1. 8: Patient Assessment

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 (1 of 2)

3. 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.

4. 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 (1 of 7)

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. 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 (1 of 3)

12. 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 (2 of 3)

13. 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: Trauma Objectives (3 of 3)

14. 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 (1 of 3)

15. 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 (2 of 3)

16. 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. Focused History and Physical Exam: Medical Patients Objectives (3 of 3)

17. 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 (1 of 2)

18. 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. Detailed Physical Exam Objectives (2 of 2)

19. 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 (1 of 2)

20. 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.

21. Patient Assessment Scene size-up Initial assessment Focused history and physical exam –Vital signs –History Detailed physical exam Ongoing assessment

22. Patient Assessment Process

23. Scene Size-up Dispatch information Inspection of scene Scene hazards Safety concerns Mechanism of injury Nature of illness/chief complaint Number of patients Additional resources needed

24. 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

25. Scene Safety: Potential Hazards 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

26. 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.

27. 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

28. 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.

29. 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.

30. 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.

31. Additional Resources Medical resources –Additional units –Advanced life support Nonmedical resources –Fire suppression –Rescue –Law enforcement

32. C-Spine Immobilization Consider early during assessment. Do not move without immobilization. Err on the side of caution.

33. Patient Assessment Process

34. Initial Assessment Develop a general impression. Assess mental status. Assess airway. Assess the adequacy of breathing. Assess circulation. Identify patient priority.

35. 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

36. Obtaining Consent Introduce self. Ask patient’s name. Obtain consent.

37. Chief Complaint Most serious problem voiced by the patient May not be the most significant problem present

38. Assessing Mental Status Responsiveness –How the patient responds to external stimuli Orientation –Mental status and thinking ability

39. Testing Responsiveness AAlert VResponsive to Verbal stimulus PResponsive to Pain UUnresponsive

40. Testing Orientation Person Place Time Event

41. Caring for Abnormal Mental Status Complete initial assessment. Provide high-flow oxygen. Consider spinal immobilization. Initiate transport. Support ABCs. Reassess.

42. 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

43. 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

44. Assessing Breathing Choking Rate Depth Cyanosis Lung sounds Air movement

45. Assessing Breath Sounds

46. High-Flow Oxygen Administration Breathing faster than 20 breaths/min Breathing slower than 12 breaths/min Breathing too shallow Decreased level of consciousness Respiratory distress Poor skin color

47. Positioning the Patient Position of comfort –Sitting up with feet dangling –High Fowler’s position Spinal precautions if possible spinal injury

48. Assessing the Pulse Presence Rate Rhythm Strength

49. AgeRange (beats/min) Infant: 1 month to 1 year100 to 160 Toddler: 1 to 3 years90 to 150 Preschool-age: 3 to 6 years80 to 140 School-age: 6 to 12 years70 to 120 Adolescent: 12 to 18 years60 to 100 Normal Pulse Rates in Infants and Children

50. 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

51. Assessing Perfusion Color Temperature Skin condition Capillary refill

52. 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

53. Transport Decision Patient condition Availability of advanced care Distance to transport Local protocols

54. Patient Assessment Process

55. Goals of the Focused History and Physical Exam Understand the circumstances surrounding the chief complaint. Obtain objective measurements. Perform physical exam.

56. Components of Focused History and Physical Exam Medical history Baseline vital signs Physical exam

57. Rapid Physical Exam 60-90 second head-to- toe exam Performed on: –Significant trauma patients –Unresponsive medical patients Identifies undiscovered conditions

58. DCAP-BTLS D Deformities C Contusions A Abrasions P Punctures/ Penetrations B Burns T Tenderness L Lacerations S Swelling

59. 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.

60. Components of a Rapid Physical Exam (2 of 3) Assess the chest. Assess the abdomen. Assess the pelvis.

61. Components of a Rapid Physical Exam (3 of 3) Assess all four extremities. Roll the patient with spinal precautions.

62. Focused Physical Exam Used to evaluate patient’s chief complaint Performed on: –Trauma patients without significant MOI –Responsive medical patients

63. Head, Neck, and Cervical Spine Feel head and neck for deformity, tenderness, or crepitation. Check for bleeding. Ask about pain or tenderness.

64. Chest Watch chest rise and fall with breathing. Feel for grating bones as patient breathes. Listen to breath sounds.

65. Abdomen Look for obvious injury, bruises, or bleeding. Evaluate for tenderness and any bleeding. Do not palpate too hard.

66. Pelvis Look for any signs of obvious injury, bleeding, or deformity. Press gently inward and downward on pelvic bones.

67. Extremities Look for obvious injuries. Feel for deformities. Assess –Pulse –Motor function –Sensory function

68. Posterior Body Feel for tenderness, deformity, and open wounds. Carefully palpate from neck to pelvis. Look for obvious injuries.

69. Specific Chief Complaints Chest pain Shortness of breath Abdominal pain Pain associated with bones or joints Dizziness

70. 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

71. Assessment Steps for Significant MOI Rapid trauma assessment Baseline vital signs SAMPLE history Reevaluate transport decision

72. Assessment Steps for Trauma Patients Without Significant MOI Focused assessment Baseline vital signs SAMPLE history Reevaluate transport decision

73. Responsive Medical Patients History of illness SAMPLE history Focused assessment Vital signs Reevaluate transport decision

74. Unresponsive Medical Patients Rapid medical assessment Baseline vital signs SAMPLE history Reevaluate transport decision

75. Patient Assessment Process

76. 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

77. Performing the Detailed Physical Exam (1 of 10) Visualize and palpate using DCAP-BTLS. Look at the face. Inspect the area around the eyes and eyelids. Examine the eyes.

78. 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.

79. Performing the Detailed Physical Exam (3 of 10) Look for bruising and lacerations about the head. Palpate the zygomas.

80. Performing the Detailed Physical Exam (4 of 10) Palpate the maxillae. Palpate the mandible.

81. Performing the Detailed Physical Exam (5 of 10) Assess the mouth and nose for obstructions and cyanosis. Check for unusual odors.

82. 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.

83. Performing the Detailed Physical Exam (7 of 10) Look at the chest. Gently palpate over the ribs.

84. Performing the Detailed Physical Exam (8 of 10) Listen for breath sounds. Listen also at the bases and apices of the lungs.

85. Performing the Detailed Physical Exam (9 of 10) Look at the abdomen and pelvis. Gently palpate the abdomen. Gently compress the pelvis.

86. Performing the Detailed Physical Exam (10 of 10) Gently press the iliac crests. Inspect all four extremities. Assess the back for tenderness or deformities.

87. Patient Assessment Process

88. 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?

89. Steps of the Ongoing Assessment Repeat the initial assessment. Reassess and record vital signs. Repeat focused assessment. Check interventions.

90. Review 1.Assessment of an unconscious patient's breathing begins by: A. inserting an oral airway. B. manually positioning the head. C. assessing respiratory rate and depth. D. clearing the mouth with suction as needed.

91. Review Answer: B Rationale: You cannot assess or treat an unconscious patient’s breathing until the airway is patent—that is, open and free of obstructions. Manually open the patient’s airway (eg, head tilt-chin lift, jaw- thrust), use suction as needed to clear the airway of blood or other liquids, insert an airway adjunct to assist in maintaining airway patency, and then assess the patient’s respiratory effort.

92. Review 1.Assessment of an unconscious patient's breathing begins by: A.inserting an oral airway. Rationale: You insert an airway adjunct to assist in maintaining airway patency after the head-tilt-chin-lift. B. manually positioning the head. Rationale: Correct answer C. assessing respiratory rate and depth. Rationale: After the airway is opened and suctioned, then determine the patient’s respiratory effort by assessing the respiratory rate and depth. D. clearing the mouth with suction as needed. Rationale: This is done after attempting to open the airway with proper positioning.

93. Review 2. You arrive at the scene of an “injured person.” As you exit the ambulance, you see a man lying on the front porch of his house. He appears to have been shot in the head and is lying in a pool of blood. You should: A. immediately assess the patient. B. proceed to the patient with caution. C. quickly assess the scene for a gun. D. Retreat to a safe place and wait for law enforcement to arrive.

94. Review Answer: D Rationale: Your primary responsibility as an EMT-B is to protect yourself. Prior to entering any scene, you must assess for potential dangers. In cases where violence has occurred, you must retreat to a safe place and wait for law enforcement personnel to arrive.

95. Review 2. You arrive at the scene of an “injured person.” As you exit the ambulance, you see a man lying on the front porch of his house. He appears to have been shot in the head and is lying in a pool of blood. You should: A.immediately assess the patient. Rationale: You must wait until the scene is safe. B. proceed to the patient with caution. Rationale: You must wait until the scene is safe. C. quickly assess the scene for a gun. Rationale: This is the responsibility of law enforcement. D. Retreat to a safe place and wait for law enforcement to arrive. Rationale: Correct answer

96. Review 3. During the scene size-up, you should routinely determine all of the following, EXCEPT: A. the mechanism of injury or nature of illness. B. the ratio of pediatric patients to adult patients. C. whether or not additional resources are needed. D. if there are any hazards that will jeopardize safety.

97. Review Answer: B Rationale: Components of the scene size-up—after taking BSI precautions—include determining if the scene is safe for entry, determining the mechanism of injury or nature of illness, determining the number of patients, and determining if additional resources are needed at the scene.

98. Review 3. During the scene size-up, you should routinely determine all of the following, EXCEPT: A.the mechanism of injury or nature of illness. Rationale: This is part of the scene size-up. B. the ratio of pediatric patients to adult patients. Rationale: Correct answer C. whether or not additional resources are needed. Rationale: This is part of the scene size-up. D. if there are any hazards that will jeopardize safety. Rationale: This is part of the scene size-up.

99. Review 4. Findings such as inadequate breathing or an altered level of consciousness should be identified in the: A. initial assessment. B. focused physical exam. C. ongoing assessment. D. detailed physical exam.

100. Review Answer: A Rationale: The purpose of the initial assessment is to identify and manage any life threats to the patient, such as inadequate breathing, an altered level of consciousness, or severe hemorrhage.

101. Review 4. Findings such as inadequate breathing or an altered level of consciousness should be identified in the: A.initial assessment. Rationale: Correct answer B. focused physical exam. Rationale: The focused physical exam will help EMS to identify specific problems, based upon the patient’s chief complaint. C. ongoing assessment. Rationale: This is performed during transport and will provide information on other clues on how the current care plan is working. D. detailed physical exam. Rationale: This will provide EMS with more information about the nature of the patient’s problem.

102. Review 5. A semiconscious patient pushes your hand away when you pinch his earlobe. You should describe his level of consciousness as: A. alert. B. unresponsive. C. responsive to painful stimuli. D. responsive to verbal stimuli.

103. Review Answer: C Rationale: Semiconscious patients are not alert, nor or they unresponsive. The fact that the patient pushes your hand away when you pinch his earlobe indicates that he is responsive to painful stimuli. If he opens his eyes or responds when you speak to him, he would be described as being responsive to verbal stimuli.

104. Review 5. A semiconscious patient pushes your hand away when you pinch his earlobe. You should describe his level of consciousness as: A.alert. Rationale: This is when the patient’s eyes open spontaneously as you approach. B. unresponsive. Rationale: This is when the patient does not respond to any stimulus. C. responsive to painful stimuli. Rationale: Correct answer D. responsive to verbal stimuli. Rationale: This is when the patient’s eyes open with verbal stimuli and tries to respond.

105. Review 6. Which of the following is considered a significant mechanism of injury for a child? A. Bicycle collision B. Fall from higher than 5' C. Slow-speed vehicle collision D. Abrasion injury of the abdomen

106. Review Answer: A Rationale: Significant mechanisms of injury for a child include falls from greater than 10’, bicycle collisions, and medium-speed vehicle collisions, among others.

107. Review 6. Which of the following is considered a significant mechanism of injury for a child? A.Bicycle collision Rationale: Correct answer B. Fall from higher than 5‘ Rationale: A significant mechanism of injury is a fall greater than 10 feet or 2 to 3 times the child’s height. C. Slow-speed vehicle collision Rationale: A significant mechanism of injury occurs with speeds greater than 20 miles per hour. D. Abrasion injury of the abdomen Rationale: An abrasion is the result of an injury.

108. Review 7. An unresponsive patient with a possible spinal injury and inadequate breathing should be placed: A. on a backboard and given assisted ventilations. B. in a PASG and given oxygen via nonrebreathing mask. C. in a semisitting position and given assisted ventilations. D. in the recovery position and given oxygen via nonrebreathing mask.

109. Review Answer: A Rationale: Use spinal motion restriction precautions (eg, backboard, cervical collar, lateral immobilization of the head) on any patient with a possible spinal injury. If the patient is breathing inadequately (eg, shallow [reduced tidal volume] breathing, fast or slow rate), assist ventilations with a bag-mask device and 100% oxygen.

110. Review 7. An unresponsive patient with a possible spinal injury and inadequate breathing should be placed: A.on a backboard and given assisted ventilations. Rationale: Correct answer B. in a PASG and given oxygen via nonrebreathing mask. Rationale: Inadequate breathing is always managed with assisted ventilations via a bag-mask device. C. in a semisitting position and given assisted ventilations. Rationale: Spinal injuries are secured to a long backboard. D. in the recovery position and given oxygen via nonrebreathing mask. Rationale: Spinal injuries are not placed on the side but supine on a long backboard and breathing is assisted in this scenario.

111. Review 8. Which of the following would you NOT detect during your general assessment of a patient? A. Cyanosis B. Gurgling respirations C. Severe bleeding D. Rapid heart rate

112. Review Answer: D Rationale: The general impression is what you first notice as you approach the patient, but before physical contact with the patient is made. It is what you see, hear, or smell. A rapid heart rate (tachycardia) would not be detected until you actually perform the initial assessment; you cannot see, hear, or smell tachycardia.

113. Review 8. Which of the following would you NOT detect during your general assessment of a patient? A.Cyanosis Rationale: You can see cyanosis during the general assessment. B. Gurgling respirations Rationale: You can hear gurgling during the general assessment. C. Severe bleeding Rationale: You can see bleeding during your general assessment. D. Rapid heart rate Rationale: Correct answer

114. Review 9. You should call for additional help before you begin to care for patients at a multiple-casualty incident because: A. a hazardous material may exist. B. the incident may be the result of terrorism. C. the patients will die if more help does not arrive quickly. D. you might get preoccupied with patient care and forget to call.

115. Review Answer: D Rationale: If the call for additional resources is delayed, it is very easy to become involved with patient care. The tendency then is to complete the assessment and treatment before turning to other matters, such as re-evaluating the situation and calling for help. This just delays the needed resources that much longer.

116. Review 9. You should call for additional help before you begin to care for patients at a multiple-casualty incident because: A.a hazardous material may exist. Rationale: This is also part of the scene size-up and scene safety. B. the incident may be the result of terrorism. Rationale: This is part of scene size-up and calling for help before providing medical treatment. C. the patients will die if more help does not arrive quickly. Rationale: Patients may die during a multiple-casualty incident, but help must be called in before treatment begins. D. you might get preoccupied with patient care and forget to call. Rationale: Correct answer

117. Review 10. Your initial assessment of an elderly woman who fell reveals an altered level of consciousness and a large hematoma to her forehead. After protecting her spine and administering oxygen, you should: A. obtain baseline vital signs. B. perform a rapid trauma assessment. C. transport the patient immediately. D. perform a focused exam of her head.

118. Review Answer: B Rationale: If any life-threatening problems are discovered in the initial assessment, they should be addressed immediately. The EMT-B should then perform a rapid trauma assessment (or rapid medical assessment in unresponsive medical patients) to look for other potentially life-threatening injuries or conditions.

119. Review 10. Your initial assessment of an elderly woman who fell reveals an altered level of consciousness and a large hematoma to her forehead. After protecting her spine and administering oxygen, you should: A.obtain baseline vital signs. Rationale: This is part of the initial assessment. B. perform a rapid trauma assessment. Rationale: Correct answer C. transport the patient immediately. Rationale: This is determined after the completion of a rapid trauma assessment. D. perform a focused exam of her head. Rationale: This is completed not only on the head but on the entire body.