1. Patient Assessment
Chapter 7

2. Topic Overview Initial Assessment Forming a General Impression
Assessing
Mental Status
Airway
Breathing
Circulation
Determining Priority-

3. Topic Overview Focused History & Physical Exam Baseline Vitals
SAMPLE History
Documentation

4. Topic Overview Components of an ongoing assessment
Observing and recording findings
Ongoing assessment for stable and unstable patients

5. Form a General Impression
Environment
Age
Sex
Apparent threats to life

6. Patient Assessment Initial Assessment
Determine General Impression of Patient
How does the patient look, general appearance of patient
Patient's chief complaint or problem
Assess the environment

7. Patient Assessment Medical or trauma Gender, Age, Race
Nature of Illness / Mechanism of Injury
Gender, Age, Race
Are Life Threatening Conditions Present
If a life threatening condition is found, treat immediately.

8. Patient Assessment Assess the Airway Open and Maintain Airway
Medical Patients
Use head-tilt / chin-lift
Clear airway and insert oral or nasal airway as necessary

9. Patient Assessment Assess Breathing Yes or No
If breathing is adequate and the patient is responsive, oxygen may be indicated.
All responsive patients breathing >24 breaths per minute or <8 breaths per minute should receive high flow oxygen (defined as a 15 LPM nonrebreather mask).
If the patient is unresponsive and the breathing is adequate, open and maintain the airway and provide high concentration oxygen (15 LPM by nonrebreather mask).

10. Patient Assessment
If the breathing is inadequate, open and maintain the airway, assist the patient's breathing and utilize ventilatory adjuncts. In all cases oxygen should be used.
If the patient is not breathing, open and maintain the airway and ventilate using ventilatory adjuncts. In all cases oxygen should be used.

11. Patient Assessment Assess Circulation Pulse Unresponsive Responsive
Adult / Child - Carotid pulse
Infant - Brachial pulse
Responsive
Adult/Child - Radial, if you cannot palpate radial check carotid

12. Patient Assessment Bleeding Skin (Perfusion) Color Temperature
Condition

13. Patient Assessment Assess if major bleeding is present.
If bleeding is present, control bleeding.
Are Life Threatening Conditions Present
If a life threatening condition is found, treat immediately.

14. Assess Mental Status Alert Verbal stimulus Painful Stimulus
Unresponsive

15. Patient Assessment Assess Mental Status (Level Of Consciousness)
Maintain spinal immobilization if needed
Speak to the patient.
State your name, level of training first responder training and ask permission to help.

16. Patient Assessment Identify Priority Patients
High priority for transport (by EMS) if:
Poor general impression
Unresponsive patients - no gag or cough
Responsive, not following commands
Difficulty breathing
Shock (hypoperfusion)
Complicated childbirth
Chest pain with BP <100 systolic
Uncontrolled bleeding
Severe pain anywhere

17. Patient Assessment SAMPLE History S = Signs and Symptoms A = Allergies
O-P-Q-R-S-T
Onset
Provocation
Quality
Radiation
Severity
Time
A = Allergies
Medications, Foods, Environment

18. Patient Assessment M = Medications P = Pertinent past history
Prescriptions, OTCs, Vitamins, Herbs
P = Pertinent past history
HIST
L = Last oral intake
E = Events leading to illness or injury

19. Patient Assessment Respirations Pulse Skin Pupils Rate Character
Normal, rapid, slow
Character
Rhythm, depth, sound and ease of breathing
Pulse
Strength
Rhythm
Skin
Color (pale, cyanotic, flushed, jaundiced)
Temperature (hot, cool, cold)
Moisture
Pupils

20. Baseline Vitals - Respirations
Observations
Rapid, shallow breathing
Deep, gasping labored breaths
Slowed breathing
Snoring
Possible Problems
Shock, heart problems, heat emergency, diabetic emergency, heart failure, pneumonia
Airway obstruction, heart failure, heart attack, lung disease, chest injury
Head or chest injury, stroke, certain drugs
Stroke, skull fracture, drug or alcohol abuse, partial airway obstruction

21. Baseline Vitals - Respirations
Observations
Crowing
Gurgling
Wheezing
Coughing blood
Possible Problem
Airway obstruction, airway injury due to heat
Airway obstruction, lung disease, lung injury due to heat
Asthma, emphysema, airway obstruction, heart failure
Chest wound, chest infection, rib fracture, punctured lung, internal injuries

22. Baseline Vitals - Pulse
Observation
Rapid, strong pulse
Rapid, weak pulse
Slow, strong pulse
No pulse
Possible Problem
Internal bleeding (early stages), fear, heat emergency, overexertion, high blood pressure, fever
Shock, blood loss, heat emergency, diabetic emergency
Stroke, skull fracture, brain injury
Cardiac arrest

23. Baseline Vitals – Skin Color
Observation
Pink
Pale
Cyanotic
Red (Flushed)
Jaundiced
Blotchiness
Possible Problem / Cause
Normal in light skinned individuals, normal in inner eyelids, lips & nail beds of dark-skinned patients
Blood loss, shock, decreased BP, emotional distress
Lack of oxygen to cells due to inadequate breathing or heart function
Heat exposure, high BP, emotional excitement, cherry red – CO poisoning
Liver abnormalities
Occasionally in patients in shock

24. Baseline Vitals – Skin Signs
Observation
Cool, clammy
Cold, moist
Cold, dry
Hot, dry
Hot, moist
Goose bumps with accompanied shivering, chattering teeth, blue lips & pale skin
Possible Problems
Shock, heart attack, anxiety
Heat loss
Exposure to cold
High fever, heat emergency, spinal injury
High fever, heat emergency
Shills, communicable disease, exposure to cold, pain or fear

25. Baseline Vitals – Pupils
Observations
Dilated, nonreactive
Constricted, nonreactive
Unequal
Possible Problems
Unresponsiveness, shock, cardiac arrest, bleeding, certain medications, head injury
Central nervous system damage, certain medications
Stroke, head injury

26. Patient Assessment Blood Pressure Pulse Oximetry Precautions NOTE:
Measures oxygen circulating in the blood
95-99% considered normal
Precautions
Not accurate in shock or hypothermia
False readings in Carbon Monoxide poisoning
Movement and nail polish can cause inaccurate readings
NOTE:
Do Not withhold oxygen from a patient who may need it because the oximeter reads “normal”

27. Patient Assessment Re-consider Mechanism of Injury
Significant mechanism of injury
Ejection from vehicle
Death in same passenger compartment
Roll-over of vehicle
High-speed vehicle collision
Deformities to vehicle’s interior may reveal mechanism

28. Patient Assessment Falls > 15 feet or 3 times patient’s height
Vehicle-pedestrian collision
Motorcycle crash
Unresponsive or altered mental status
Penetrations of the head, chest, or abdomen

29. Patient Assessment Hidden injuries Seat belts
If buckled, may have produced injuries.
If patient had seat belt on, it does not mean they do not have injuries.
Airbags
May not be effective without seat belt.
Patient can hit wheel after deflation.
Lift the deployed airbag and look at the steering wheel for deformation.

30. Patient Assessment Infant and child considerations Falls >10 feet
"Lift and look" under the bag after the patient has been removed.
Any visible deformation of the steering wheel should be regarded as an indicator of potentially serious internal injury, and appropriate action should be taken.
Infant and child considerations
Falls >10 feet
Bicycle collision
Vehicle in medium speed collision

31. Patient Assessment If Significant Mechanism of Injury
Reconsider mechanisms of injury
Continue spine stabilization
Consider requesting Adv. Life Support
Reconsider transport decision (activation of EMS)
Assess mental status
Do detailed physical exam
Assess baseline vitals
Obtain SAMPLE history

32. Patient Assessment Perform a detailed head to toe exam
To obtain additional information.
As you perform the exam, inspect and palpate, look for and/or feel for the following examples of injuries or signs or injuries
DOTS
Deformity
Open Injuries
Tenderness
Swelling

33. Patient Assessment D = Deformities O = Open Injuries T = Tenderness
S = Swelling

34. Patient Assessment DCAP BTLS Deformities Contusions Abrasions
Punctures/Penetrations

35. Patient Assessment
Burns
Tenderness
Lacerations
Swelling

36. Patient Assessment
Assess the head, inspect and palpate for injuries or signs of injury.
DOTS / DCAP BTLS +
Check the eyes
Check DOTS (DCAP BTLS) +
Discoloration
Unequal pupils
Foreign Bodies
Blood in anterior chamber

37. Patient Assessment Check both ears Check the nose Check the mouth
Look for signs of bleeding from the ears.
Can perform halo test
Bleeding from the ears without tympanic rupture indicates possible head injury
Look for “Battle’s sign” and/or “Raccoon eyes”
Check the nose
Deviation
Bleeding
Check the mouth
Swollen or lacerated tongue
Teeth

38. Patient Assessment
Assess the neck, inspect and palpate for injuries or signs of injury.
DOTS / DCAP BTLS
Jugular vein distension (JVD)
Tracheal deviation
Apply cervical spinal immobilization collar (CSIC).
Assess the chest, inspect and palpate for injuries or signs of injury.

39. Patient Assessment Paradoxical motion Unequal movement of chest wall
Crepitus
Breath sounds in the apices, mid-clavicular line, bilaterally and at the bases, mid-axillary line, bilaterally
Present
Absent
Equal

40. Patient Assessment
Assess the abdomen, inspect and palpate for injuries or signs of injury.
DOTS / DCAP BTLS
Palpate all four quadrants
Check for tenderness, rebound tenderness, rigidity, distention
Assess the pelvis, inspect and palpate for injuries or signs of injury.
Pelvic rock / pelvic squeeze (if appropriate)

41. Patient Assessment
Assess all four extremities, inspect and palpate for injuries or signs of injury.
DOTS / DCAP BTLS
Assess bilaterally
Circulation (distal pulse and/or capillary refill)
Sensation
Motor function
Assess Back (if and when possible)
Roll patient with spinal precautions and assess posterior body
Inspect and palpate using DOTS or DCAP BTLS
Examining for injuries or signs of injury.

42. Patient Assessment
Problems not requiring a full head-to-toe exam include:
Isolated injuries or no significant mechanism of injury
Responsive medical patients
Illness-related problems, such as difficulty breathing or chest pain may not require a full head-to-toe exam
Note: Do Toe-to-Head exam on children

43. Patient Assessment Medical Patient Trauma Patient Unresponsive
Significant Mechanism
Perform a rapid trauma assessment
Vital signs
Gather SAMPLE history
No Significant Mechanism
Perform a focused trauma assessment
SAMPLE history
Medical Patient
Unresponsive
Perform a rapid physical
Vital signs
SAMPLE history
Responsive
Focused physical

45. Patient Assessment Ongoing Assessment While waiting for EMS to arrive
Repeat initial assessment
Reassess and record vital signs
Repeat physical assessment
As dictated based on injury or illness
Check on treatment in progress

46. Patient Assessment Stable patient Repeat every 15 minutes
Trauma Patient
Isolated injury or no significant mechanism of injury
Medical Patient
Responsive patient

47. Patient Assessment Unstable Patient Reassess every 5 minutes
Trauma Patient
Serious injury or serious mechanism of injury
Medical Patient
Unresponsive
Deteriorating condition

48. Patient Assessment Observing Trends Trends change over time
Changes noted over time are significant (e.g. changes in BP or pulse)
Repeated assessments are required to observe trends

49. Patient Assessment Check interventions Adequacy of oxygen delivery
Adequacy of artificial ventilation
External bleeding
Other
Splinted extremities

50. Patient Assessment Once EMS arrives
Provide a report of findings to EMS
Recap patient information
Mechanism or Illness
Positive findings & pertinent negative findings
Baseline Vitals & changes
Results of SAMPLE history
Care provided

51. Patient Assessment Review Initial assessment
Provide care for immediate life threatening problems
Detailed assessment
Head-to-Toe Exam
Vital Signs
SAMPLE History
Care for problems found during detailed assessment
On-going assessment
Report of findings