Patient Assessment

EMERGENCY MEDICAL SERVICE

REGION XII
 ASSESSMENT PLAN
1.Scene size-up
– Arrival on the Scene- personal safety (PPE, Scene Safety),
– Identify Yourself
– Immediate Sources of Information
2. Primary assessment
3. Physical Examination
4. Patient History
5. Reassessment
6. Hand off Reports

• The order in which the steps are performed depends on the

patient’s condition
 Importance of MOI and NOI
• Considering the MOI and NOI early can be of
value in preparing to care for the patient.
• You may be tempted to categorized the
patient immediately as either trauma or
medical
• Fundamentals of good patient assessment
are the same.
Check for level of consciousness (LOC)

• Gently shake the patient’s shoulders and shout,

“Are you okay?” This is important for many reasons
(for example, a patient with altered mental status
may need airway care or other life-saving aid).

• There are four levels of responsiveness commonly

used to classify patients. They are: Alert, Verbal,
Painful, Unresponsive (A-V-P-U)
 Unresponsive (A.V.P.U.)
• A =Alert: A patient who is alert responsive and
oriented

• V =Verbal: A patient who responds only when

spoken to. We say he/she responsive to verbal
stimulus.
 Unresponsive (A.V.P.U.)
• P = Painful: The patient responds only to
painful stimulus.

• U =Unresponsive: The patient does not

respond to any stimulus. Does not open eyes,
respond verbally or even flinch when pain is
applied.
For a patient who is alert and responsive to verbal
stimuli, you should next evaluate orientation (P-P-T-E).
• Person - The patient remember 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 tell you what happened.

 Ensure adequate airway
- how you do this depends on patient responsiveness.

• Responsive Patient: Determine if the patient can

speak clearly. Gurgling or similar sounds may indicate
airway obstruction.

• Unresponsive Patient: Needs aggressive airway

maintenance immediately – make sure airway is
open and patient is breathing adequately.
 Ensure adequate airway
There are two methods commonly used to open the
airway:
• Head-tilt/chin-lift manoeuver
• Jaw thrust manoeuver (Pedia, Trauma Patient)
• Both methods remove the tongue (most common
obstruction) from the back of the throat, allowing
air into lungs.
 Verify breathing
Look, Listen and Feel for air exchange (3-5 seconds).
Respirations must be adequate. Adequate breathing is
characterized by three factors:

1. Full rise and fall of chest

2. Easy breathing
3. Normal respiratory rate
 Inadequate breathing is
characterized by:
• Insufficient rise and fall of chest
• Increased respiratory effort
• Cyanosis (bluish/Gray discoloration of skin,
lips or nail beds)
• Altered Mental Status or sudden change of
Mental Status
• Inadequate respiratory rate (<8 in adults, <10
in children, <20 in infants)
Inadequate breathing is characterized by:

If airway obstruction is present, or if respirations are

inadequate or absent, you must take immediate action.

• Apply oxygen as needed

• Oxygen is used for both medical and trauma patients.

 Assess circulation
Take 5-7 seconds to determine if the patient has an adequate pulse.

• Responsive patient:
– Radial pulse - verbally responsive adults
– Brachial pulse - infant
• Check rate and rhythm
• Unresponsive patient:
– Carotid artery - Unresponsive adult
– Carotid/Femoral pulse - Children
– Brachial Artery -Infants

• Control serious external bleeding: Identify Life threatening Injury and treat
aggressively.

Do not let minor wounds sidetrack you.

 Patient status update
Inform responding EMS units of your findings.

• If more resources will be needed, request them.

• If patient has life threatening injuries or illness, let
the responding units know.
 Patient status update
• If patient is stable with minor injuries, advise
responding units.

The initial assessment should be completed and all life

threats treated before you can proceed to the physical
exam.
 Physical Exam
• The INITIAL ASSESSMENT is designed to help
you identify and treat life-threatening
conditions.
• The physical exam is a thorough survey of the
patient’s entire body. It is meant to reveal any
signs of illness or injury.
• The physical exam proceeds in a logical order,
usually from HEAD TO TOE, but may vary from
patient to patient.
 Physical Exam

The main purpose of the physical exam is to reveal any

injury or medical problem that could be a threat to
patient survival if left untreated.
 Principles of Patient Assessment
Patient assessment is a skill, and must be practised.
The patient assessment process involves the use of your senses.
Three methods are used during your patient assessment:

• Inspection (looking): Involves looking for signs of injury or illness.

Simply make an overall observation of your patient.

• Auscultation (listening): Involves listening for signs of illness or

injury.
– Determine respiratory status- Air entering and leaving the lungs

• Palpation (feeling): Involves feeling for signs of illness or injury.

 Conducting an Exam
Medical vs. Trauma Patients

• Trauma patient is different from an examination of a

medical patient.
• Physical signs of an injury can be observed and
palpated.
• Medical problems are felt by the patient. In order to
provide emergency care, you must ask questions to
encourage the patient to describe their symptoms.
 Conducting an Exam
When conducting an exam, look for the following
signs of injury. You may use the mnemonic
“D.C.A.P. B. T. L. S” to remember them:

D = Deformities B = Burns
C = Contusion/Concussion T = Tenderness
A = Abrasion/Avulsion L = Laceration
P = Punctured wound S = Swelling
Abrasion Avulsion
PUNCTURED WOUND
BURNS
 Tenderness
- pain or discomfort when the affected area is
touched.
LACERATION
SWELLING
 Conducting an Exam

As you proceed, listen to your patient. Listening

shows you care and will usually enable you to
gather important information.
 Physical Exam (Head-to-Toe)

• Observe and palpate (with both hands and equal pressure),

compare (symmetry), smell and listen (unusual scent and
sounds) in the following order:

1. Examination of the Head

2. Examination of the Neck
3. Examination of the Chest
4. Examination of the Abdomen
5. Examination of the Back
6. Examination of the Pelvis
7. Examination of the Lower Extremities
8. Examination of the Upper Extremities
 Examination of the Head
• Scalp and skull: Check for deformities, open injuries,
tenderness and swelling.
• Ears and nose: Look for blood or cerebrospinal fluid (CSF) in
or around openings.
• Pupils: Normally constrict with more light and dilate with less
light; usually symmetrical (unless otherwise due to prior
condition or injury - consider possible artificial eye).
– Abnormal findings include no reactivity to light, pupils that remain
constricted, or unequal pupils.
• Mouth: Check for deformities, open injuries, tenderness and
swelling. Check for possible airway obstructions such as
foreign objects, loose teeth, etc.
 Examination of the Neck
• Always go front to back (anterior to posterior).
• Check for deformities, open injuries, tenderness
and swelling.
• Check trachea for mid-line position.
• Palpate vertebrae.
• Open injuries (bandage immediately with
occlusive dressing (prevent air from entering
veins).
• Check for medic alert necklace
 Examination of the Chest
Any injury may involve the vital organs or major
blood vessels.

• Use the stethoscope, assess lungs for equal

breath sounds.
• Check for deformities, open injuries, tenderness
and swelling.
• Feel ribs for deformities all the way to spine.
• Palpate the sternum.
 Examination of the Abdomen
Abdominal organs may be injured without external
signs.

• Check for rigidity (hardness) or distension.

• Cuts, scrapes (lacerations and abrasions), penetrating
wounds, protruding organs. Potential bleeding and
infection.
• May indicate underlying injury. Palpate quadrant with
pain last.
• Swelling or discoloration.
 Examination of the Back
• Check chest wall for deformities that may
indicate broken ribs.
• Check for obvious deformities and/or
tenderness along entire length of spine that
may indicate spinal cord injury.
• As with chest injuries, check for sucking
wounds, penetrating injuries, cuts, etc.
• Blood accumulation in the flanks and/or
tenderness may indicate abdominal injury.
 Examination of the Pelvis
• Pelvic or hip fracture could result in blood loss of 2 litres or
more.
• Internal organs, blood vessels and nerves pass through
pelvic area.
• Spinal injury possible.
• Genital region: priapism in males.
• Deformities not always obvious. Palpate iliac crest (pelvic
wings) and pubic bones.
• Open injuries may occur, but are uncommon. Penetrating
injuries possible.
• Assess for tenderness.
 Examination of the Lower Extremities

Common sites of injury – do not rush your

examination.

• Check for deformities, open injuries, tenderness and

swelling.
(P-M-S)
• Pulse- Dorsalis pedis or Posterior tibial
• Motion – wiggle toes
• Sensation – gently squeeze one extremity then another.
Ask patient, “Can you feel this?”
 Examination of the Upper Extremities

Common sites of injury – do not rush your examination.

• Check for deformities, open injuries, tenderness and

swelling.
(P-M-S)
• Pulse- Radial pulse/if negative check Brachial pulse.
• Motion – wiggle fingers
• Sensation – gently squeeze one extremity then
another. Ask patient, “Can you feel this?”
• Check for medic-alert bracelet.
 Measuring Vital Signs
A patient’s vital signs include:
• Blood pressure
• Respiratory rate
• Pulse rate
• Temperature
• Pupils (PERRLA)

At the conclusion of the lesson, we will practice

measuring vital signs. You can assess and monitor most
vital signs by looking, listening and feeling.
Proper Equipment to Measure Vital Signs

• Wristwatch – count seconds

• Penlight – examine pupils
• Stethoscope – respiration and blood pressure
• Pen and notebook – take notes
• Blood pressure cuff (sphygmomanometer) –
measure systolic and diastolic blood pressure.
 Respiration
A respiration consists of one inhalation and one
exhalation.

To count respirations, count the number of times a chest or abdomen

rises and falls in 30 seconds, then multiply by 2. Pretend to count pulse
or do something so the patient is unaware and breathing naturally.

When respirations are all the same frequency and depth (shallow or
deep breathing), breathing is considered regular. If frequency or rate is
different, breathing is irregular (rhythm).

Unusual noises (snoring or wheezing) can indicate an obstructed

airway.
 Abnormal breathing conditions:

• Poor rise and fall of the chest

• Increased effort
• Cyanosis
 Pulse

The pulse is the pressure wave generated

by the heartbeat. It directly reflects the rate,
rhythm, and strength of contractions of the
heart.

Each time the heart beats, arteries expand and

contract. You can feel the pulse by pressing on
an artery over a bony prominence.
 Pulse

When measuring pulse, note the following:

• Pulse Rate: Slow or fast
• Strength of pulse
– Normal (full and strong)
– Thready (weak and rapid)
– Bounding (unusually strong)
• Rhythm: Are beats spaced regularly?

Rate, strength and regularity tell you what the heart is doing at any given
time.

Avoid using your thumb — it has a pulse of its own.

 Pulse
Other noted locations to measure a pulse:
• Brachial – upper arm
• Carotid – neck
• Femoral – groin/Inguinal
• Dorsalis pedis – top of the foot
• Posterior tibial artery – medial surface of ankle
 Skin
• Assessment of the temperature, colour and condition
can tell you about the patient's circulatory system.

Temperature
• Normal body temperature: 98.6 °F or 37°C

Method: Place the back of the hand against the patient’s

skin. This type of reading is called relative skin
temperature. It is not an exact measurement, but can tell
you if it is high or low.
• Temperature is reported as normal, hot, cool, or cold.
 Skin Colour
Skin colour provides information on the heart, lungs and other problems
(circulation).

Skin colour can be characterized by:

• Paleness (white ashen): Caused by shock or heart attack, resulting in
impaired blood flow. Also caused by fright, fainting or emotional stress.
• Redness (flushing): Caused by high blood pressure, alcohol abuse, sunburn,
heat stroke, fevers, infection or disease.
• Blueness (cyanosis): A serious problem, seen first around fingertips and
mouth, caused by reduced levels of oxygen due to shock, MI, poisoning,
etc.
• Yellowness: Indicates liver disease. Includes sclera (eyes).
• Black and blue mottling: Caused by blood seeping under the skin (a blow
or severe infection) (livedo reticularis) (patchy irregular colors)
 Skin Condition
• Reported as dry, moist or wet with respect to
the immediate environment.

Capillary Refill
Used for infants and children under 6 years old. Not always
accurate in adults. Press on nail bed and observe how long it
takes for the normal pink colour to return after releasing.
Always re-check at the same place.

Capillary refill may be delayed in patients with cold

extremities. This method is used on adults in triage situations.
 Pupils
• Normal response: Pupils constrict with exposure to light
and dilate when amount of light is reduced. Both pupils
should be the same size unless a prior injury or condition
has changed this. To assess, shine a penlight to the eyes.
If outdoors, cover the eyes and assess for dilation.

(P-E-R-R-L-A)
(Pupils are Equally Rounded, Reactive to Light and
Accommodation)
 Pupils
• Abnormal findings:

– No reaction to light
– Constricted pupils (possible drug overdose)
– Unequal pupils (head injury or stroke).
 Blood Pressure
This is the amount of pressure the surging blood
exerts against the artery walls.

• Systolic pressure is the result of a contraction of

the heart, forcing blood through the arteries.
• Diastolic pressure is the relaxation between
contractions. Both normally rise and fall together.

.
Blood Pressure
 Methods
A. Listening for systolic and diastolic sound
(auscultation) using a blood pressure cuff &
stethoscope.

B. Feeling for (palpating) the return of a pulse as cuff is

deflated.
• Used when is too noisy or bumpy to auscultate. It can
only measure systolic blood pressure.
 Patient History
Re-evaluate what you observed when you arrived on
scene.
• Secure scene for rescuer and patient, remove
obvious mechanism of injury.
• Patient history is gathered mostly in the interview.
• Generally you ask the patient questions; however, if
unresponsive, gather facts by observing scene M.O.I.,
looking for identification tags, speaking to family
members and bystanders.
 Patient History
(S) Signs and Symptoms
(A) Allergies.
(M) Medication
(P) Pertinent history
(L) Last oral intake
(E) Events
 (S) Signs and Symptoms
Signs- conditions you can observe
Symptoms- conditions that only the patient can
feel or describe

Asking patient open-ended questions:

• How do you feel?
• Why did you call us today?
 (A) Allergies.
Determine if patient is allergic to
• Medications
• food
• Anything in the environment
 (M) Medication.

• Identify all medications the patient is

currently taking or has recently taken.

***These may identify a medical condition.

(P) Pertinent history.
• Pertinent to the emergency care you are
providing

(L) Last oral intake

Ask your patient when the last time was he or she
had anything to eat or drink. Pertinent to a patient
who is unresponsive or confused. Important if the
patient needs immediate surgery.
(E) Events

• Ask your patient when the last time was

he or she had anything to eat or drink.
Pertinent to a patient who is
unresponsive or confused. Important if
the patient needs immediate surgery.
 OPQRTS – Pain Assessment
• O – Onset
• P – Provocation/Palliation
• Q – Quality
• R – Radiation
• S – Severity
• T – Time
 Re-Assessment
• A patient may be in stable or unstable
condition. The assessment process must be
ongoing until your patient is turned over to
the next level of care. Complete the following
every 5 minutes for unstable patients and
every 15 minutes for stable patients.
 Re-Assessment
A. Reassess LOC (alert, verbal, painful, unresponsive).
B. Reassess and correct any airway problems.
C. Reassess breathing for rate & quality. Ventilate as needed.
D. Reassess pulse rate and quality.
E. Reassess skin temperature, colour and condition.
F. Repeat any part of physical exam that may be needed.
G. Reassess your interventions (treatment) to check
effectiveness.
H. Continue to calm & reassure the patient.

Maintain professionalism and respect for patient’s concerns and modesty. Do not
leave patient unattended.
 Hand-Off Report
• When you are relieved of your patient by a
higher-level care provider. Be prepared to give
appropriate information about your patient.

• This is the hand-off report, also known as

patient transfer information.
 Hand-Off Report
The hand-off report contains eight items of information:

• Patient age and sex

• Chief complaint
• Level of consciousness
• Airway status
• Breathing status
• Circulation status
• Patient history
• Treatment given
 Hand-Off Report
• The report is designed to be an up-to-
the-minute account of the patient’s
condition, treatment and other
information. Sometimes this will also
appear in your written report.