Patient Assessment Beginning the Physical Examination: Scene Size-Up, General Survey, Vital Signs, and Pain

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

Initial Assessment Figure 14-1

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

Components of General Survey General Appearance/Impression Height and Weight

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

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

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

Initial Assessment?

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

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

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

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

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

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

Answer Repeat the blood pressure measurement and verify in the contralateral arm

Pain Assess OPQRST

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

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

Thoracic Landmarks—Anterior Chest

Shoulders and Related Structures

Percussion and Auscultation of Chest

Thoracic Landmarks—Posterior Chest

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

Breath Sounds Fig. 11-26

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

Abdomen four quadrants Inspect Auscultate Percuss Palpate

Abdomen—Inspection Skin Umbilicus Contour Abdominal movement

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

Ankles and Feet Dorsiflexion Plantar flexion Inversion Eversion Range of motion Dorsiflexion Plantar flexion Inversion Eversion

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