M12_LEBA5700_09_SE_C12.qxd 3/14/11 7:24 PM Page 238 M12_LEBA5700_09_SE_C12.qxd 3/25/11 5:36 PM Page 239 Principles of Patient Assessment EDUCATION STANDARDS • Assessment—Scene Size-up, Primary Assessment, Secondary Assessment, Reassessment COMPETENCIES • Use scene information and simple patient assessment findings to identify and manage immediate life threats and injuries within the scope of practice of the Emergency Medical Responder. CHAPTER OVERVIEW The foundation of all emergency care lies in a good assessment of the patient. One of the most fundamental skills you will learn and develop is that of patient assess- ment. Patients cannot receive the care they need until their problems are identified. You must assess each patient to detect possible illness or injury and determine the most appropriate emergency care for the patient. This assessment must be done in a structured and orderly fashion to minimize the chance of overlooking an important sign or symptom. Remember that a good patient assessment almost always leads to good patient care. A poor assessment almost always results in poor patient care. This chapter will assist you in learning a thorough and methodical patient assessment. Upon successful completion of this chapter, the student t. mechanism of injury (MOI) (p. 248) OBJECTIVES should be able to: u. medical patient (p. 243) COGNITIVE v. nature of illness (p. 248) 1. Define the following terms: w. OPQRST (p. 269) a. ABCs (p. 251) x. paradoxical movement (p. 267) b. accessory muscle use (p. 267) y. patient assessment (p. 241) c. AVPU scale (p. 253) z. primary assessment (p. 243) d. baseline vital signs (p. 244) aa. radial pulse (p. 255) e. brachial pulse (p. 256) bb. rapid secondary assessment (p. 260) f. BP-DOC (p. 265) cc. reassessment (p. 244) g. capillary refill (p. 256) dd. SAMPLE history (p. 262) h. carotid pulse (p. 254) ee. scene size-up (p. 241) i. chief complaint (p. 244) ff. secondary assessment (p. 243) j. crepitus (p. 265) gg. signs (p. 241) k. DCAP-BTLS (p. 265) hh. symptoms (p. 241) l. dorsalis pedis pulse (p. 268) ii. track marks (p. 268) m. focused secondary assessment (p. 257) jj. trauma patient (p. 243) n. general impression (p. 251) kk. tracheal deviation (p. 267) o. guarding (p. 267) ll. trending (p. 271) p. immediate life threats (p. 244) 2. Explain the importance that safety plays at the scene of an emergency. (p. 245) q. interventions (p. 241) r. jugular vein distention (p. 267) 3. Describe hazards commonly found at emergency scenes (medical and trauma). (p. 247) s. manual stabilization (p. 251) M12_LEBA5700_09_SE_C12.qxd 3/25/11 5:37 PM Page 240 4. Explain the role that the Emergency Medical Responder 16. Describe the unique assessment methods used for plays in ensuring the safety of all people at the scene of an pediatric and geriatric patients. (p. 256) emergency. (p. 247) 5. Describe the components of an appropriate scene PSYCHOMOTOR size-up and the importance of each component. 17. Demonstrate the ability to identify immediate and potential (p. 246) hazards to safety. 6. Differentiate between mechanism of injury and nature of 18. Demonstrate the ability to properly perform a scene size-up. illness. (p. 248) 19. Demonstrate the ability to properly perform a primary 7. Differentiate between a significant and non-significant assessment. mechanism of injury. (p. 258) 20. Demonstrate the ability to properly perform a secondary 8. Explain the purpose of the primary assessment. (p. 249) assessment. 9. Describe the components of a primary assessment. 21. Demonstrate the ability to properly perform a reassessment. (p. 250) 22. Demonstrate the ability to properly identify and perform 10. Describe patients who are high and low priority for trans- appropriate interventions during a patient assessment. port. (p. 256) AFFECTIVE 11. Explain the purpose of the secondary assessment. (p. 257) 23. Value the priority that safety plays in the overall 12. Describe the components of a secondary assessment. assessment and care of the patient. (p. 257) 24. Model a caring and compassionate attitude with 13. Describe the components of the SAMPLE history tool. classmates and simulated patients. (p. 262) 25. Support the role of the Emergency Medical Responder 14. Describe the components of the BP-DOC assessment tool. with respect to patient advocacy. (p. 265) 26. Model an appropriate level of concern for a patient’s 15. Explain the purpose of the reassessment. (p. 271) modesty when exposing the body during an assessment. “Attention all employees.” The voice from the overhead “Okay,” Renee Murphy replies, fishing a pair of gloves FIRST ON SCENE paging system in the Booker Manufacturing warehouse from her bag and putting them on. Renee is actually re- halts the bustle of the shipping staff. They all turn to look up lieved to be with an experienced Medical Emergency at the loudspeaker. “Will all third-shift MERT members Response Team member. She is new to the company’s please respond to the number-seven loading dock for a MERT, and the patient-assessment process is still a little medical emergency.” confusing to her. Two of the warehouse employees remove their leather As the two pass the dock manager’s small office and gloves and face shields and quickly walk to a white locker turn left, they are met by a forklift operator whose name, ac- with “MERT” stenciled on its side in wide red letters. They cording to his embroidered shirt, is Tariq. “I’m glad you’re open the cabinet, remove two nylon bags, and hurry toward here,” he says quickly. “It’s one of the truck drivers. I think the loading docks at the south end of the building. he’s having a heart attack.” “I’ll be the patient-care person if you’ll do scene con- trol,” Joanie Sutter says. Patient Assessment Many EMS systems use an assessment-based approach to providing care to patients (Figure 12.1). This is to say that Emergency Medical Responders and other EMS person- nel are trained to identify, prioritize, and care for major signs and symptoms. What they will not do is try to diagnose a patient’s specific problems. For example, an Emergency Medical Responder will do what he can to make sure a patient with difficulty breathing has an open airway and supplemental oxygen. What he will not do is waste critical time attempting to figure out the underlying cause of the patient’s difficulty. Once all life threats have been cared for, the Emergency Medical Responder will complete a more 240 www.bradybooks.com M12_LEBA5700_09_SE_C12.qxd 3/14/11 7:24 PM Page 241 ᭤ Figure 12.1 • A thorough pa- signs objective indications of illness or injury that can be tient assessment will be the seen, heard, felt, and smelled foundation for the care of all by another person. patients. symptoms ᭤ subjective indica- tions of illness or injury that cannot be observed by another person but are felt and reported by the patient. IS IT SAFE? Patient assessment proce- dures can bring you into contact with a patient’s blood and body fluids. Always take appropriate BSI thorough assessment of the patient, identify less obvious signs and symptoms, and gather precautions whenever you a pertinent medical history. care for a patient. Disposable gloves should always be worn during as- Assessment-Based Care sessment and emergency care. Eye protection also A typical patient assessment contains four major components (Figure 12.2): may be required, depend- • Scene size-up. The scene size-up is an overview of the scene to identify any obvious or ing on the type of emer- gency and patient condi- potential hazards. tion. Wear any other items • Primary assessment. This is a quick assessment of the patient’s airway, breathing, of personal protection re- circulation, and bleeding undertaken to detect and correct any immediate life- quired for your safety and threatening problems. that of your patients. Follow • Secondary assessment. The secondary assessment is a more thorough assessment of OSHA, CDC, and local the patient and has two subcomponents: guidelines to help prevent • History. This includes all the information that you can gather regarding the pa- the spread of infectious dis- tient’s condition as well as any previous medical history. eases. Review the personal • Physical exam. This includes using your hands and eyes to inspect the patient for safety and protection infor- any signs of illness and/or injury. mation in Chapter 3. • Reassessment. Monitoring the patient to detect any changes in his condition, this component repeats the primary assessment (usually done en route to the hospital), scene size-up ᭤ an overview of corrects any additional life-threatening problems, repeats vital signs, and evaluates the scene to identify any and adjusts as needed any interventions performed, such as repositioning the patient obvious or potential hazards; or increasing supplemental oxygen. You will find that the condition of your patient consists of taking BSI precau- tions, determining the safety of will improve, stay the same, or get worse. the scene, identifying the mech- anism of injury or nature of While the responsibilities of the Emergency Medical Responder may differ from one illness, determining the number EMS system to another, most use an assessment-based approach to patient care. After en- of patients, and identifying addi- suring one’s own personal safety, an Emergency Medical Responder’s first concern is to tional resources. detect and begin to correct life-threatening problems in his patient. The second concern is interventions ᭤ actions taken to identify and provide care for problems that are less serious or may become serious. The to correct or stabilize a patient’s third concern is to constantly monitor the patient’s condition to quickly detect any illness or injury.