Sensory or developmental challenges Limited education or intelligence Hearing loss, low vision, or blindness

76. Managing Age-Related Considerations Pediatric patients Include child in the history-taking process. Be sensitive to the fears of the parents. Pay attention to the parent-child relationship.

77. Managing Age-Related Considerations Pediatric patients (cont ’ d) Tailor your questions to the age of the child. Neonates/infants: Maternal history and birth history 3 to 5 years: Performance in school Adolescent: Risk-taking behaviors, self-esteem issues, rebelliousness, drug and alcohol use, and sexual activity Gather an accurate family history.

78. Managing Age-Related Considerations Geriatric patients Present a variety of medical and traumatic conditions not seen in other patients Accommodate sensory losses. Patients tend to have multiple problems. May have multiple chief complaints May take a multitude of medications

79. Managing Age-Related Considerations Geriatric patients (cont ’ d) Symptoms may be less dramatic. Consider including a functional assessment. Assessment of mobility Upper extremity function Activities of daily living

80. Responsive Medical Patients Chief complaint Reason someone called 9-1-1 Should be recorded in patient ’ s own words Determine patient’s alertness. Ask about events to begin elaborating on chief complaint. Look for clues on scene.

81. Responsive Medical Patients History of illness OPQRST Onset Provocation Quality Region/radiation/ referral Severity Time SAMPLE Signs and symptoms Allergies Medications Pertinent past history Last oral intake Events that led to injury or illness

82. Responsive Medical Patients “What made you call 9-1-1?” If the patient’s behavior is inappropriate, consider: Hypoxia Medical issue Low blood glucose or hypothermia Psychiatric emergency Drug or alcohol ingestion

83. Responsive Medical Patients Current health status Made up of unrelated pieces of information Ties together past history with history of current event Focuses on environmental and personal habits

84. Responsive Medical Patients Current health status ( con’d ) Examples of questions to ask: What prescription medicines do you take? Are you allergic to anything? Do you drink beer, wine, or cocktails? Do you smoke? Decide which items to explore.

85. Responsive Medical Patients Family history Helps establish patterns and risk factors for potential diseases Information should be related to the patient ’ s current medical condition.

86. Responsive Medical Patients Social history Patient’s occupation may indicate possible toxic exposures. Environment indicates lifestyle and chronic exposures. Travel history may be relevant. Questions regarding diet may be appropriate.

87. Responsive Medical Patients Past medical history Should include: Current medications and dosages Allergies Childhood illnesses Adult illnesses Past surgeries Past hospitalizations and disabilities

88. Responsive Medical Patients Past medical history (cont ’ d) Patient ’ s emotional affect provides insight into overall mental health. Determine whether the patient has ever experienced the problem. A new problem or condition is best considered serious until proven otherwise.

89. Unresponsive Patients Rely on: Head-to-toe physical examination Normal diagnostic tools

90. Trauma Patients Life-threatening MOIs Falls Greater than 20 feet for adults Greater than 10 feet for children High-risk motor vehicle crash Intrusion Ejection Death of another occupant Vehicle-pedestrian collision Motorcycle/ATV crash

91. Trauma Patients © Corbis/Getty. © Dan Myers, Figure. © Jack Dagley Photography/Shutterstock, © Larry St. Pierre/Shutterstock. © Enigma/Alamy © Corbis/Getty © JOSEPH EID/AFP/Getty © Dan Myers © Jack Dagley Photography/Shutterstock © Larry St. Pierre/Shutterstock © micheal ledray/Shutterstock © Jones & Bartlett Learning

92. Trauma Patients High-priority infant or child MOIs: Falls from more than 2–3 times child ’ s height Fall of less than 10 feet with loss of consciousness Medium- to high-speed vehicle crash Bicycle collision © Jones & Bartlett Learning. © Jones & Bartlett Learning. © Jones & Bartlett Learning.

93. Trauma Patients Multiple MOIs often come into play during a traumatic event . In an MVC, determine whether seat belts and/or air bags were involved. Improperly installed child seats can be useless. © Thinkstock/Getty.

94. Review of Body Systems General symptoms Ask questions regarding: Fever Chills Malaise Fatigue Night sweats Weight variations

95. Review of Body Systems Skin, hair, and nails Rash, itching, hives, or sweating Musculoskeletal Joint pain, loss of range of motion, swelling, redness, erythema, and localized heat or deformity

96. Review of Body Systems Head and neck Severe headache or loss of consciousness Eyes and ears Ask about visual acuity, blurred vision, diplopia, photophobia, pain, changes in vision, and flashes of light. Ask about hearing, loss, pain, discharge, tinnitus, and vertigo.

97. Review of Body Systems Nose, throat, and mouth Sense of smell, rhinorrhea, obstruction, epistaxis, postnasal discharge, and sinus pain Sore throat, bleeding, pain, dental issues, ulcers, and changes to taste sensation

98. Review of Body Systems Endocrine Enlargement of the thyroid gland Temperature intolerance Skin changes Swelling of hands and feet Weight changes Polyuria, polydipsia, polyphagia Changes in body and facial hair

99. Review of Body Systems Chest and lungs Dyspnea and chest pain Coughing, wheezing, hemoptysis, and tuberculosis status Previous cardiac events Pain or discomfort Orthopnea, edema, and past cardiac testing

100. Review of Body Systems Hematology and lymph nodes History of anemia, bruising, and fatigue Tender and enlarged lymph nodes

101. Review of Body Systems Gastrointestinal Ask about: Appetite and general digestion Food allergies and intolerances Heartburn, nausea and vomiting, diarrhea Hematemesis Bowel regularity, changes in stool, flatulence, Jaundice Past GI evaluations and tests Consider GI bleeding and urinary habits.

102. Review of Body Systems Genitourinary Ask about sexually transmitted diseases. For women ask: If menstrual cycle is regular When last period was If she has dysmenorrhea When last sexual intercourse was Whether she has had multiple partners What kind of contraception she uses Whether she has ever been pregnant

103. Review of Body Systems Genitourinary For men: Ask about erectile dysfunction, fluid discharge, and testicular pain. When most recent sexual encounter was If they use condoms About the characteristics of any discharge or lesions

104. Review of Body Systems Neurologic Seizures or syncope, loss of sensation, weakness in extremities, paralysis, loss of coordination or memory, and muscle twitches Facial asymmetry If you suspect stroke or TIA, use appropriate stroke scale.

105. Review of Body Systems Psychiatric Depression, mood changes Difficulty concentrating Anxiety, irritability Sleep disturbances, fatigue Suicidal or homicidal tendencies

106. Critical Thinking Goal of assessment: Figure out most likely reason for patient’s chief complaint and how best to address it. Five aspects of critical thinking : Concept formation Data interpretation Application of principles Reflection in action Reflection on action

107. Clinical Reasoning Combines knowledge of anatomy, physiology, pathophysiology, and patient ’ s complaints Pay attention to signs or symptoms that are inconsistent with working diagnosis. Differential diagnosis—a working hypothesis of the nature of the problem

108. Secondary Assessment

109. Secondary Assessment Process by which quantifiable, objective information is obtained from a patient about his or her overall state of health Consists of two elements: Obtaining vital signs Performing a systematic physical exam

110. Secondary Assessment Prehospital setting may determine how secondary assessment is performed. Identifying abnormalities requires direct hands-on experience. Factors in starting exam: Stability of patient Chief complaint History Communication ability

111. Secondary Assessment Not every aspect will be completed in every patient. Factors to consider: Location Positioning of the patient The patient ’ s point of view Maintaining professionalism

112. Physical Exam of Priority Patients The physical exam performed depends on patient needs. If traditional physical exam isn’t possible, a rapid full-body scan may be required. A 60- to 90-second nonsystematic review and palpation of the patient’s body Inspect the soft tissue, look for open or closed wounds, and palpate for pain or tenderness.

113. Assessment Techniques Inspection Looking at the patient Palpation Touching to obtain information Pulses: Use finger Skull: Use palms Skin: Use back of hand © Jones & Bartlett Learning. © Jones & Bartlett Learning.

114. Assessment Techniques Percussion Striking surface of the body, typically where it overlies various body cavities Detects changes in the densities of the underlying structures

115. Assessment Techniques Auscultation Listening with a stethoscope Requires: Keen attention Understanding of what “normal” sounds like Lots of practice

116. Vital Signs

117. Vital Signs Pulse Assess rate, presence, location, quality, regularity To palpate, gently compress an artery against a bony prominence. Count for 30 seconds and multiply by 2. Check for central pulse in unresponsive patients.

118. Vital Signs © Jones & Bartlett Learning.

119. Vital Signs Respiration Assess rate by inspecting the patient ’ s chest. Quality Pathologic respiratory patterns or rhythms Tripod positioning, accessory muscle use, retractions Rate should be measured for 30 seconds and multiplied by 2 for pediatric patients.

120. Vital Signs

121. Vital Signs Blood pressure Product of cardiac output and peripheral vascular resistance Systolic pressure Diastolic pressure Measured using a cuff Ideally should be auscultated

122. Vital Signs Temperature When measuring the tympanic membrane temperature: External auditory canal must be free of cerumen. Position the probe so the infrared beam is aimed at the tympanic membrane. Wait 2 – 3 seconds until temperature appears.

123. Vital Signs Pulse oximetry Should never be used as an absolute indicator of the need for oxygen Measures percentage of hemoglobin saturation © Jones & Bartlett Learning.

124. Equipment Used in the Secondary Assessment Stethoscope Blood pressure cuff (sphygmomanometer) Capnography Glucometry Ophthalmoscope Otoscope Scissors Reliable light source Gloves Sheet or blanket

125. Equipment Used in the Secondary Assessment Stethoscope Acoustic: Blocks out ambient sounds Electronic: Converts sound waves into electronic signal and amplifies them © Denis Pepin/Shutterstock.

126. Equipment Used in the Secondary Assessment Blood pressure cuff Measurement of blood pressure Consists of inflatable cuff and manometer (pressure meter) © WizData, Inc./Shutterstock.

127. Equipment Used in the Secondary Assessment Ophthalmoscope Allows you to look into patient ’ s eyes Otoscope Evaluates ears of a patient

128. Physical Examination Look for signs of significant distress. Other aspects: Dress Hygiene Expression Overall size Posture Untoward odors Overall state of health © Jones & Bartlett Learning. Courtesy of MIEMSS.

129. Physical Examination Terms to describe the degree of distress: No apparent distress Mild Moderate Acute Severe Terms to describe the general state of a patient ’ s health : Chronically ill Frail Feeble Robust Vigorous

130. Full-Body Exam A systematic head-to-toe examination Patients who should receive: Sustained a significant MOI Unresponsive Critical condition

131. Focused Exam Performed on patients who have sustained nonsignificant MOIs and are responsive Focus on the immediate problem.

132. Mental Status For any patient with a “head” problem, assess and palpate for signs of trauma. Assess the patient in four areas: Person Place Day of week The event

133. Mental Status Use the Glasgow Coma Scale Assigns point value for eye opening, verbal response, and motor response General appearance Speech and language patterns Mood Thoughts and perceptions Information relevant to thought content Insight and judgment Cognitive function (attention and memory)

134. Skin Perhaps the quickest and most reliable way to assess overall distress Serves three major functions: Transmits information from the environment to the brain Protects the body from the environment Regulates the temperature of the body

135. Skin Examine: Color Moisture Temperature Texture Turgor Significant lesions Evidence of diminished perfusion: Pallor Cyanosis Diaphoresis Vasodilation (flushing)

136. Skin Pallor: Poor red blood cell perfusion to the capillary beds Vasoconstriction: Indicated by pale skin Cyanosis: Low arterial oxygen saturation Mottling: Severe hypoperfusion and shock

137. Skin Ecchymosis: Localized bruising or blood collection within or under the skin Turgor: Relates to hydration Skin lesions: May be only external evidence of a serious internal injury

138. Hair Examine by inspection and palpation. Note: Quantity Distribution Texture Recent changes in growth or loss of hair

139. Nails Note: Color Shape Texture Presence or absence of lesions Normal nail should be firm and smooth. © Biophoto Associates/Photo Researchers, Inc.

140. Nails

141. Head Inspect and feel the entire cranium. Deformity Asymmetry Warm, wet areas Tenderness Shape and contour Scars or shunts © E. M. Singletary, M.D. Used with permission.

142. Head Evaluate the face. Color Moisture Expression Symmetry and contour Swelling or apparent areas of injury DCAP-BTLS

143. Eyes Assess functions of CNS. Anterior chamber Posterior chamber Inspect and palpate the upper and lower orbits.

144. Eyes Note periorbital ecchymosis (raccoon eyes). Assess visual acuity. Snellen ( “E”) chart Light/dark discrimination Finger counting © German Ariel Berra/Shutterstock.

145. Eyes Assess pupils. Normally round and equal size Pupils should react instantly to change in light level. Check for size, shape, and symmetry, and reaction to light. © American Academy of Orthopaedic Surgeons. © Jones & Bartlett Learning.

146. Ears Involved with hearing, sound perception, and balance control Includes: Outer portion Middle portion Inner portion

147. Ears Assess for: Changes in hearing perception Wounds Swelling Drainage Assess mastoid process of the skull for discoloration and tenderness.

148. Nose Nasal cavity is divided into two chambers. Each chamber contains three layers of bone. Assess anteriorly and inferiorly. © Jones & Bartlett Learning.

149. Nose Look for: Asymmetry Deformity Wounds Foreign bodies Discharge or bleeding Tenderness Evidence of respiratory distress

150. Throat Evaluate mouth, pharynx, and neck. Prompt assessment is mandatory in patients with altered mental status. Assess for a foreign body or aspiration. Be prepared to assist with manual techniques and suction.

151. Throat Mouth Lips Symmetry Gums Look for cyanosis around the lips. Inspect airway for obstruction.

152. Throat Tongue Size Color Moisture Maxilla and mandible Integrity Symmetry Oropharynx Discoloration Pustules Unusual odors on the breath Fluids that might need suctioning Edema and redness

153. Throat Neck Symmetry Masses Venous distention Palpate carotid pulses. Palpate the suprasternal notch.

154. Cervical Spine Consider MOI. Evaluate for: Pain Altered mental status Loss of consciousness at the time of the event © Augustino/Shutterstock.

155. Cervical Spine Indications for spinal immobilization: Tenderness on palpation of spinal column Complaint of pain in spine Altered mental status Inability to communicate effectively GCS of less than 15 Evidence of a distracting injury Paralysis or other neurologic deficit or complaint

156. Cervical Spine Inspect and palpate. Stop exam if pain, tenderness, or tingling results. Assess range of motion when there is no potential for serious injury. Passive exam Active exam

157. Chest Contains lungs, heart, and great vessels Three phases of exam Chest wall exam Pulmonary evaluation Cardiovascular assessment

158. Chest Check for: Symmetry Respiratory effort Signs of obstruction General shape of the chest wall Signs of abnormal breathing Chest deformities Tenderness or crepitus

159. Chest Auscultate breath sounds. Normal Tracheal Bronchial Bronchovesicular Vesicular Adventitious Wheezing, rales, rhonci, stridor, pleural friction rubs

160. Chest © Jones & Bartlett Learning. © Jones & Bartlett Learning.

161. Chest © Jones & Bartlett Learning.

162. Chest Are sounds: Dry or moist? Continuous or intermittent? Course or fine? Are breath sounds diminished or absent? In a portion of one lung or entire chest? If localized, assess transmitted voice sounds.

163. Cardiovascular System Circulates blood throughout the body Blood flows through two circuits: Systemic circulation Pulmonary circulation

164. Cardiovascular System Cardiac cycles involves: Cardiac relaxation (diastole) Filling Contraction (systole)

165. Cardiovascular System The contraction and relaxation of the heart generates heart sounds. © Jones & Bartlett Learning.

166. Cardiovascular System Splitting: Events on the right of the heart usually occur later than those on the left. Creates two discernible sounds Korotkoff sounds: Related to blood pressure There are five (first and fifth are significant): First: Thumping of the systolic Fifth: Disappears as the diastolic pressure drops below that created by the blood pressure cuff

167. Cardiovascular System Use the point of maximum impulse (PMI) to assess apical pulse. Bruit: Abnormal “whoosh”-like sound Turbulent blood flow through narrowed artery Murmur: Abnormal “whoosh”-like sound Turbulent blood flow around a cardiac valve Graded by range of intensity from 1 to 6

168. Cardiovascular System Arterial pulses are an expression of systolic blood pressure. Palpable where artery crosses bony prominence Venous pressure tends to be low. Assess extremities for signs of obstruction or insufficiency.

169. Cardiovascular System Jugular venous distention (JVD) With penetrating left chest trauma, may indicate cardiac tamponade With pedal edema, consider heart failure. Note how much distention is present.

170. Cardiovascular System An older patient’s ability to compensate for cardiovascular insult may be compromised. Arterial atherosclerosis and diabetes Medications, such as for high blood pressure

171. Cardiovascular System Pay attention to arterial pulses. Obtain blood pressure and repeat. Note history and class of hypertension.

172. Cardiovascular System Palpate and auscultate carotid arteries. For a suspected heart problem, assess: Pulse Skin Breath sounds Baseline vital signs Extremities

173. Abdomen Divided into quadrants Umbilicus serves as central reference point. Diaphragm is at top of abdominal cavity. Pelvis is at bottom of abdominal cavity. © Jones & Bartlett Learning.

174. Abdomen Abdomen can also be divided into ninths. © Jones & Bartlett Learning.

175. Abdomen Abdomen contains: Almost all of the organs of digestion Organs of the urogenital system Significant neurovascular structures Peritoneum: Well-defined layer of fascia made up of parietal and visceral peritoneum Intraperitoneal organs Extraperitoneal organs

176. Abdomen Three basic mechanisms produce pain Visceral pain Inflammation Referred pain

177. Abdomen Orthostatic vital signs (tilt test) Blood pressure and pulse are taken in the supine and sitting or standing positions. Determines extent of volume depletion If volume-depleted, there is not enough circulating blood to push into core circulation.

178. Abdomen Orthostatic vital signs (tilt test) (cont ’ d) Generally considered positive if: Decrease in systolic pressure Increase in diastolic pressure of 10 mm Hg Increase in pulse rate by 20 beats/min

179. Abdomen For inspection: Make patient comfortable. Proceed in systematic fashion. Abdomen can be described as: Flat Rounded Protuberant (bulging out) Distinguish from obesity Scaphoid Pulsatile

180. Abdomen Ascites Fluid within the peritoneal cavity Abdomen may appear markedly distended A visible or palpable fluid wave may be evident Shifting dullness to percussion Bluish discoloration in periumbilical area (Cullen sign) or along flanks (Grey Turner sign) Indicates ruptured ectopic pregnancy or acute pancreatitis

181. Abdomen Auscultation May have limited utility in prehospital setting Setting must be quiet to hear bowel sounds. Differentiating normal from abnormal can be challenging. Practice on healthy people. Note presence or absence of bowel sounds.

182. Abdomen Palpation Palpate each quadrant gently but firmly. Should appear soft without tenderness or masses. Guarding: Contraction of abdominal muscles Rebound tenderness: Pain upon release Abdominal rigidity: Peritoneal irritation and guarding Less discrete (localized) guarded tenderness may indicate a more visceral problem.

183. Abdomen Palpation (cont ’ d) To palpate the liver: Place left hand behind patient, parallel to right 11th and 12th ribs. Place right hand on right abdomen below rib cage. Ask patient to take a deep breath. Try to feel the liver edge.

184. Abdomen Palpation (cont ’ d) To palpate the gallbladder: Use same technique as for liver. Response indicating pain may mean possible inflammation. When patient takes deep breath, move fingers under liver edge.

185. Abdomen Palpation (cont ’ d) To palpate the spleen: With left hand, reach over and around patient. Press forward lower left rib cage and adjacent soft tissues. With right hand below costal margin, press toward the spleen.

186. Abdomen Aortic aneurysm May be seen pulsating in the upper midline Do not palpate an obvious pulsatile mass. Hernia Place patient in supine position and raise the head and shoulders. Bulge of hernia will usually appear.

187. Female Genitalia Consists of: External genitalia Ovaries Fallopian tubes Uterus Vagina

188. Female Genitalia Limited and discreet assessment Reasons to examine include: Life-threatening hemorrhage Imminent delivery in childbirth Assessment includes: Palpating the bilateral inguinal regions Palpating the hypogastric region

189. Female Genitalia Reasons for pain on palpation include: Ectopic pregnancy Complications of third trimester pregnancy Nonpregnant ovarian problems Pelvic infections

190. Male Genitalia Consists of: Reproductive ducts Testes Urethra Prostate Penis © Jones & Bartlett Learning.

191. Male Genitalia Limited exam with partner present. Assess for bleeding, injury, or fracture. Note inflammation, discharge, swelling, or lesions. Priapism: Prolonged erection Look for evidence of urinary incontinence.

192. Anus Distal orifice of the alimentary canal Often evaluated at same time as genitalia Examined in limited circumstances Keep patient draped. Partner should be present. Assess for need of bleeding control or another intervention. Examine sacrococcygeal and perineal areas.

193. Musculoskeletal System Joints: Areas where bone ends abut each other and form a kind of hinge Skeletal muscles: Used to flex and extend joints Joints become more vulnerable to injury, stress, and trauma as they age.

194. Musculoskeletal System Common injuries: Fractures Sprains Strains Dislocations Contusions Hematomas Open wounds

195. Musculoskeletal System Note: Structure and function Limitation or pain in range of motion Bony crepitance Inflammation or injury Obvious deformity Diminished strength Atrophy Asymmetry Pain

196. Musculoskeletal System Problems with the shoulders can often be determined by noting posture. Assess: Sternoclavicular joint Acromioclavicular joint Subacromial area Bicipital groove

197. Musculoskeletal System Assess range of motion: Ask patient to raise arms above the head. Have patient demonstrate external rotation and abduction. Perform internal rotation.

198. Musculoskeletal System Inspect elbows. Palpate between the epicondyles and olecranon. Range of motion: Flex and extend passively and actively. Pronate the forearms while the elbows are flexed. © Jones & Bartlett Learning.

199. Musculoskeletal System Inspect hands and wrists. Palpate the hands. Palpate the carpal bones. Range of motion: Make fists, then extend fingers. Flex/extend wrists. Move hands laterally and medially. © Jones & Bartlett Learning.

200. Musculoskeletal System Inspect knees and hips. Range of motion: Ask patient to bend each knee and raise toward chest. Assess for rotation and abduction of hips. Palpate each hip. Palpate pelvis. © Jones & Bartlett Learning. © Jones & Bartlett Learning.

201. Musculoskeletal System Observe ankles and feet. Palpate feet and ankles. Assess range of motion: Have patient plantar flex, dorsiflex, and invert and evert ankles and feet. Inspect, palpate, and check forefoot and toes. © Jones & Bartlett Learning.

202. Peripheral Vascular System Comprises aspects of circulatory system. Lymphatic system: Network of nodes and ducts dispersed throughout the body Lymph nodes: Larger accumulations of lymphatic tissues © Jones & Bartlett Learning.

203. Peripheral Vascular System Perfusion occurs in the peripheral circulation. Diseases of the peripheral vascular system are often seen in patients with other underlying medical conditions.

204. Peripheral Vascular System During assessment, pay attention to upper and lower extremities. Signs of acute or chronic vascular problems

205. Peripheral Vascular System Assessment Inspect upper extremities. Five P s of acute arterial insufficiency: Pain Pallor Paresthesias Paresis Pulselessness

206. Peripheral Vascular System Assessment (cont ’ d) Palpate epitrochlear and axillary lymph nodes. Inspect lower extremities. Palpate lower extremities. Note temperature of feet and legs. Attempt to palpate edema. Palpate superficial inguinal lymph nodes.

207. Spine Consists of 33 individual vertebrae Inspect the back. Lordosis Kyphosis Scoliosis

208. Spine © Dr. P. Marazzi/Photo Researchers, Inc. © Southern Illinois University/Photo Researchers, Inc. Figure 11-44 © Jones & Bartlett Learning.

209. Spine Palpate the spine. Check back for any other findings. Tap over costovertebral angles. Palpate scapulae, paraspinal areas, and base of neck. Check the buttocks. © Living Art Enterprises/Science Source.

210. Spine Range of motion: Check passively first, then actively. If any pain or tingling is elicited, stop the exam and immobilize the spine.

211. Nervous System Nervous system is divided into: Voluntary nervous system Involuntary (autonomic) nervous system Sympathetic Parasympathetic

212. Nervous System Reflexes Involuntary motor response to specific sensory stimuli Primitive reflexes Babinski reflex test may be used to check neurologic function. Do not perform on a patient with lower-extremity injuries.

213. Nervous System Neurologic exam Mental status (AVPU) Cranial nerve function Distal motor function Distal sensory function Deep tendon reflexes Mental status exam COASTMAP Consciousness Orientation Activity Speech Thought Memory Affect (mood) Perception

214. Nervous System Cranial nerve examination Determines presence and degree of disability Can be performed in less than 3 minutes

215. Nervous System Evaluation of the motor system Posture and body position Involuntary movements Muscle strength Coordination Proprioception © Jones & Bartlett Learning.

216. Nervous System Check sensory function. Assess primary and cortical sensory functions. Evaluate deep tendon reflexes.

217. Nervous System Results of the neurologic exam Delirium Consistent with an acute sudden change in mental status Dementia Representative of deterioration of cognitive cortical functions

218. Secondary Assessment of Unresponsive Patients After ruling out trauma, position in recovery position. If trauma, position in neutral alignment. Perform a thorough assessment of the body and look for signs of illness.

219. Secondary Assessment of Unresponsive Patients Perform at least two sets of vital signs. Should include: Auscultated blood pressure Accurate pulse and respiratory rates Patient ’ s temperature Consider unresponsive patients to be in unstable condition.

220. Secondary Assessment of Trauma Patients Two classifications of trauma patients: Isolated injury Multisystem trauma “High visibility factor” Do not become distracted by obvious but non–life-threatening injuries.

221. Secondary Assessment of Trauma Patients Patient who is unresponsive or has altered mentation is considered high risk. Perform rapid exam. When time and condition permit, perform physical examination.

222. Recording Secondary Assessment Findings Should be orderly and concise Document using the forms recommended by your medical director. Note: Objective signs Pertinent negatives Similar relevant information

223. Limits of the Secondary Assessment Not everything can be discovered in the secondary assessment. Keep total time in field to a minimum. Evaluation by trained physician coupled with laboratory and radiographic studies may be needed for a definitive diagnosis.

224. Monitoring Devices Continuous ECG monitoring Purpose is to establish a baseline. Electrodes must be placed properly. The leads are usually colored and labeled to help with placement. © Jones & Bartlett Learning.

225. Monitoring Devices Continuous ECG monitoring (cont ’ d) Bipolar leads consist of two electrodes. Placed on different limbs Einthoven triangle

226. Monitoring Devices 12-lead ECG monitoring Patient should be supine. Prepare the skin. Connect electrodes. Connect and apply the precordial leads. Record the ECG. © Jones & Bartlett Learning.

227. Monitoring Devices Carbon dioxide monitoring Capnometry Measures carbon dioxide output Capnography Measures carbon dioxide output and provides a waveform

228. Monitoring Devices Blood glucometer Can obtain reading in two ways in the field: From the hub of an IV catheter From a finger stick Most take only a few seconds. Should be calibrated regularly

229. Monitoring Devices Cardiac biomarkers Used to assess presence of damage to cardiac muscle May take several hours following a myocardial infarction for the cardiac biomarkers to become elevated

230. Monitoring Devices Other blood tests Basic and complete metabolic profile (CHEM 7 and CHEM 12) Brain natriuretic peptide (BNP) test Arterial blood gases

231. Reassessment

232. Reassessment Stable patients should be reassessed every 15 minutes. Unstable patients should be reassessed every 5 minutes.

233. Reassessment of Mental Status and the ABCDEs Compare LOC with baseline assessment. Review the airway. Reassess breathing, circulation, pulse.

234. Reassessment of Patient Care and Transport Priorities Have you addressed all life threats? Do priorities need to be revised? Is initial transport decision appropriate? Obtain another complete set of vital signs and compare with expected outcomes. Priority patients: Minimum three sets

235. Reassessment of Patient Care and Transport Priorities Look for trends. Revisit patient complaints. Document all of your findings.