CH09 Patiemt Assessment summarised notes

Assessment
Applies scene information and patient
assessment findings (scene size-up, primary
and secondary assessment, patient history,
and reassessment) to guide emergency
management.
Scene Size-up
•Scene safety
National EMS Education
Standard Competencies (1 of 9)

• Scene Size-up (cont’d)
• Scene management
– Impact of the environment on patient care
– Addressing hazards
– Violence
– Need for additional or specialized resources
– Standard precautions
– Multiple patient situations

Primary Assessment
• Primary assessment for all patient situations
– Initial general impression
– Level of consciousness
– ABCs
– Identifying life threats
– Assessment of vital functions

Primary Assessment (cont’d)
• Begin interventions needed to preserve life
• Integration of treatment/procedures needed
to preserve life

History Taking
• Determining the chief complaint
• Investigation of the chief complaint
• Mechanism of injury/nature of illness
• Past medical history
• Associated signs and symptoms
• Pertinent negatives

Secondary Assessment
• Performing a rapid full-body scan
• Focused assessment of pain
• Assessment of vital signs
• Techniques of physical examination
– Respiratory system
• Presence of breath sounds

Secondary Assessment (cont’d)
• Techniques of physical examination (cont’d)
– Cardiovascular system
– Neurologic system
– Musculoskeletal system
– All anatomic regions
• Assessment of
– Lung sounds

Monitoring Devices
• Obtaining and using information from
patient monitoring devices including (but not
limited to)
– Pulse oximetry
– Noninvasive blood pressure
– Blood glucose determination

Reassessment
• How and when to reassess patients
• How and when to perform a reassessment
for all patient situations

Introduction (1 of 3)
• Patient assessment is very important.
• AEMTs must master the patient
assessment process.
• Patient assessment is used, to some
degree, in every patient encounter.

• Five main
parts:
– Scene size-up
– Primary
assessment
– History taking
– Secondary
assessment
– Reassessment

• Rarely does one
sign or symptom
reveal the patient’s
status.
– Symptom:
subjective condition
patient feels and
tells you about
– Sign: objective
condition you can
observe

Scene Size-up
• How you prepare for a specific situation
• Begins with the dispatcher’s basic
information
• Is combined with an inspection of the scene

Ensure Scene Safety (1 of 4)
• The prehospital
setting is not a
controlled and
isolated scene.
• It is:
– Unpredictable
– Dangerous
– Unforgiving

• Ensure your own safety first and your
patient’s second.
• Wear a public safety vest.
• Forms of hazards:
– Chemical and biologic
– Electricity from downed lines or lightning
– Water hazards, fires, explosions
– Potentially toxic environments

• Consider traffic
safety issues.
• Consider
environmental
conditions.
• Protect
bystanders from
becoming
patients.
Courtesy of James Tourtellote/U.S. Customs and Border Protection

• Occasionally, you will not be able to enter a
scene safely.
– If the scene is unsafe, make it safe.
– If this is not possible, do not enter.
– Request law enforcement or other assistance.
– Beware of scenes with potential for violence.

Determine the Mechanism of
Injury or Nature of the Illness
(1 of 8)
• To care for trauma patients, you must
understand the mechanism of injury (MOI).
• Fragile and easily injured areas include:
– Brain
– Spinal cord
– Eyes

(2 of 8)
• You can use the MOI as a guide to predict
the potential for a serious injury.
• Evaluate three factors:
– Amount of force applied to the body
– Length of time the force was applied
– Areas of the body that are involved

(3 of 8)
• Blunt trauma
– The force occurs over a broad area.
– Skin is usually not broken.
– Tissues and organs below the area of impact
may be damaged.

(4 of 8)
• Penetrating trauma
– The force of the injury occurs at a small point of
contact between the skin and the object.
– Open wound with high potential for infection
– The severity of the injury depends on:
• The characteristics of the penetrating object
• The amount of force or energy
• The part of the body affected

(5 of 8)
• Motor vehicle crashes
– Amount of force to body is related to speed of
crash.
– Assess according to area of body most likely
injured.
– Drivers are at higher risk than passengers.
• Steering wheel
• Also, passengers in the front seat
– Unrestrained victims are at high risk.

(6 of 8)
• Falls
– Amount of force is related to:
• Distance fallen
• Type of landing surface
• Bodily area that impacts first
– With fall over three times a patient’s height:
• Risk for multiple systems injury
• Two rather than three times patient height for
children

(7 of 8)
• Gunshot and stab wounds
– Difficult to assess
– Often little external evidence of actual damage
– Gunshot wounds can be high-velocity injuries.
– Stab injuries exert little force, but can be lethal.
– Gunshot entrance and exit wounds may be
unrelated to organs injured.
– You can only estimate extent of injury.

(8 of 8)
• For medical patients, determine the nature
of illness (NOI).
– Often best described by patient’s chief
complaint
• Similarities between MOI and NOI
– Both require you to search for clues.
• Talk with the patient, family, or bystanders.
• Use your senses to check for clues.

Take Standard Precautions
(1 of 3)
• Wear personal
protective
equipment (PPE).
– Should be adapted
to the prehospital
task at hand
Courtesy of Rhonda Beck

(2 of 3)
• Standard precautions have been developed
for use in dealing with:
– Objects
– Blood
– Body fluids
– Other potential exposure risks of communicable
disease

(3 of 3)
• When you step out of the EMS vehicle,
standard precautions must have been taken
or initiated.
– At a minimum, gloves must be in place.
– Consider glasses and a mask.

Determine the Number of
Patients (1 of 2)
• During scene size-up, accurately identify
the total number of patients.
– Critical in determining the need for additional
resources
• When there are multiple patients, use the
incident command system, call for
additional units, then begin triage.

Determine the Number of
Patients (2 of 2)
• Triage is the
process of sorting
patients based on
the severity of
each patient’s
condition.
© Peter Willott, The St. Augustine Record/AP Photos

Consider Additional or
Specialized Resources (1 of 2)
• Some situations may require:
– More ambulances
– Specialized resources
• Advanced life support (ALS)
• Air medical support
• Fire departments, who may handle high-angle rescue,
hazardous materials, water rescue
• Search and rescue teams

Consider Additional or
Specialized Resources (2 of 2)
• To determine if you require additional
resources, ask yourself:
– How many patient’s are there?
– What is the nature of their condition?
– Does the scene pose a threat to me, my patient,
or others?

Primary Assessment
• Begins when you
greet your patient
• The goal is to identify
and initiate treatment
of immediate or
potential life threats.
• The patient’s vital
signs will determine
the extent of your
treatment.

Form a General Impression
(1 of 3)
• Formed to determine the priority of care
• Based on your immediate assessment
• Make a note of the person’s:
– Age, sex, and race
– Level of distress
– Overall appearance

(2 of 3)
• Position yourself
lower than the
patient.
• Introduce yourself.
• Address the patient
by name.
• Ask about the chief
complaint.

(3 of 3)
• Treat life-
threatening
conditions
immediately.
• Determine if the
patient’s condition
is:
– Stable
– Stable but
potentially unstable
– Unstable

Assess Level of
Consciousness (1 of 7)
• The level of
consciousness
(LOC) is
considered a vital
sign.
– Relates to
patient’s
neurologic and
physiologic status
• Categories:
– Responsive with an
unaltered LOC
– Responsive with an
altered LOC
– Unresponsive

Assess Level of
• Responsive with an altered LOC may be
due to inadequate perfusion.
• Could also be caused by medications,
drugs, alcohol, or poisoning

Assess Level of
• Assessment of an unresponsive patient
focuses on ABCs.
– Sustained unresponsiveness should warn you
of a critical problem.
– Package the patient and provide rapid transport.

Assess Level of
• To assess for
responsiveness,
use the mnemonic
AVPU:
– Awake and alert
– Responsive to
Verbal stimuli
– Responsive to
Pain
– Unresponsive

Assess Level of
• Test responsiveness to painful stimuli.
Pinch earlobe.
Press down on
bone above eye.

Assess Level of
• Orientation tests mental status.
• Evaluates a person’s ability to remember:
– Person, place, time, event
• Evaluates long-term memory, intermediate-
term memory, and short-term memory
• The Glasgow Coma Scale (GCS) score can
be helpful.

Assess Level of

Assess the Airway (1 of 4)
• Moving through the primary assessment,
always be alert for signs of airway
obstruction.
• Determine if the airway is open (patent) and
adequate.

• Responsive patients
– Patients who are talking or crying have an open
airway.
– Watch and listen to how patients speak.
– If you identify an airway problem, stop the
assessment and obtain a patent airway.

• Unresponsive patients
– Immediately assess the airway.
– Use the modified jaw-thrust technique when
necessary.
– Use the head tilt–chin lift technique when
necessary.
– Relaxation of the tongue muscles is a cause of
airway obstruction.

• Signs of obstruction
in an unresponsive
patient:
– Obvious trauma,
blood, or obstruction
– Noisy breathing
(snoring, bubbling,
gurgling, crowing,
abnormal sounds)
– Extremely shallow
or absent breathing

Assess Breathing (1 of 12)
• Make sure the patient’s breathing is present
and adequate.
• Obtain the following information:
– Respiratory rate
– Rhythm—regular or irregular
– Quality and character of breathing
– Depth of breathing

• Ask yourself:
– Does the patient appear to be choking?
– Is the respiratory rate too fast or too slow?
– Are the patient’s respirations shallow or deep?
– Is the patient cyanotic (blue)?
– Do I hear abnormal sounds when listening to
the lungs?
– Is the patient moving air into and out of the
lungs on both sides?

• Administer supplemental oxygen if:
– Respirations are too fast
(more than 20 breaths/min)
– Respirations are too shallow
– Respirations are too slow
(fewer than 12 breaths/min)

• Consider providing positive-pressure
ventilations with an airway adjunct when:
– Respirations exceed 24 breaths/min
– Respirations are fewer than 8 breaths/min

• Respiratory rate
– A normal rate in adults ranges from
12 to 20 breaths/min.
– Children breathe at even faster rates.
– Count the number of breaths in a 30-second
period and multiply by two.

• Respiratory rate
(cont’d)
– While counting
respirations,
also note the
rhythm.

• Quality of breathing
– Listen to breath sounds on each side of the
chest.
– Normal breathing is silent.
– You can always hear a patient’s breath sounds
better from the patient’s back.

• What are you listening for?
– Normal breath sounds
– Wheezing breath sounds
– Rales
– Rhonchi
– Stridor
– Pleural friction rubs

• Normal breathing
– Effortless process that does not affect speech,
posture, or positioning
• Labored breathing
– Retractions
– Use of accessory muscles
– Two- to three-word dyspnea
– Tripod or sniffing position

Sniffing position
Courtesy of Health Resources and Services Administration, Maternal and Child
Health Bureau, Emergency Medical Service for Children Program
Tripod position

Assess Circulation (1 of 15)
• Assess:
– Pulse rate
– Pulse quality
– Pulse rhythm
• Identify external bleeding.
• Evaluate skin.

• Assess pulse
– Pulse: pressure
wave that occurs as
each heartbeat
causes a surge in
the blood circulating
through the arteries.
– If you cannot
palpate a pulse in
an unresponsive
patient, begin CPR.

• Tachycardia: >100 beats/min
• Bradycardia: <60 beats/min

• Pulse quality
– A normal pulse is “strong.”
– A stronger-than-normal pulse as “bounding.”
– A pulse that is weak and difficult to feel is
“weak” or “thready.”

• Pulse rhythm
– Determine whether it is regular or irregular.
– When the interval between each ventricular
contraction is short, the pulse is rapid.
– When the interval is longer, the pulse is slower.

• The skin
– A normally functioning circulatory system
perfuses the skin with oxygenated blood.
– Evaluate the patient’s skin color, temperature,
moisture, and capillary refill.

• Skin color
– Determined by the blood circulating through
vessels and the amount and type of pigment
present in the skin
– Poor peripheral circulation will cause the skin to
appear pale, white, ashen, or gray.

• Skin color (cont’d)
– When blood is not
properly saturated
with oxygen, it
appears bluish.
– Changes in skin
color may result
from chronic
illness.
© St. Bartholomew’s Hospital,
London/Photo Researchers, Inc.

• Skin temperature
– Normal skin will be
warm to the touch
(98.6ºF).
– Abnormal skin
temperatures are
hot, cool, cold,
and clammy.
• Skin moisture
– Dry skin is normal.
– Skin that is wet,
moist, or
excessively dry and
hot suggests a
problem.

• Capillary refill
– Evaluated to assess the ability of the circulatory
system to restore blood to the capillary system
– Press on the patient’s fingernail.
– Remove the pressure.
– The nail bed should return to its normal pink
color.

• Capillary refill (cont’d)
– Should be restored to normal within 2 seconds

• Restoring circulation
– Take immediate action to:
• Restore or improve inadequate circulation
• Control severe bleeding
• Improve oxygen delivery to tissues
– No pulse in unresponsive adult:
• CPR, AED, or manual defibrillator

• Assess bleeding:
– Bleeding from a
large vein—
steady blood flow
– Bleeding from an
artery—spurting
blood flow
• Immediately
control all
external bleeding.

• Identify and treat life threats.
– You must determine the life threat and quickly
address it.
– There will be a loss of meaningful
communication between you and the patient.
– Loss of consciousness occurs.

• Identify and treat life threats (cont’d).
– The jaw muscles become slack (airway
obstruction).
– The patient stops breathing.
– The heart cannot function without oxygen.
– Brain cells become damaged.

Perform a Rapid Scan (1 of 2)
• Scan the body to identify injuries that must
be managed or protected immediately.
– Take 60 to 90 seconds to perform.
– Not an in-depth physical examination
– Use inspection, palpation, auscultation

Determine Priority of Patient
Care and Transport (1 of 5)
• High-priority
patients:
– Difficulty breathing
– Serious MOI
– Poor general
impression
– Unresponsive with
no gag or cough
reflex
– Chest pain
– Pale skin, other signs
of poor perfusion
– Complicated childbirth
– Uncontrolled bleeding
– Responsive but
unable to follow
commands
– Severe pain in any
area of the body
– Inability to move any
part of the body

• Provide spinal
immobilization if:
– Possible spinal
injury exists
– You are unsure
if spinal injury is
possible
© Michael Donne/Photo Researchers, Inc.

• Golden period
– Time from injury to
definitive care
– Treatment of shock
and traumatic injuries
should occur.
– Aim to assess,
stabilize, package,
and begin transport
within 10 minutes
(Platinum 10).

• Transport decisions should be made at this
point, based on:
– Patient’s condition
– Availability of advanced care
– Distance of transport
– Local protocols

• Reconsider the MOI
– You may have missed something earlier.
– MOI severity helps guide:
• Your full-body scan or focused assessment
• Hospital staff
– Seat belts and air bags:
• Save lives
• Also cause injuries

History Taking (1 of 3)
• Provides detail about the chief complaint
and signs and symptoms
• Document:
– Date of the incident
– Times of assessments and interventions
– Patient’s age, sex, race, past medical history,
and current health status

• Investigate the chief
complaint.
– Make introductions,
make the patient feel
comfortable, and obtain
permission to treat.
– Ask a few simple, open-
ended questions.
– Refer to the patient as
Mr., Ms., or Mrs., using
the patient’s last name.

• If the patient is
unresponsive,
obtain clues from:
– Family members
present
– Person who may
have witnessed the
situation
– Medical alert
jewelry

Obtain a SAMPLE History (1 of 6)
• Use the mnemonic SAMPLE to obtain the
following information:
– Signs and symptoms
– Allergies
– Medications
– Pertinent past medical history
– Last oral intake
– Events leading up to the injury/illness

• Use the OPQRST-I
mnemonic to assess
pain.
– Onset
– Provocation or palliation
– Quality
– Region/radiation
– Severity
– Time
– Interventions
• Document pertinent
negatives.

Quality of pain

• Taking history on
sensitive topics
– Alcohol and
drugs
• Signs may be
confusing,
hidden, or
disguised.
• History may be
unreliable.
© Jack Dagley Photography/ShutterStock, Inc

• Physical abuse or
violence
– Report all physical
abuse or domestic
violence to the
appropriate authorities.
– Follow local protocols.
– Do not accuse; instead,
immediately involve law
enforcement.

• Sexual history
– Consider all female patients of childbearing age
who report lower abdominal pain to be
pregnant.
– Inquire about urinary symptoms with male
patients.
– Ask all patients about the potential for sexually
transmitted diseases.

Special Challenges in
Obtaining Patient History (1 of 11)
• Silence
– Patience is extremely important.
– Use yes/no questions.
– Is the silence a clue to the patient’s chief
complaint?

• Overly talkative
– Reasons why a patient may be overly talkative:
• Excessive caffeine consumption
• Nervousness
• Ingestion of cocaine, crack, or
methamphetamines
– Summarize and clarify patient’s statements.

• Multiple symptoms
– Expect multiple
symptoms in the
geriatric group.
– Prioritize the
patient’s
complaints as you
would in triage.
– Start with most
serious and end
with least serious
• Anxiety
– Expect anxious
patients to show
signs of
psychological
shock.
– Reassure patient.
– Be confident.
– Watch for clues of
violence.

• Anger and hostility
– Friends, family, or bystanders may direct their
anger toward you.
– Remain calm, reassuring, and gentle.
– Have the scene secured if it is not safe.

• Intoxication
– Do not put an intoxicated patient in a position
where he or she feels threatened.
– High potential for violence or physical
confrontation exists.
– Be accepting, diplomatic, objective, and
nonjudgmental.
– History taking may be more difficult.

• Crying
– Patient may be sad,
in pain, or
emotionally
overwhelmed.
– Remain calm.
– Be patient,
reassuring, and
confident.
– Maintain a soft
voice.
• Depression
– Among the leading
causes of disability
worldwide
– Symptoms include:
• Hopelessness
• Irritability
• Sleeping and
eating disorders
– Be a good listener.

• Confusing behavior or history
– Can result from hypoxia, stroke, diabetes,
trauma, medications, and other drugs
– Geriatric patients could have dementia,
delirium, or Alzheimer’s disease.
– Ask patient, friend, or family members for more
details.

• Limited cognitive abilities
– These patients are developmentally
handicapped.
– Keep your questions simple; limit use of medical
terms.
– Rely on the presence of family, caregivers, and
friends to supply answers.

• Language barriers
– Find an interpreter, if possible.
– If not, determine if the patient understands who
you are.
– Keep questions straightforward and brief.
– Use hand gestures.
– Be aware of the language diversity in your
community.

• Hearing problems
– Ask questions slowly and clearly.
– Use a stethoscope to function as a hearing aid.
– Learn simple sign language during your career.
– Use a pencil and paper.

• Visual impairments
– Identify yourself verbally when you enter the
scene.
– Return any items that have been moved to their
previous positions.
– Explain to the patient what is happening in each
step of the assessment and history-taking
process.

Secondary Assessment
• Performed at the scene, in the back of the
ambulance en route to the hospital, or not
at all.
• Purpose is to perform a systematic physical
examination of the patient.
• May be a full-body scan or an assessment
that focuses on a certain area of the body.

Assess Vital Signs (2 of 6)
• Use the appropriate
monitoring devices.
– Devices should never
replace comprehensive
assessment.
• Pulse oximetry
– Measures the oxygen
saturation of hemoglobin
in the capillary beds

• Pulse oximetry (cont’d)
– Patients with difficulty breathing should receive
oxygen regardless of their pulse oximetry value.
• Noninvasive blood pressure measurement
– Sphygmomanometer (blood pressure cuff) is
used to measure blood pressure.

• End-tidal carbon dioxide
– Reflects the amount of oxygen consumed.
– Capnography measures noninvasively.
– End-tidal CO2: partial pressure or maximal
concentration of CO2 at end of exhaled breath
– Normal range: 35 to 45 mm Hg, or 5% to 6%
CO2
– Colorimetric devices provide continuous end-
tidal monitoring.

• Capnometry and capnography provide
digital reading and waveform of end-tidal
CO2 .
Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP

• Blood glucose determination
– Repeated glucometer checks allow you to
assess intervention impact.
– Indications:
• Patient with known diabetes with a decreased
LOC
• Patient with decreased LOC of unknown origin
– Normal reading is 80 to 120 mg/dL.

Full-Body Scan
• Systematic head-to-toe
examination
• Identify injuries or causes
missed during the primary
assessment’s rapid scan.
• Perform on:
– Patient who sustained a
significant MOI
– Patient who is unresponsive
– Patient who is in critical
condition

Focused Assessment (1 of 20)
• Based on the chief complaint
• Focus your attention on the immediate
problem.
• Performed on:
– Patients with nonsignificant MOIs
– Responsive medical patients

• Respiratory system
– Look for signs of airway obstruction.
– Expose the patient’s chest, and inspect for
symmetry.
– Listen to breath sounds.
– Measure the respiratory rate.
– Look for retractions.
– Reevaluate pulse rate, skin, blood pressure.

• Cardiovascular system
– Look for trauma to the chest.
– Reevaluate pulse, respiratory rate, blood
pressure.
– Reevaluate the skin.
– Check and compare distal pulses.
– Consider auscultation for abnormal heart
sounds.

• Blood pressure
– Pressure of
circulating blood
against the walls
of the arteries
– Drop indicates:
• Loss of blood
• Loss of vascular
tone
• Cardiac pumping
problem
– Decreased blood
pressure
• Late sign of shock
– High blood
pressure
• May result in a
rupture or other
critical damage in
arterial system

• A blood pressure
cuff contains the
following
components:
– A wide outer cuff
– An inflatable wide
bladder
– A ball-pump with a
one-way valve
– A pressure gauge
© WizData, Inc/ShutterStock, Inc

• Measure blood
pressure by
auscultation.
• The palpation
(feeling) method
can also be used.

• Normal blood pressure
– Hypotension: Blood pressure is lower than
normal.
– Hypertension: Blood pressure is higher than
normal.

• Neurologic system
– Perform on any
patient who has:
• Changes in mental
status
• Possible head injury
• Stupor
• Dizziness
• Drowsiness
• Syncope
– Evaluate the level of
consciousness and
orientation.
– Assess the patient’s
thought process.
– Inspect the head for
trauma.

• Pupils
– Diameter and reactivity to light reflect the status
of the brain’s:
• Perfusion, oxygenation, condition
– The pupils are normally round and of
approximately equal size.
Constricted Dilated

• Pupils (cont’d)
– Assume unequal pupils indicate depressed
brain function, unless anisocoria is confirmed.

– Causes of depressed brain function:
• Injury of the brain or brain stem
• Trauma or stroke
• Brain tumor
• Inadequate oxygenation or perfusion
• Drugs or toxins

– PEARRL is a useful
assessment guide:
• Pupils
• Equal
• And
• Round
• Regular in size
• React to Light

• Musculoskeletal system
– Assess for posture and look at joints.
– Compare the right side with the left.
– Look for trauma to the abdomen, distention.
– Palpate the abdomen for tenderness, rigidity,
patient guarding.

• Pelvis
– Inspect for symmetry
and any obvious
signs of injury,
bleeding, deformity.
• Extremities
– Inspect for DCAP-
BTLS.
– Palpate for deformities.
– Check pulse and motor
and sensory functions.

• The back
– Inspect for DCAP-BTLS.
– Palpate the spine from the neck to the pelvis for
tenderness and deformity.
– Perform assessment of back while performing log
roll, before placing patient on backboard.

• Head, neck, and cervical spine
– Palpate the scalp and skull.
– Check the patient’s eyes.
– Assess the patient’s cheekbones.
– Check the patient’s ears and nose for fluid.

• Head, neck, and
cervical spine
(cont’d)
– Check the upper
(maxillae) and lower
(mandible) jaw.
– Check the patient’s
mouth.
– Note any unusual
odors in the mouth.

• Chest
– Examine for injury or signs of trauma.
– Both sides of chest should rise and fall together.
• Paradoxical motion: one section falls on inspiration
while rest of chest rises
– Auscultate for breath sounds.

• Abdomen
– Inspect for obvious injuries.
– Severe distention may be
caused by:
• Ascites
• Sepsis
– Palpate front and back of
abdomen.
– Assess for rebound
tenderness.

• Additional physical examinations
– If time permits, perform examination of each
body system.
– You may learn additional information that leads
to:
• Modifying treatment that is underway
• Initiating new treatment
• Modifying transport decisions

Reassessment (1 of 4)
• Perform at regular intervals during the
assessment process.
• Repeat the primary assessment.
• Reassess vital signs.
– Compare the baseline vital signs obtained
during the primary assessment.
– Look for trends.

• Reassess the chief complaint.
– Ask and answer the following questions:
• Is the current treatment improving the patient’s
condition?
• Has an already identified problem gotten better?
• Has an already identified problem gotten worse?
• What is the nature of any newly identified
problems?

• Recheck interventions.
– Check all interventions.
– Most important are the patient’s ABCs.
– Ensure management of bleeding.
– Ensure adequacy of other interventions, and
assess need for new interventions.

• Identify and treat
changes in the
patient’s condition.
– Document any
changes, positive
or negative.
• Reassess the
patient.
– Unstable patients:
every 5 minutes
– Stable patients:
every 15 minutes

Clinical Decision Making and
Critical Thinking (1 of 3)
• Effective clinical decision making depends
on your ability to:
– Gather and evaluate patient information
– Develop an idea of patient’s problem
– Formulate a field impression
• Culminates in appropriate treatment plan

• In every assessment, practice critical
thinking skills:
– Ensure you have an adequate fund of
knowledge.
– Focus on specific and multiple elements of data.
– Identify and organize data and form concepts.
– Differentiate between relevant and irrelevant
data.

• Critical thinking skills (cont’d):
– Analyze and compare similar situations.
– Recall contrary situations.
– Articulate assessment-based situations, and
construct arguments.

• The assessment process begins with the scene
size-up, which identifies real or potential
hazards. The patient should not be approached
until these hazards have been dealt with in a
way that eliminates or minimizes risk to the
AEMT and patient.
Summary (1 of 6)

• The primary assessment is performed on all
patients. It includes forming an initial general
impression of the patient, including the level of
consciousness, and identifies any life-
threatening conditions by assessing the ABCs.
– The AVPU scale is a test for responsiveness.
– A patient’s orientation tests mental status.
– The GCS score can provide information on patients
with changes in mental status.
– After quickly forming a general impression, perform
a rapid scan to prioritize time and mode of transport.
Summary (2 of 6)

• History taking includes an investigation of the
patient’s chief complaint or history of present
illness. This information may be obtained from
the patient, family, friends, or bystanders.
– A SAMPLE history is generally taken during this
step. By asking several important questions, you will
be able to determine the patient’s signs and
symptoms, allergies, medications, pertinent past
history, last oral intake, and events leading up to the
incident.
Summary (3 of 6)

• History taking (cont’d)
– OPQRST-I is a mnemonic to remember what to ask
about a chief complaint.
– At times you will need to ask patients about
sensitive topics. Be familiar with techniques for
successfully asking patients about these topics.
• The secondary assessment is a systematic
physical examination of the patient. It is
performed on scene, in the back of the
ambulance en route to the hospital, or not at
all.
Summary (4 of 6)

• There are times when you may not have time
to perform a secondary assessment if the
patient has serious life threats. Or, you may
focus on the area of the chief complaint first,
then move on to assessing all other body
systems if time permits.
• The reassessment is performed on all patients.
It gives you an opportunity to reevaluate the
chief complaint and to reassess interventions,
modifying treatment as appropriate.
Summary (5 of 6)

• A patient in stable condition should be
reassessed every 15 minutes, whereas a
patient in unstable condition should be
reassessed every 5 minutes.
• Critical thinking skills help AEMTs make
effective clinical decisions and accurately
assess the patient.
• The assessment process is systematic and
dynamic. Each assessment will be slightly
different, depending on the patient’s needs.
Summary (6 of 6)

Review
1. 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.

Review
Answer: B.
Rationale: Components of the scene size-
up—after taking standard 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.

Review (1 of 2)
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

Review (2 of 2)
EXCEPT:
C. whether or not additional resources are
needed.
D. if there are any hazards that will jeopardize
safety.

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.

Review
Answer: D.
Rationale: Your primary responsibility as an
AEMT 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.

Review (1 of 2)
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.

Review (2 of 2)
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:
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.

Review
3. Findings such as inadequate breathing or
an altered level of consciousness should
be identified in the:
A. primary assessment.
B. full-body scan.
C. secondary assessment.
D. reassessment.

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

Review (1 of 3)
A. primary assessment.
B. full-body scan.
Rationale: The full-body scan takes place
during the secondary assessment.

Review (2 of 3)
C. secondary assessment.
Rationale: The purpose of the secondary
assessment is to perform a systematic
physical examination of the patient after the
primary assessment.

Review (3 of 3)
D. reassessment.
Rationale: Reassessment is performed to
identify and treat changes in a patient’s
condition after the primary assessment.

Review
4. Which of the following would you NOT
detect while determining your initial general
impression of a patient?
A. Cyanosis
B. Gurgling respirations
C. Severe bleeding
D. Rapid heart rate

Review
Answer: D.
Rationale: The initial 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
entire primary assessment; you cannot see,
hear, or smell tachycardia.

Review (1 of 2)
A. Cyanosis
Rationale: You can see cyanosis while
determining your initial general impression.
B. Gurgling respirations
Rationale: You can hear gurgling while

Review (2 of 2)
C. Severe bleeding
Rationale: You can see bleeding while
D. Rapid heart rate

Review
5. Your primary 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. reassess your interventions.
B. perform a rapid scan.
C. transport the patient immediately.
D. perform an exam focusing on her head.

Review
Answer: B.
Rationale: If any life-threatening problems
are discovered in the primary assessment,
they should be addressed immediately. The
AEMT should then perform a rapid scan to
look for other potentially life-threatening
injuries or conditions.

Review (1 of 2)
consciousness and a large hematoma to
her forehead. After protecting her spine
and administering oxygen, you should:
A. reassess your interventions.
Rationale: This is the last step of the patient
assessment process.
B. perform a rapid scan.

Review (2 of 2)
consciousness and a large hematoma to her
forehead. After protecting her spine and
administering oxygen, you should:
C. transport the patient immediately.
Rationale: This is determined after the
completion of a rapid scan.
D. perform a focused exam of her head.
Rationale: This is completed not only on the
head but on the entire body.

Review
6. A patient with an altered level of
consciousness 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.

Review
Answer: C.
Rationale: 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.

Review (1 of 2)
consciousness 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.

Review (2 of 2)
consciousness pushes your hand away
when you pinch his earlobe. You should
describe his level of consciousness as:
C. responsive to painful stimuli.
D. responsive to verbal stimuli.
Rationale: This is when the patient’s eyes
open with verbal stimuli and he or she tries to
respond.

Review
7. Assessment of an unresponsive 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.

Review
Answer: B.
Rationale: You cannot assess or treat an
unresponsive 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.

Review (1 of 2)
A. inserting an oral airway.
Rationale: You insert an airway adjunct to
assist in maintaining airway patency after
proper positioning.
B. manually positioning the head.

Review (2 of 2)
C. assessing respiratory rate and depth.
Rationale: After the airway is opened and
suctioned, 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.

Review
8. Your 12-year-old patient can speak only
two or three words without pausing to take
a breath. He has a serious breathing
problem known as:
A. nasal flaring.
B. two- to three-word dyspnea.
C. labored breathing.
D. shallow respirations.

Review
Answer: B.
Rationale: Two- to three-word dyspnea is a
severe breathing problem in which a patient
can speak only two to three words at a time
without pausing to take a breath.

Review (1 of 3)
problem known as:
A. nasal flaring.
Rationale: Nasal flaring is the flaring out of
the nostrils.
B. two- to three-word dyspnea.

Review (2 of 3)
problem known as:
C. labored breathing.
Rationale: Labored breathing requires
increased effort and is characterized by
grunting and stridor.

Review (3 of 3)
problem known as:
D. shallow respirations.
Rationale: Shallow respirations are
characterized by little movement of the chest
wall or poor chest excursion.

Review
9. How should you determine the pulse in an
unresponsive 8-year-old patient?
A. Palpate the radial pulse at the wrist.
B. Palpate the brachial pulse inside the upper
arm.
C. Palpate the radial pulse with your thumb.
D. Palpate the carotid pulse in the neck.

Review
Answer: D.
Rationale: In unresponsive patients older
than 1 year, you should palpate the carotid
pulse in the neck. If you cannot palpate a
pulse in an unresponsive patient, begin CPR.

Review (1 of 2)
A. Palpate the radial pulse at the wrist.
Rationale: Only palpate here in responsive
patients who are older than 1 year.
B. Palpate the brachial pulse inside the upper
arm.
Rationale: Only palpate here in children
younger than 1 year because the radial and
carotid pulses are difficult to locate.

Review (2 of 2)
C. Palpate the radial pulse with your thumb.
Rationale: Do not palpate a pulse with your
thumb. You may mistake the strong pulsing
circulation in your thumb for the patient’s
pulse.
D. Palpate the carotid pulse in the neck.

10. When assessing your patient’s pain, he
says it started in his chest but has spread
to his legs. This is an example of what
part of the OPQRST-I mnemonic?
A. Onset
B. Quality
C. Region/radiation
D. Severity
Review

Review
Answer: C.
Rationale: The region/radiation section of the
OPQRST-I mnemonic assesses a patient’s
pain—where it hurts and where the pain has
spread. Because the patient informed you that
his pain spread from his chest to his legs, this
would be an example of radiation.

Review (1 of 2)
to his legs. This is an example of what part
of the OPQRST-I mnemonic?
A. Onset
Rationale: This assesses the cause of the
pain and when it began.
B. Quality
Rationale: This assesses the patient’s
description of the pain.

Review (2 of 2)
to his legs. This is an example of what part
of the OPQRST-I mnemonic?
C. Region/radiation
D. Severity
Rationale: This assesses the severity of the
patient’s pain.

Credits
• Chapter Opener: Courtesy of Rhonda Beck
• Background slide images: (red) Courtesy of
Rhonda Beck; (light blue) © Jones & Bartlett
Learning. Courtesy of MIEMSS; (orange) ©
John Sartin/ShutterStock, Inc.
• Review slide image: Courtesy of Rhonda
Beck

CH09 Patiemt Assessment summarised notes

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CH09 Patiemt Assessment summarised notes