Patient Assessment Notes

Initial Assessment Notes: Assess Mental Status:

 Alert – the patient’s eyes open spontaneously as you approach, and the patient appears aware of you and responsive to the environment. The patient appears to follow commands, and the eyes visually track people and objects.

 Responsive to verbal stimulus – the patient’s eyes do not open spontaneously. However, the patient’s eyes do open to verbal stimuli, and the patient is able to respond in some meaningful way when spoken to.

 Responsive to pain – the patient does not respond to your questions but moves or cries out in response to painful stimulus. There are appropriate and inappropriate methods of applying painful stimulus based a great deal on personal preference. Be aware that some methods may not give an accurate result if a spinal cord injury is present.

 Unresponsive – the patient does not respond spontaneously or to verbal or painful stimulus. These patients usually have no cough or gag reflex and lack the ability to protect their airway. If you are in doubt about whether a patient is truly unresponsive, assume the worst and treat appropriately.

The most common test evaluates a patient’s ability to remember four things:

 Person – the patient is able to identify his or her name  Place – the patient is able to identify his or her current location  Time – the patient is able to tell you the current year, month, and approximate date  Event – the patient is able to describe what happened (MOI or NOI) Mental status may be difficult to evaluate in children. First determine whether the child is alert. Even infants should be alert to your presence and should follow you with their eyes. Ask the parent whether the child is behaving normally, particularly in regards to alertness. Most children older than 2 years should know their name and the names of their parents and siblings. Evaluate mental status in school – age children by asking about holidays, recent school activities, or teacher’s name.

Assess The Airway: Responsive patients  Patients of any age who are talking and crying have an open airway  Watching and listening to how patients speak, particularly those with respiratory problems, may provide important clues about the adequacy of their airway and the status of their breathing.  Stridor suggest a partially occluded airway caused by swelling  High pitched crowing sounds may indicate a partial airway obstruction form a foreign body  A conscious patient who cannot speak or cry most likely has a complete airway obstruction  If you identify an airway problem, stop the assessment process and obtain a patent airway, this may be as simple as positioning the patient so the air moves in and out easier or a complex as abdominal thrust to remove a foreign body from the airway.  If you patient has signs of respiratory difficulty or is not breathing you should immediately take corrective actions using appropriate airway management techniques

Unresponsive patient:  With an unresponsive patient or a patient with a decreased level of consciousness, you should immediately assess the patency of the airway.  If it is clear then you can continue your assessment, if the airway is not clear, your next priority is to open it using the head tilt chin lift or jaw thrust maneuver.  Airway obstruction in an unconscious patient is most commonly due to relaxation of the tongue muscles, allowing the tongue to fall to the back of the throat  Dentures, blood clots, vomitus, mucus, food, or other foreign objects may also create an obstruction.  Signs of airway obstruction in an unconscious patient include the following: o

Obvious trauma, blood, or other obstruction

o

Noisy breathing, such as snoring, bubbling, gurgling, crowing, or other abnormal sounds (normal breathing is quiet)

o

Extremely shallow or absent breathing (airway obstructions may impair breathing)

 The body will not have the necessary oxygen needed to survive if the airway is not managed quickly and efficiently. Remember that airway positioning depends on the age and size of you patient. Spinal considerations:  Managing a patient’s airway can be complicated by the presence of a spinal injury.  Trauma patients, those who are conscious or unconscious, should be stabilized to protect their spine.  Conscious or unconscious medical patients, however may have fallen and have a potential for a spinal injury.  It is important for you to consider spinal precautions during scene size up and evaluate the MOI and NOI further when determining the chief complaint  Thousands of deaths per year occur from airway obstruction following acute alcohol intoxication or drug overdose. Generally, these patients vomit while lying on their backs and cannot protect their airway because of a severely decreased level of consciousness. Never leave anyone who has passed out unattended. If the person cannot be continually monitored, place the patient prone or on their side, not supine Assess breathing:  Look, listen, and feel for the presence of breathing and then assess the adequacy of breathing  A normal respiratory rate varies widely in adults, ranging from 12 to 20 breaths/min  Children breathe at even faster rates  Remember the goal of your initial assessment is to identify and treat airway, breathing, and circulation problems as quickly as possible.  Normal respirations are not usually shallow or excessively deep  Shallow respirations can be identified by little movement of the chest wall  Deep respirations cause a great deal of chest rise and fall

 Retractions or the use of accessory muscles of respiration is also a sign of inadequate breathing  Nasal flaring and see saw breathing in pediatric patients indicate inadequate breathing  As you assess the patient’s breathing you should ask yourself the following questions: o

Does the patient appear to be choking

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Is the respiratory rate too fast or too slow

o

Are the patient’s respirations shallow or deep

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Is the patient cyanotic

o

Do you hear abnormal sounds when listening to the lungs

o

Is the patient moving air into and out of the lungs on both sides

 Any patient with a decrease level of consciousness, respiratory distress, or poor skin color should also receive high flow oxygen  If there is no risk of spinal injury, the patient should remain in a comfortable position that supports breathing; this is usually sitting up with the legs dangling or even a high fowler’s position  Oxygen should be delivered to patients using a non re breathing mask at 15 L/min  Do not with hold oxygen from any patient at the scene! Assess The Circulation:  Assessing the circulation helps you to evaluate how well blood is circulating to the major organs including the brain, lungs, heart, kidneys, and the rest of the body.  A variety of problems can impair circulation, including blood loss, shock and conditions that affect the heart and major blood vessels.  Circulation is evaluated by assessing the rate and quality of the pulse, identifying external bleeding and evaluation the skin. Assess the Pulse:  Our first goal in assessing circulation is to determine if the patient’s pulse is present and adequate.  Assess the pulse by feeling the radial artery at the distal end of the forearm.  If a pulse cannot be felt at eth radial artery, check the carotid artery in the neck.

 If you cannot palpate a pulse in an unresponsive patient, begin CPR  If the patient has a pulse but is not breathing, provide ventilations at a rate of at least 12 breaths/min for adults and at least 20 breaths/min for an infant or child.  You can feel the pulse of a child at the carotid artery, as in an adult. However, palpating the pulse in an infant may present a problem. Because an infant’s neck is often very short and fat, and its pulse is often quiet fast, you may have a hard time finding the carotid pulse. Therefore, in infants younger than 1 year, you should palpate the brachial artery to assess the pulse. normal pulse rates for children are: o

Infant: 1 month to 1 year 100 to 160

o

Toddler: 1 to 3 years 90 to 150

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Preschool age: 3 to 6 years 80 to 140

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School age: 6 to 12 years 70 to 120

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Adolescent: 12 to 18 years 60 to 100

 Determining that a pulse is present, next determining its adequacy  Assessing the rate, rhythm, and strength of the pulse  Adult normal resting rate should be between 60 and 80, but could be as much as 100 beats per minute in geriatric patients  Pediatrics generally the younger the patient, the faster the pulse rate.  The actual number of pulsations per minute is not as important as obtaining a sense of whether the rate is too slow, in the normal range, or too fast.  With practice you can develop a sense for pulse rate without actually counting the pulsations. This will help you speed up your initial assessment and allow you to focus on finding potentially life threatening problems  A pulse too slow or too fast may change decisions related to transporting your patient  If it is difficult to feel or irregular, the patient may have problems with his circulatory system. Assess and Control External Bleeding:  Identify any major external bleeding

 In some instances blood loss can be very rapid and can quickly result in shock or even death  Therefore, this step demands your immediate attention as soon as the patient’s airway is patent and breathing has been stabilized.



Control external bleeding is often very simple

 The direct pressure stops the bleeding and helps the blood to coagulate or clot naturally  When direct pressure and elevation are not successful, you may apply pressure directly over arterial pressure points Assess Perfusion:  Assessing the skin is one of the most important and most readily accessible ways of evaluating circulation  A lack of perfusion or hypo perfusion will result in hypoxia of the brain, lungs, heart and kidneys.  Perfusion is assessed by evaluating a patient’s skin color, temperature, and moisture.

Color:  Skin color depends on pigmentation, blood oxygen levels, and the amount of blood circulating through the vessels of the skin  Skin color is a valuable assessment tool  Normal skin color of pigmented people is pinkish  Deeply pigmented skin may hid skin color changes that result from injury or illness  You should look for changes in color areas of the skin that have less pigment: o

Finger nail beds

o

Sclera (white of the eyes)

o

Conjunctiva ( lining of the eye lid)

 Normal skin color, particularly of the conjunctiva and mucous membrane, is pinkish  Skin colors should alert you to possible medical problems including

o

Cyanosis (blue)

o

Flushed (red)

o

Pale (white)

o

Jaundice (yellow)

 Cyanosis and pale skin colors indicate a lack of perfusion Temperature:  The skin has many functions, it helps maintain the water content of the body, acts as insulation and protection from infection, and also plays a role in regulating body temperature by changing the amount of blood circulation through the surface of skin  Poor perfusion, the body pulls blood away from the surface of the skin and diverts it to the core of the body  A good indication in your initial assessment of hypo perfusion and inadequacy of circulatory system function (shock) Condition:  Assessing the skin condition of the skin is really assessing the presence of moisture on the skin  Normal skin is warm and dry  Skin that is cool or cold, moist, or clammy suggests shock (hypo perfusion)  These characteristics are important findings in your initial assessment because hypo perfusion can lead to serious consequences if treatment is delayed or ignored Capillary Refill:  Another way to assess perfusion is to check capillary refill  This method is most accurate in children younger than 6 years old  Although capillary refill is a quick and delivery general way to evaluate perfusion, it is important to remember that other conditions, not related to the body’s circulation, may also slow capillary refill.  Conditions include, but are not limited to the patient’s age as well as exposure to a cold environment: o

Hypothermia

o

Frozen tissue (frostbite)

o

Vasoconstriction

 Injuries to bones and muscles of the extremities may cause local circulatory comprise resulting in hypo perfusion of an extremity rather than hypo perfusion of the body in general Identify Priority Patients and Make Transport Decisions:  As complete your assessment you have to make a decision about patient care  Patients with any of the following conditions are examples of high priority patients and should be transported immediately: o

Difficulty breathing

o

Poor general impression

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Unresponsive with no gag or cough reflexes

o

Severe chest pain, especially when the systolic blood pressure is less than 100 mm Hg

o

Pale skin, or other signs of poor perfusion

o

Complicated childbirth

o

Uncontrolled bleeding

o

Responsive but unable to follow commands

o

Severe pain in any area of the body inability to move any part of the body

 60-90 seconds to identify injuries that must be protected during packaging and loading for transport  Protecting the patient’s spine and identifying fractured extremities are an integral part of packaging for transport

 Recognizing the need to transport serious trauma patients is of such IMPORTANCE that you may hear colleagues refer to the GOLDEN HOUR  After the first 60 minutes the body has increasing difficulty in compensating for shock and traumatic injuries

 Assess, stabilize, package, and begin transport to the appropriate facility within 10 minutes after arrival on scene whenever possible ( a difficult or complex extrication may obviously limit possibilities)  Some patients may benefit from remaining on scene and receiving continuing care.  ALS should be called for if not already en route to the scene, and depending on the travel distance, can be met while transporting the critical patient  Facts: o

Discovery of incident and activation of EMS 20 minutes

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The Platinum Ten Minutes, initial assessment and intervention

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EMS intervention

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EMS packaging and transport 10 minutes

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Initial hospital stabilization 20 minutes

Patient Assessment: Focused History and Physical Exam:  Focused history and physical exam will help you to identify specific problems  It is based on the patient’s chief complaint (what happened to this patient) and has the following goals: o

Understand the specific circumstances surrounding the chief complaint. What key factors were associated with the event? Does the mechanism of injury put the patient at high risk for serious injuries?

o

Obtain objective measurements of the patient’s condition. Do these measurements validate the seriousness of this patient’s condition? How well is the patient dealing with his or her injury or illness?

o

Direct further physical examination. What physical clues help us to identify problems?

 Focused history and physical exam has three components to meet these goals: o

An evaluation of the patient’s medical history, obtaining baseline vital signs, performing a physical exam based on the patient’s complaint, or in the case of critical patient, the MOI or NOI.

o

SAMPLE history (general medical history using the mnemonic)

o

OPQRST

o

If the patient is stable, you should reassess vital signs every 15 minutes until you reach the emergency department

o

If the patient is unstable you should reassess at a minimum of every 5 minutes, look at your patient’s trends in for a change or treat for shock

Rapid Physical Exam:  Is a quick head to toe exam use DCAP BTLS  This exam is performed in as quickly as 60 to 90 seconds  Assessment should follow: o

Assess the head

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Assess the neck

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Assess the chest

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Assess the abdomen

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Assess the pelvis

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Assess all four extremities

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Assess the back and buttocks

Focused Physical Exam:  This exam generally focuses on the location or body system related to the chief complaint  The goal of a focuses assessment is to focus your attention on the immediate problem.  It is usually performed on a trauma patient without a significant mechanism of injury or a responsive medical patient. o

head, neck, and cervical spine

o

chest and breath sounds

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abdomen

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pelvis

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extremities: pulse, motor function, sensory function

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posterior body

 suggestions for assessing some common chief complaints, remember that you will also be assessing history and vital signs with each of these: o

Chest pain- looks for trauma to the chest and listens for breath sounds.

o

Shortness of Breath – look for signs of airway obstruction, as well as trauma to the neck or chest.

o

Abdominal pain – look for trauma to the abdomen distention. Palpate the abdomen for tenderness, rigidity, and patient guarding.

o

Dizziness – evaluate level of consciousness and orientation to determine to patient’s ability to think.

Physical Exam Techniques:  Inspection , palpation, and auscultation  DCAP BTLS will help remind you what to look for when inspecting and palpating various body regions. Head, Neck and Cervical Spine:  Crepitus is the grating or grinding that is often felt or heard when two ends of a broken bone rub together  Ask a responsive patient is he or she feels any pain or tenderness  Subcutaneous emphysema bleeding as well as a cracking sound produced by air bubbles under the skin.  It is particularly important to assess the neck before covering it with a cervical collar  Also, in patients where spinal injury is not suspected, inspect for pronounced or distended jugular veins with the patient sitting at a 45 degree angle.  Patients who are sitting up suggest a problem with blood returning to the heart.

 Report and record your finding carefully Chest and Breath Sounds:  Inspect, visualize, and palpate over the chest area for injury or signs of trauma, including bruising, tenderness, or swelling.  Watch both sides of the chest to rise and fall together with normal breathing  Retractions – when the skin pulls in around the ribs during inspiration  Paradoxical motion – when only one section of the chest rises on inspiration while another area of the chest falls  Retractions indicate the patient has some condition, usually medical that is impairing the flow of air into and out of the lungs.  Paradoxical motion is associated with a fracture of several ribs (flail) causing a section of the chest to move independently from the rest of the wall.  Feel for grating of the bones as the patient breathes  Crepitus is often associated with rib factures  Palpate the chest for subcutaneous emphysema, especially in cases of severe blunt chest trauma.  Auscultate you need a stethoscope!!!  First remember that you can almost always hear a patient’s breath sounds better from the patient’s back  Auscultate over the upper lungs (apices), the lower lungs (bases), and over the major airways (midclavicular and midaxillay lines)  Lift the clothing  Place the diaphragm of the stethoscope firmly against the skin to hear the breath sounds Abdomen:  Inspect the abdomen for any obvious injuries, bruising ,and bleeding  Palpate both the front and back of the abdomen, evaluating for tenderness and bleeding  As you palpate the abdomen, use the terms “firm,” “soft,” “tender,” or “distended”

 Do not palpate obvious soft tissue injuries, and be careful not to palpate too firmly Pelvis:  If the patient reports no pain, gently press downward and inward on the pelvic bones  Do not rock the pelvis; this motion may result in motion of an unstable spine  Injuries to the pelvis and surrounding abdomen may bleed profusely, so continue to monitor the patient’s skin color and vital signs and be sure to give supplemental oxygen to minimize the effects of shock Extremities:  Inspect for cuts, bruises, swelling, obvious injuries, and bleeding  Check for pulses and motor and sensory function: o

Pulses check the distal pulses on the foot and wrist. Also check circulation, noted skin color.

o

Motor functions ask the patient to wiggle his or hers fingers or toes. Inability to move a single extremity can be the result of a bone, muscle, or nerve injury. An inability to move several extremities may be a sign of brain abnormality or spinal cord injury

o

Sensory function – ask the patient to close his or hers eyes. Gently squeeze or pinch a finger or toe, and ask the patient to identify what you are doing. Inability to feel sensation in the extremity may indicate a local nerve injury.

Posterior:  Feel the back for tenderness, deformity, and open wounds.

Trauma Patients with a significant MOI:  Remember that significant mechanisms of injury for adults and children may include the following: o

Ejection from a vehicle

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Death of another occupant of the vehicle

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Any fall equal to or greater than the patient’s height, especially if the head strikes a firm surface first or simultaneously with torso.

o

Vehicle rollover

o

High speed vehicle collision

o

Vehicle pedestrian collision

o

Motorcycle or bicycle crash

o

Unresponsive or altered mental status, following trauma

o

Penetrating trauma to the head, chest, or abdomen

Rapid Trauma Assessment:  Taking 60 to 90 seconds to identify both hidden and obvious injuries will help you in two ways Baseline Vital Signs:  A good baseline set of vital signs will be useful as you continue to monitor changes in the patient’s condition SAMPLE History:  Trauma patient with a significant MOI, the patient’s history is not as critical as performing a rapid physical exam or obtaining vital signs; however it should not be ignored. Reevaluate Transport Decision:  If transport is not yet under way, consider transporting the patient at this time  Focused Trauma Assessment Based on Chief Complaint, after evaluating the MOI of your trauma patient, you determine the patient has sustained only minor trauma Baseline Vital Signs:  Obtain the patient’s pulse, respirations, and blood pressure and assess the patient’s pupils and skin Sample History:  SAMPLE history should be gathered to determine whether a medical problem may have caused the trauma  Mnemonic OPQRST Reevaluate Transport Decision:  Consider transporting the patient at this time

Medical Patients who are Responsive:  The patient response to questions about the chief complaint drives your assessment of the history of the present illness and physical exam in the medical patient  Listen to develop an increased understanding of the patient’s condition  Be careful not to jump to conclusions regarding the chief complaint because of what you have seen or heard about the patient  Chief complaint may not be obvious; it may even be different than the dispatched complaint.  Don’t forget if the patient cannot tell you the complaint due to language barriers, hearing barrier or altered mental status seek information from the family. SAMPLE History:  Evaluate as many signs and symptoms as possible in your sample history Focused Medical Assessment Based on Chief Complaint:  Use the OPQRST Baseline Vital Signs:  Remember to do these Reevaluate Transport Decision:  Consider

Medical Patients who are Unresponsive:  Rapid Medical Assessment 60 to 90 seconds  Baseline vital signs  SAMPLE History  Reevaluate Transport Decision Detailed Physical Exam:

 The goal of this exam is to further define problems that were identified in the focused history and physical exam and to possibly identify the cause of complaints that were not identified during the focused history and physical exam.  You must simply ask and answer one question: “What additional problems can be identified through a detailed physical exam?”  This exam is more in depth examination that builds on the focused history and physical exam portion of your assessment. Perform the Detailed Physical Exam:  Head, neck, and cervical spine  Chest- noted breath sounds: o

Normal breath sounds

o

Wheezing

o

Wet – riles or crackles

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Congested – rhonchi

o

Crowing – stridor

 Abdomen : o

Tenderness

o

Guarding

 Pelvis fractured are potential for shock  Extremities – DCAP BTLS  Back spinal immobilization  Reassess vital signs Ongoing Assessment:  Performed on all patients during transport  Its purpose is to ask and answer the following question:

o

Is treatment improving the patient’s condition?

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Has an already identified problem gotten better? Worse?

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What is the nature of any newly identified problems?

 Steps of ongoing assessment: o

Repeat initial assessment

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Reassess and record vital signs

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Repeat your focused assessment regarding patient complaint or injuries, including questions about the patient’s history

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Check interventions

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Ensure management of bleeding

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Ensure adequacy of other interventions