Principles of Patient Assessment in EMS By: Bob Elling, MPA, EMT-P & Kirsten Elling, BS, EMT-P

Chapter 21 – Comprehensive Exam and Health Assessment © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Objectives List the categories included in the comprehensive examination. List the categories included in the comprehensive examination. Describe how the EMS provider uses the sense of vision, hearing, and touch to perform the comprehensive examination. Describe how the EMS provider uses the sense of vision, hearing, and touch to perform the comprehensive examination. Describe the possible findings associated with a patient’s mental status including: AVPU, GCS, behavior, appearance, speech, mood, thought content, perceptions, and memory. Describe the possible findings associated with a patient’s mental status including: AVPU, GCS, behavior, appearance, speech, mood, thought content, perceptions, and memory. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Objectives (continued) List the components incorporated into the general survey of a patient. List the components incorporated into the general survey of a patient. Describe the technique used to examine the skin and the specific features to be assessed. Describe the technique used to examine the skin and the specific features to be assessed. Describe what patient information is obtained in the comprehensive patient history and health assessment. Describe what patient information is obtained in the comprehensive patient history and health assessment. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Describe the assessment features of the skin, head, eyes, ears, nose and throat, chest, the cardiovascular system, the abdomen and genitalia, upper and lower extremities, the spine, the peripheral vascular system, and the nervous system. Describe the assessment features of the skin, head, eyes, ears, nose and throat, chest, the cardiovascular system, the abdomen and genitalia, upper and lower extremities, the spine, the peripheral vascular system, and the nervous system. Objectives (continued) © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Introduction Comprehensive exam and health assessment is an exam of the body as a whole. Comprehensive exam and health assessment is an exam of the body as a whole. Most often performed in the clinic setting. Most often performed in the clinic setting. This is a lengthy process, thus not appropriate in the prehospital setting. This is a lengthy process, thus not appropriate in the prehospital setting. Some parts of the exam may be useful in the field. Some parts of the exam may be useful in the field. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Using the Senses Examiner utilizes inspection, auscultation, palpation, and percussion to complete the process. Examiner utilizes inspection, auscultation, palpation, and percussion to complete the process. In forming a general impression, inspection (both visual and smell) are utilized. In forming a general impression, inspection (both visual and smell) are utilized. Look for signs of distress and begin to differentiate normal from abnormal findings. Look for signs of distress and begin to differentiate normal from abnormal findings. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Inspection & Palpation Note age, gender, behavior, skin CTC, hygiene and appropriate dress. Note age, gender, behavior, skin CTC, hygiene and appropriate dress. Note any unusual odors or pertinent visual clues. Note any unusual odors or pertinent visual clues. Utilize light tough, deep touch, and compare side-to-side for symmetry. Utilize light tough, deep touch, and compare side-to-side for symmetry. Warm your hands/equipment prior to touching the patient. Warm your hands/equipment prior to touching the patient. Explain your steps prior to touching. Explain your steps prior to touching. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Percussion Combines touching and tapping the fingertips on various body parts while listening to determine size, position and consistency of underlying structures. Combines touching and tapping the fingertips on various body parts while listening to determine size, position and consistency of underlying structures. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

The Comprehensive Exam A complete head-to-toe exam (small children toe-to-head). A complete head-to-toe exam (small children toe-to-head). Components include: MS, a general survey, VS, skin CTC, head, eyes, ears, nose, and throat (HEENT), chest and cardiopulmonary system, abdomen, external genitalia, musculoskeletal, peripheral vascular and nervous systems. Components include: MS, a general survey, VS, skin CTC, head, eyes, ears, nose, and throat (HEENT), chest and cardiopulmonary system, abdomen, external genitalia, musculoskeletal, peripheral vascular and nervous systems. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Comprehensive Exam (continued) MS: MS: Observe appearance, behavior and posture Observe appearance, behavior and posture IA use AVPU and GCS (as necessary) IA use AVPU and GCS (as necessary) Appearance: Appearance: Observe dress, grooming, personal hygiene Observe dress, grooming, personal hygiene Facial expressions often provide clues Facial expressions often provide clues © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Behavior: Behavior: Observe emotions, character of responses, appropriate physical movement and ROM Observe emotions, character of responses, appropriate physical movement and ROM Observe the patient’s manner, affect, and interaction to their surroundings Observe the patient’s manner, affect, and interaction to their surroundings Comprehensive Exam (continued) © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Comprehensive Exam (continued) Speech: Speech: Assess speech and language for quality, rate, loudness and impairments Assess speech and language for quality, rate, loudness and impairments 4 types of speech impairments include: language, articulation, voice production and fluency disorders 4 types of speech impairments include: language, articulation, voice production and fluency disorders New onset is a significant finding (CVA, TBI, tumor) New onset is a significant finding (CVA, TBI, tumor) © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Mood: Mood: Assess for appropriateness for present situation Assess for appropriateness for present situation Some patient’s will have diagnosis of mood disorders and may exhibit changes due to disorders (mania, depression) Some patient’s will have diagnosis of mood disorders and may exhibit changes due to disorders (mania, depression) Comprehensive Exam (continued) © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Comprehensive Exam (continued) Thought Content: Thought Content: Assess patient’s thought content and perceptions for logical and organized thought processes Assess patient’s thought content and perceptions for logical and organized thought processes Assess patient’s insight into his own illness and ability of judgment/decision making about daily routine/care Assess patient’s insight into his own illness and ability of judgment/decision making about daily routine/care Abnormal findings may include: phobias, hypochondriasis, obsession, compulsion or delusions Abnormal findings may include: phobias, hypochondriasis, obsession, compulsion or delusions © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Perceptions: Perceptions: Abnormal findings may include: illusions, hallucinations, blocking, confabulation, neologism, circumlocation, circumstantiality, loosening associations, flight of ideas, word salad, echolalia, and clanging Abnormal findings may include: illusions, hallucinations, blocking, confabulation, neologism, circumlocation, circumstantiality, loosening associations, flight of ideas, word salad, echolalia, and clanging Comprehensive Exam (continued) © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Comprehensive Exam (continued) Memory: Memory: Assess short term, long term, and recall memory Assess short term, long term, and recall memory If AMS check blood sugar If AMS check blood sugar © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

General Survey: General Survey: LOC and signs of distress LOC and signs of distress Apparent state of health and skin CTC Apparent state of health and skin CTC Height, build, and sexual development Height, build, and sexual development Weight Weight Posture, gait and motor activity Posture, gait and motor activity Dress, grooming, personal hygiene Dress, grooming, personal hygiene Odors and facial expressions Odors and facial expressions Comprehensive Exam (continued) © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Comprehensive Exam (continued) Vital Signs: Vital Signs: Obtain a complete set of baseline and serial vitals Obtain a complete set of baseline and serial vitals The Skin: The Skin: Inspect and palpate noting the following characteristics: Inspect and palpate noting the following characteristics: Color, moisture, temperature, texture, mobility and turgor, lesions, hair distribution, nails Color, moisture, temperature, texture, mobility and turgor, lesions, hair distribution, nails © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Comprehensive Exam (continued) Head, Ears, Eyes, Nose, and Throat (HEENT): Head, Ears, Eyes, Nose, and Throat (HEENT): Palpate and inspect the scalp for DCAP-BTLS Palpate and inspect the scalp for DCAP-BTLS Note facial asymmetry/deficits, skin CTC, hair distribution Note facial asymmetry/deficits, skin CTC, hair distribution Assess visual acuity, visual fields, EOMS, accomodation, and pupillary reaction Assess visual acuity, visual fields, EOMS, accomodation, and pupillary reaction Use of an opthalmoscope to perform a detailed exam of the eye requires practice Use of an opthalmoscope to perform a detailed exam of the eye requires practice Assess ears for drainage acute hearing loss is a significant finding Assess ears for drainage acute hearing loss is a significant finding Use of an otoscope to perform a detailed exam of the ear requires practice Use of an otoscope to perform a detailed exam of the ear requires practice Inspect the nose for DCAP-BTLS and drainage Inspect the nose for DCAP-BTLS and drainage Inspect lips, mouth, tongue, teeth and throat Inspect lips, mouth, tongue, teeth and throat Inspect neck, note scars and JVD and ROM Inspect neck, note scars and JVD and ROM Inspect and palpate posterior neck for DCAP-BTLS Inspect and palpate posterior neck for DCAP-BTLS © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Comprehensive Exam (continued) Chest: Chest: Have the patient expose the chest (female keep on bra) Have the patient expose the chest (female keep on bra) Proceed in an orderly fashion comparing side-to-side by inspection, palpation, percussion, and auscultation Proceed in an orderly fashion comparing side-to-side by inspection, palpation, percussion, and auscultation Cardiovascular System: Cardiovascular System: Assessment includes: Assessment includes: Pulses Pulses BP BP JVD JVD lung sounds lung sounds Heart sounds and PMI Heart sounds and PMI edema (peripheral/pulmonary) edema (peripheral/pulmonary) ECG ECG © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Comprehensive Exam (continued) Abdomen: Abdomen: Normal abdomen is soft, non-tender, and without masses or bulges Normal abdomen is soft, non-tender, and without masses or bulges Inspect, auscultate and palpate in order Inspect, auscultate and palpate in order External Genitalia: External Genitalia: Exam is usually not necessary unless there is a specific injury or imminent childbirth Exam is usually not necessary unless there is a specific injury or imminent childbirth Same sex examiner is often preferred Same sex examiner is often preferred Protect patient modesty Protect patient modesty © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Comprehensive Exam (continued) Musculoskeletal Exam of the Upper and Lower Extremities: Musculoskeletal Exam of the Upper and Lower Extremities: Assess DCAP-BTLS and ROM Assess DCAP-BTLS and ROM In lower extremities assess reflexes and gait In lower extremities assess reflexes and gait Spine: Spine: Assess normal spinal curves (cervical, thoracic, and lumbar) Assess normal spinal curves (cervical, thoracic, and lumbar) Note any abnormal curvatures (lordosis, kyphosis, or scoliosis) Note any abnormal curvatures (lordosis, kyphosis, or scoliosis) Assess ROM and DCAP-BTLS Assess ROM and DCAP-BTLS © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Comprehensive Exam (continued) Peripheral Vascular System: Peripheral Vascular System: Exam includes: palpation of distal pulse points, inspection for symmetry, size, presence of swelling, venous patterns, color of skin, nail beds, and skin texture Exam includes: palpation of distal pulse points, inspection for symmetry, size, presence of swelling, venous patterns, color of skin, nail beds, and skin texture Note unusual venous enlargement, absent pulses, pigmentation, enlarged nodes, rashes, scars, ulcers, and edema Note unusual venous enlargement, absent pulses, pigmentation, enlarged nodes, rashes, scars, ulcers, and edema © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Nervous System: Nervous System: The components of the neuro exam may be completed concurrently with other assessments The components of the neuro exam may be completed concurrently with other assessments Organize the exam into 5 categories: Organize the exam into 5 categories: MS and speech MS and speech Cranial nerves Cranial nerves Motor system Motor system Sensory system Sensory system Reflexes Reflexes Comprehensive Exam (continued) © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

The Health Assessment Focus on the current state of health, past medical history environmental conditions, and patient’s personal habits. Focus on the current state of health, past medical history environmental conditions, and patient’s personal habits. The comprehensive patient history. is generally not obtained in the field due to lack of time. The comprehensive patient history. is generally not obtained in the field due to lack of time. Use SAMPLE to rapidly obtain relevant medical info. Use SAMPLE to rapidly obtain relevant medical info. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

The patient history includes: date, time, age, sex, birthplace, and occupation, info that is not identified using SAMPLE. The patient history includes: date, time, age, sex, birthplace, and occupation, info that is not identified using SAMPLE. Additional pertinent info includes: Additional pertinent info includes: Who was the source of referral? Who was the source of referral? Who was the source of the history and how reliable is it? Who was the source of the history and how reliable is it? The Health Assessment © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

The Health Assessment (continued) The history of present illness identifies the c/c. The acronym OPQRST is used to elaborate the c/c. The history of present illness identifies the c/c. The acronym OPQRST is used to elaborate the c/c. The past medical history is a description of pertinent medical info such as: The past medical history is a description of pertinent medical info such as: General state of health General state of health Childhood or adulthood illnesses Childhood or adulthood illnesses Psychiatric illnesses Psychiatric illnesses Accidents/injuries Accidents/injuries Major operations and hospitalizations Major operations and hospitalizations © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

The Health Assessment (continued) Environmental conditions and personal habits may offer insight into a patient’s state of health: Environmental conditions and personal habits may offer insight into a patient’s state of health: Med schedules, compliance, allergies Med schedules, compliance, allergies Tobacco and alcohol use Tobacco and alcohol use Drug use and related substances Drug use and related substances Diet, exercise and leisure activities Diet, exercise and leisure activities Screening tests and immunizations Screening tests and immunizations Sleep patterns Sleep patterns Home situation and social status Home situation and social status Significant others and family history Significant others and family history Environmental hazards and use of safety measures Environmental hazards and use of safety measures Daily living activities Daily living activities Important experiences and religious beliefs Important experiences and religious beliefs General outlook on life General outlook on life © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Conclusion The comprehensive exam and health assessment has not traditionally been a responsibility of the EMS provider. The comprehensive exam and health assessment has not traditionally been a responsibility of the EMS provider. It is conducted on a stable patient in a clinical setting. It is conducted on a stable patient in a clinical setting. Expanded scope of practice may include the comprehensive exam and health assessment. Expanded scope of practice may include the comprehensive exam and health assessment. This info should help the EMS provider to better understand each component and its application to evaluating the whole patient. This info should help the EMS provider to better understand each component and its application to evaluating the whole patient. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.