Transcript for:
Patient Assessment in Emergency Care

hello and welcome to the emergency care and transportation of the sick and injured chapter 10 patient assessment after you complete this chapter in the related coursework you will understand the scope and sequence of patient assessment from medical and trauma patients and all the phases and components of the patient assessment please note that this chapter is divided into five sections scene size up primary assessment history taking secondary assessment and reassessment these divisions will help facilitate the instructor's approach for teaching this skill as a whole concept okay so let's begin as an introduction the importance of a patient assessment cannot be overemphasized the assessment process is divided into five main parts as stated earlier and that's the scene size up the primary assessment history taking the secondary assessment and then the reassessment the order in which these steps are performed depends on the patient's condition and the environment in which the patient is found it may be necessary to change the order of some of these steps after scene size up based on your findings and the need to prioritize the care of certain conditions rarely does one sign or symptom show you the patient status and underlying problem a symptom is a subjective condition the patient feels and tells you about and a sign is the objective condition you can observe or measure about the patient so let's begin with the scene size up the scene size up refers to your evaluation of the conditions in which you will be operating situational awareness is necessary throughout the entire call to ensure safety dispatch provides basic information about the request for assistance okay so the scene size up combines information and observations to help observe ensure safe and effective operations an understanding of the situation conditions prior to responding the dispatcher's information and then an observation of the scene you must ensure scene safety and this cannot be stressed enough issues that you may encounter in a pre-hospital setting can range from minor difficulties to major dangers if the scene is not safe for you and your team to enter the scene and approach and manage the patient do what you can to make it safe or call for additional resources consider traffic safety issues and issues related to scene safety if you must approach a patient on a working roadway consider environmental conditions at the same at the scene as well if appropriate help protect bystanders from becoming patients as well some forms of hazards include environmental physical chemical electrical water fire explosions physical violence also be aware of scenes that have the potential for violence such as violent patients or distraught family members angry bystanders or gangs or unruly crowds an emergency seen as a dynamic changing environment determine the mechanism of injury or moi or the nature of illness so calls for assistant to which you may respond can be categorized as either medical conditions trauma conditions or both so traumatic injuries are a result of physical force that's applied to the outside of the body usually from an object striking the body or the body striking an object for patients who've experienced traumatic injuries determine the mechanism of injury and you're going to hear that as moi terms commonly associated with moi include blunt trauma and penetrating trauma medical patients determine the nature of illness and this there are some similarities between the mechanism of injury and natural illness and sometimes you might have to talk to the patient family or bystanders to get it or use your senses to check for clues be aware of the scenes with multiple patients who are exhibiting similar signs and symptoms such as carbon monoxide and this could indicate an unsafe scene for emts the importance of mechanism of injury or nature of illness is valuable in preparing you to care for the patient so consider this next we need to take standard precautions standard precautions and personal protective equipment need to be considered and adapted to the pre-hospital task at hand standard precautions are protective measures that are traditionally been recommended by centers for disease control and prevention for use in dealing with so objects body or blood bodily fluids or other potential exposures risks of communicable diseases the concept of standard precautions assumes that all blood body fluids non-intact skin and mucous membranes may pose a substantial risk of infection when you step out of the ems vehicle and before actual patient contact standard precautions must have been taken or initiated at minimum gloves must be in place before any patient contact also consider glasses and a masks and determine the number of patients that is our next in the scene safety scene size up okay so during the scene size up it's important to accurately identify the total number of patients when there are multiple patients you should use the instant command system identify the number of patients and begin triage so let's talk about triage a little bit triage is the process of sorting patients based on the severity of the patient's condition and consider additional resources so maybe more ambulances or maybe we need police officers or a helicopter or perhaps maybe more fire trucks and then it or it could be advanced life support or air medical also as i stated fire departments may handle hazmat management technical rescue services and perhaps might include extrication from automobile accidents or wilderness search and rescue okay rope rescue or water rescue and then you might also need as an additional resource law enforcement personnel so questions to ask when determining the need for additional resources so you could does the scene pose a threat to you or the patient how many patients are there and do we have the resources to respond to their conditions after you do the scene survey scene size up now we're doing the primary assessment okay so this is when we actually are about to meet the patient so the patient assessment begins when you greet your patient the single all-important goal of a primary assessment is to identify and begin the treat of immediate or imminent life threats okay so you must physically examine the patient and assess the level of consciousness and airway breathing and circulation the very first thing we do when we walk in is we're going to form that general impression and so this is to determine the priority of care and what is the first part of the primary assessment it includes making a note of the person's age sex race level distress and overall appearance as we approach we want to make sure the patient sees us coming okay so note the patient's position and whether the patient is moving or still avoid standing over the patient if possible address the patient by name introduce yourself to the patient ask about the chief complaint the patient's response can give you insight to the level of consciousness air patency respiratory status and overall circulatory status life-threatening problems should be treated immediately and define whether your patient's condition is stable stable but potentially unstable or unstable to direct further assistance and treatment and next we're going to scan for signs of uncontrolled external bleeding so uncontrolled external bleeding takes priority over other assessments now we're going to assess the level of consciousness so the level of consciousness can tell you a great deal about the patient's neurologic and physiologic status we're going to assess uh assessment of an unconscious patient focuses on the abcs and so sustained unconsciousness should warn you that a critical respiratory circulatory or central nervous system problem there is a problem and some type of deficit might exist conscious with altered level of consciousness may be due to inadequate perfusion medication drugs alcohol or poisoning to assess for responsiveness we're going to use that mnemonic avu and choose one description so we're going to test to determine whether the patient who resp who does not respond to verbal stimuli um will respond to painful stimulus these tests include we could pinch the back of the patient's arm uh pinch the the patient's skin or trap area apply upward pressure along the ridge of the orbital ring along the underside of the eyebrow or the patient who moans or withdraws is responding to the stimulus all right next we want to orient and test the mental status by checking the patient's memory and thinking ability so we're going to evaluate if the patient's ability if he has ability to remember so person does the person does he remember his or her name place can he identify the current location time that's the current year month and appropriate approximate date an event can he describe what is happening he or she okay and if they could answer all those questions that is being alert and oriented times for for and that's person place time and event any deviation from alert and oriented to person place time in an event or from the patient's normal baseline is considered an altered mental status next we're going to identify and treat life threats okay so conditions that cause sudden death are considered life threats and this could be for an example an airway obstruction or respiratory failure or respiratory arrest or shock severe bleeding or prime or cardiac rest in most cases identifying correcting life-threatening issues begins with the airway followed by breathing and then circulation and we say abc in some cases it is more appropriate to address life threats with circulation first so following a sequence of c a b cap okay now we're going to just go right down through into the abcs okay so in the primary assessment we're in the abcs as we move through that primary assessment we're going to stay alert for signs of an airway obstruction we need to ensure the airway remains patent and adequate responsive patients so patients of any age who are talking or crying have an open airway a conscious patient who cannot speak or cry most likely will have a severe airway obstruction and if you identify an airway problem we need to stop the assessment process and work to clear the patient's airway because if the patient has signs of difficulty breathing and is not breathing at it immediately take corrective actions all right so in unresponsive patients we know that they have um unresponsive patients we need to assess the airway patency okay so if there is a potential for trauma we know we're using that jaw thrust maneuver to open the airway if you cannot obtain a patent airway using the jaw thrust maneuver or if it is it can be confirmed that the patient did not experience any trauma we could use that head tilt chin lift maneuver to open the airway signs of obstruction for an unconscious patient so any obvious trauma blood or any other obstruction noisy breathing such as snoring bubbling gurgling cro crowing strouder or other abnormal sounds or extremely shallow or absent breathing these are all signs of an obstruction in an unconscious patient all right so after we have assessed um if the patient is breathing now we need to assess the breathing so once you have um make sure that there is a patent airway make sure that the patient's breathing is present and adequate so as you assess that we're going to ask the following questions so is the patient breathing is the patient breathing adequately and is the patient hypoxic positive pressure ventilation should be performed for patients who are not breathing or whose breathing is too slow or too shallow if the patient is breathing adequately but remains hypoxic administer oxygen so the goal of oxygenation for most patients is a saturation of approximately 94 to 99 percent if the patient seems to develop difficulty breathing after your primary assessment you should immediately re-evaluate the airway consider providing positive pressure ventilations with an airway adjunct when the respirations exceed 28 respirations are fewer than 8 and respirations are too shallow to provide adequate air exchange or shallow respirations can be defined by little movement of the chest wall okay so poor chest exertion observe how much effort is required to make that patient breathe so are there presence of retractions use of accessory muscles are they nasal flaring two to three word dipsnia meaning they get short of breath just talking tripod position that's when they're sitting up and it looks like they're actually in a triangle in the sniffing position or labored breathing respiratory distress is an increased effort and rate okay and then respiratory failure occurs when the blood is inadequately oxygenated or ventilation is inadequate to meet the oxygen demands of the body the ultimate result of respiratory failure could result in respiratory failure if not corrected assess circulation so now we're into the c's so evaluate by assessing the patient's mental status pulse and skin condition so there's three different parts of the circulation that is the mental status pulse and skin condition okay so assess the pulse the pulse if there is a pulse present you will need to palpate it so responsive patients who are older than one year we're going to palpate the radial pulse and that's at the wrist unresponsive patient older than one year we're going to palpate the carotid and that's at the neck and then we're going to palpate the brachial pulse located in the middle area medial area inside the upper arm and children under 1 h okay if you cannot palpate a pulse we're in an unresponsive patient we're going to start cpr skin condition so perfusion is assessed by evaluating the patient's skin color temp and condition and cap refill so skin color which is the description so we're going to talk about poor peripheral circulation will cause the skin to appear pale white ashen or gray high blood pressure can also cause the skin to be abnormally flushed or red and when the blood pressure is not properly saturated with oxygen it'll look blue okay so this might be a little bit hard to see but this little baby's uh face area is bluish it's cyanotic okay so skin color poor peripheral circulation once again causes that skin color to be pale white ashen or gray okay skin temp so normal skin temp will be warm to the touch abnormal skin temperatures are hot cold cool or clammy and then moisture normal moisture is dry and if the skin is wet moist or excessively dry and hot that suggests a problem and then there's cap refills so cap refill is often evaluated in pediatric patients by assessing the ability of the circulatory system to perfuse the capillary system in the fingers and toes okay and so this is a great photo of the skill drill cap refill should be restored within two seconds and it to test it you're going to gently push down on the fingertip until it blanches or turns white okay and then we're releasing it and then we're going to count to see when the normal pink color returns should be less than two seconds all right then we're going to assess and control any external bleeding so should occur before addressing airway or breathing bleeding from a large vein is going to be a steady flow of blood but bleeding from an artery is characterized by spurting okay so that's how you know the difference if it's a flow or if it's spurting venus versus arterial controlling external bleeding is very simple we're just applying direct pressure and then if direct pressure is not quickly successful or if there is an obvious arterial hemorrhage of an extremity we're putting on a tourniquet okay then we're going to perform a rapid scan to identify any life threats so identifying injuries that must be managed or protected before the patient is transported and this is a 60 to 90 seconds to perform a rapid scan it is not a systematic or focused physical exam and to see that you could see skill drill 10-1 in your book okay then after the abc we're going to do the d this is how i remember it and that it stands for determined priority of patient care and transport abcd and the priority of patient include those with any of the following conditions so high priority so if anybody's unresponsive difficulty breathing or uncontrolled bleeding we're going to do it as a high priority patient okay any altered level of consciousness severe chest pain pale skin or other signs of poor perfusion maybe a complicated childbirth or severe pain in any area of the body that's going to be a high priority patient so we're going to load and go okay the golden hour so let's let's talk about the golden hour some people call it the golden period and this is from the time of injury to definitive care during which treatment of shock and traumatic injuries must occur in order to maximize the patient's chance of survival so immediate transport is one of the keys to a survival of the patient who needs immediate care that the emt cannot provide and this is a great slide and it shows the golden hour also called the golden period okay and so discovery of the accident and activation of ems the first 20 minutes then the platinum 10 minutes and that's the initial assessment intervention and packaging of the patient getting that patient off the scene and then you have the ems transport and initial hospital stabilization okay transport decisions should be made at this point transport decisions are based on the patient's condition ability availability of advanced care distance of transport and local protocols all right so next we're going to move into the history taking part and this is the next part of the patient assessment and this includes the history of the patient and the history of the present illness okay so history taking this provides details about the patient's chief complaint and an account of the patient's signs and symptoms so we want to be sure to document all of the following so we want to talk about the date of the incident the patient's age gender patients race medical history and the current uh patient's current health status okay now we're going to investigate the chief complaint and so the chief complaint often is the opqrt questions but we're going to investigate the history of the present illness and we're going to begin by making introductions make the patient feel comfortable and obtain permission to treat we're going to ask few simple and direct questions refer to the patient as mr miss or mrs using the patient's last name ask open-ended questions and they're going to help determine the chief complaint and use eye contact to encourage the patient to continue speaking and repeat statements back to show understanding if the patient's unresponsive of course we're gonna where are we gonna get the information from the patient we're gonna get it from the family all right so we're gonna try and get the the past pertinent medical history and clues about the incident um may be obtained from and that the family a person who may witness or bystanders and see if there's any medical alert jewelry or other patient medical history documentation like a card okay next we're going to use that opqrst mnemonic and this is the mnemonic we use to gather information on the present illness okay so opqrst and uh we're going to gather additional information about the patient's present illness and current symptoms all right so identify pertinent negatives so pertinent negatives are negative findings that weren't no care or intervention okay so let's talk about the op qrst a little bit more the o stands for onset and that is when the um when the problem started p stands for provocation and that's if anything makes the problem better or does anything make the problem worse okay q stands for quality and that's how would you describe the the feeling like the pain is it a stabbing or shooting a pressure r stands for region or radiation so where the actual problem is and does it radiate anywhere severity stands for uh how severe it is so on a scale of zero to ten what does the pain or discomfort feel like and then timing when did it start okay is it uh constant or um does it come and go okay then we're gonna obtain sample and sample stein stands for the s stands for signs and symptoms the a stands for the allergies of the patient m stands for medications p is the past pertinent medical history l is the last oral intake and e is the events leading up to the illness or injury and so sample is the history of the patient whereas opqrsd is the history of the present illness and this is all in the history section of the patient assessment critical thinking and assessment okay so let's talk about critical thinking and this is an essential component in assessing a patient and it involves gathering so we're seeking the facts to help our clinical decision making and scene management we're evaluating so we're considering what the information gathered means and then we're synthetic sizing putting together the information that you have gathered and validated and synthesized into a plan to manage the scene and or care for the patient taking history on sensitive topics okay so these could include alcohol or drugs signs may be confused and hidden or disguised so many patients may deny having any problems the history gathered from a clinically or chemically dependent patient may be unreliable do not judge the patient and be professional in your approach also a sensitive topic include physical or abuse or violence so we have to report all physical abuse or domestic violence to the appropriate authorities you need to follow state laws and local protocols do not accuse instead immediately involve law enforcement it's a mandatory reporting and sexual history it may be a sensitive topic consider all female patients of child bearing age who repeat report lower abdominal pain to be pregnant unless ruled out by history or other information ask about the patient's last menstrual period inquire about urinary symptoms with male patients and when appropriate ask about the fam the potential for sexually transmitted disease in all patients another special challenge is going to be a silence so patience um inextremely is extremely important in dealing with patients and their emergency crisis using close-ended questions that require a simple yes or no may work best so consider whether the silence is a cue or a clue to the patient's chief complaint then you have overly talkative patients and reasons why a patient may be overly talkative include excessive caffeine consumption they might have nervousness or they might have taken crack or cocaine or other methamphetamines and there might be an underlying physiological issue then another special challenge is a patient could have multiple symptoms so you need to prioritize the patient's complaints as you would in a triage so stop with start with the most serious and then end with the least serious another special challenge in obtaining a patient history could be anxiety so consider the context of the situation and recognize that the observed anxiety may be a sign of a serious underlying medical condition frequently anxious patients can be observed in emergency scenes that involve a large number of patients such as a disaster some anxious patients show signs of physiological shock such as polar diaphoresis shortness of breath numbness and tingling in the hands and the feet dizziness or lightheadedness or loss of consciousness anxiety can be an early indicator of low blood sugar levels or shock or hypoxia all right anger and hostility could be a challenge when you're trying to obtain that patient history friends family or bystanders may direct their anger and rage towards you but remain calm reassuring and gentle if the scene is not safe or secured treat retreat until it is secured also if the patient is intoxicated so this is going to be a special challenge do not put an intoxicated patient in a position where he or she feels threatens and has no way out okay the potential for violence and physical confrontation is high when the patient's intoxicated alcohol dolls dulls the patient's senses and then another special challenge could be crying a patient who cries may be sad in pain or emotionally overwhelmed remain calm and be patient reassuring and confident and maintain a soft voice and then there's depression okay so depression is among the leading cause of disability worldwide the symptoms include sadness a feeling of hopelessness restlessness irritability sleeping and eating disorders and a decreased energy level the most effective treatment in handling a patient's depression is being a good listener limited cognitive abilities is also going to be a special challenge in obtaining patient history and so keep your symp keep your questions simple and limit the use of medical terms be alert for partial answers and keep asking questions in cases of patients with severely limited cognitive function rely on the presence of family caregivers and friends to supply answers to your questions and then there will be cultural challenges so don't use medical language patients from some cultures may prefer to speak only with a healthcare provider of the same gender so gain the assistance of a patient's friends or family member too and enlist the health help of health care providers of the same culture or background if possible then there might be language barriers and so you if you can find an interpreter if if possible and if not determine whether the patient understands who you are keep questions straightforward and brief and use hand signals or gestures if needed okay be aware of the language diversity in your community also hearing problems so ask patients slowly and clearly and you can use a stethoscope to function as a hearing aid for the patients you could also learn simple sign language during your career and it will help communicate right or you could use a pencil and a piece of paper then visual impairments so identify yourself verbally when entering the scene it is important that you put any items that have been moved back into the previous position and during the assessment and history taking process explain each step in your assessment of vital signs notify the patient before preparing to lift the patient or move the patient or him or her onto the stretcher all right so we've just concluded the history taking of the of the patient that's the third section now the four section of the patient care report or assessment patient care assessment is the secondary assessment okay so the secondary assessment is the fourth the fourth section so if the patient is stable condition and has an isolated complaint you may choose to perform the secondary assessment at scene but if the secondary assessment is not performed at the scene it is performed in the back of the ambulance and route to the hospital however there are situations where you may not have time to perform the secondary assessment you may have to continue to manage life threats identified during the primary assessment and route to the hospital the purpose is to perform a systemic or systematic physical exam of the patient an assessment that focuses on a certain area or system of the body often determined through the chief complaint or a focused assessment okay and so how and what you assess during your physical exam we're going to inspect paul payton oscar tape and i always say it's look listen and feel so inspection that's the look at the patient for abnormalities palpate that's the feel for abnormalities and the auscultate that's listening with the stethoscope auscultation the mnemonic d-cap btls reminds you what to look for when you're inspecting and palpating various body regions for trauma okay so compare findings on one side of the body with the other side okay so d cap btls it stands for deformities contusions abrasions punctures or penetrations burns tenderness laceration and swelling so systematically assess the patient is the secondary assessment and like we mentioned the goal is to identify hidden injuries or causes that may have been identified during your 60 to 90 second exam during your primary assessment okay so you're going to see the skill drill on 10-2 and then um it's we also do a focus assessment so for the medical and we're going to perform this on patients who sustained non-significant mois or response to medical patients okay so typically based on our chief complaint and the goal of this focused assessment is to focus your attention on the body part or system that is affected okay and so when we talk about this focused assessment we're going to um explain uh different areas so we're going to start with a respiratory system first and so if a patient's having difficulty breathing this is what we're going to focus our focus assessment on we're going to look at the patient's chest we need to expose it we're looking for any signs of airway obstruction or maybe some trauma to the neck of the chest we're inspecting the chest for overall symmetry okay so both sides are rising and falling we're listening we're going to auscultate and listen to breath sounds noting abnormalities and we're going to measure the respiratory rate chest rise and fall for tidal volume and effort we're looking for retractions and we're looking for increased work of breathing when assessing for breathing obtain the following of course we're going to do the rrq and that stands for respiratory rate rhythm quality of breathing and depth of breathing all right so continuing with the respiratory system a normal rate in adults range from 12 to 20 breaths a minute children breathe at an even faster rate so what we're going to do and how we're going to do this is we're going to count the number of breaths in a 30 second period and then we're going to multiply them by 2. the respiratory rhythm should be regular or irregular and so regular is the time from one peak chest rise to the next and it should be consistent irregular respirations can vary and it could mean a underlying medical condition or trauma condition serious trauma condition and then the cue the quality of breathing okay so um normal breathing is silent and breathing accompanied by other sounds may indicate a significant respiratory problem we call these advantageous breath sounds and then we're going to look at the depth of breathing so that's the amount of there the patient can exchange and it depends on the title rate and title volume all right and here we go this is a good demonstration and it shows the locations for auscultating breath sounds and you're going to do it on both sides of the chest and multiple lung fields all right and then we're going to listen for breath sounds okay so what are we listening for normal snoring remember snoring that's an upper respiratory that could be from croup or from the tongue then there's wheezing is wheezing upper lower well wheezing is lower right wheezing is lower crackles rhonchi strider so crackles and bronchi are going to be lower and strider could be upper okay so during the focus exam we just talked about the respiratory system if you have some type of respiratory problem now we're going to talk about the focus exam of the cardiovascular system and so what we're going to do if they have some type of chest area pain or chest area complaint okay so we're going to look for trauma to the chest and listen for breast sounds once again and then we're going to consider the pulse and respiratory rate and blood pressure we want to pay particular attention to rate and quality and rhythm of the pulse we need to consider our findings when assessing the skin okay so check and compare distal pulses to determine any right or left-sided differences and then consider auscultation for abnormal heart tones and then the pulse okay so normal resting poles for an adult is between 60 to 100 the younger the patient the faster the pulse rate is what we usually say and this slide is going to show you the normal ranges for the pulse rate and then we're going to do the quality so the rrq once again except for this time it's going to be for the pulse so the rate rhythm and quality so pulse quality where you want to just um they're they could be described as strong or bounding and a pulse that is weak or difficulty of field is is usually described as weak or thready and the pulse rhythm so is it regular or irregular the interval between each contraction should feel the same the pulse should occur over constant regular rhythm the rhythm is irregular it could be because the heart periodically has an early or late beat and if the pulse beat is missed it could create an irregular rhythm and then we're going to take the blood pressure so the pressure of the blood against the walls of the artery is the blood pressure and a drop in blood pressure may indicate a loss of blood or fluid components or a loss of vascular tone and arterial construction and a cardiac pumping problem it could indicate decreased blood pressure is a late sign of shock and abnormally high blood pressure may result in a rupture or other critical damage in the arterial system so when we take the blood pressure the cuff the gauge is a signal and it contains of the following components so the the blood pressure cuff has a wide upper cuff an inflatable wide bladder which is sewn into the cuff it has a ball pump or a one-way valve and a pressure gauge which is calibrated in millimeters of mercury auscultation is one of the most common means of measuring the blood pressure and so you could see the skill drill on 10-3 and also there's palpation so that's feeling and that just depends on the ability to hear sounds and should be used in certain cases to obtain a blood pressure measurement we call that blood pressure by palp and that's on skill drill 10-4 okay all right and so normal blood pressures uh are showing on the screen if it's a low blood pressure meaning lower than normal that's hypo tension and higher than normal is hypertension okay so we've covered respiratory and um cardiovascular and now we're going to get into the neurologic system so when we're doing this focus assessment on the neurological system we are going to assess um anytime we're confronted with a patient who has any changes in mental status or some type of head injury or stupor dizziness drowsiness or syncope we're going to do this neurological assessment okay and so we're going to evaluate the level of consciousness and orientation uh determined the by the patient's ability to talk and once again we're going to use that to have poo scale and if appropriate to determine that mental status also we're going to use the glass calcoma scales and this is a score which can be helpful in providing additional information on patients with mental status changes okay pupils so and during the neurologic assessment we're going to do pupils we're going to look at those and we want them to be normally round and approximately equal size and they should adjust their size depending on the light so the diameter and reactivity to the light of the patient's pupils can reflect the status of the person's brain perfusion oxygenation and condition if the absence of light the pupils will become fully relaxed and they'll be dilated okay so this is a good photo of on this slide and it shows some examples so the up one the top one there's light being shown in the eyes those are constricted then dilated is big and wide open and dark and then there's unequal in slide c unequal pupils okay so a small number of the population exhibit unequal pupils and abnormal pupillary response can indicate an altered brain function so we use this mnemonic and it's pearl and it's useful assessment guide to to um to talk about the pupils so pupils pearl stands for pupils equal and round regular in size and reactive to light all right so neurovascular status and so we perform a hands-on assessment to determine sensory and motor response when we're doing the neuro exam focus examine so we want to look for bilateral muscle strength and weakness so we're going to complete a thorough sensory assessment test for pain sensations and position and compare distal and proximal sensories and motor responses on one side to the other we we're going to look at skill drill 10-5 okay in order to get a better understanding for that now once we've done let's say we've done the neuro exam we've done these focus exams now let's say that the patient has a trauma it's a trauma situation and so we're going to do that dcap btls right and so we're going to look at all the atomic regions and we're going to look at the head neck and cervical spine and we're going to palpate check the eyes check the color um assess the cheekbones we're going to check the patient's ears and we're going to look for fluid okay well then we're going to move into the head and neck and cervical spine and we're going to check um all those things related so the max cell maxilla and the mandible we're going to look in the mouth to see if there's any broken teeth and also notice any unusual odors in the mouth okay then we're going to move down to the chest and we're going to look listen and feel in the chest area we're going to move down into the abdomen okay so we're going to palpate for tenderness rigidity and patient gardening guarding not gardening so and then we're going to move into the four quadrants so we're going to move to the um and palpate the fourth quadrants the left upper left lower right upper and right lower quadrant then we're going to move into the pelvis and we're going to inspect the pelvis for symmetry and then we're going to look for the extremities for the d-cap btls in all the extremities we're going to check for pulses motor and sensory functioning okay then we're going to roll the patient usually when we roll them we're putting them on the backboard at that point and we're going to inspect the back for any decap btls symmetry and open wounds we're going to palpate the spine from the neck to the pelvis and and see if we can feel any tenderness or deformity all right now finally we're in the vital sign section okay so now we're going to move into the vital sign section that's the next area of the medical assessment or trauma assessment okay so we're going to assess the vital signs and we're going to use appropriate monitoring devices all right so these devices should need never be used to replace our comprehensive assessment of our patient but let's talk about the pulse ox okay so it's used to evaluate the oxygenation's effectiveness and so it measures the oxygen saturation of the hemoglobin on those capillary beds and so patients with difficulty breathing they should receive oxygen regardless of their pulse ox though okay so even if it says 99 if they have difficulty breathing we're going to give them oxygen all right next we're going to talk about capnography and that can quickly provide information on the patient's ventilation circulatory and metabolism then you're going to do um blood glucose or blood glucometry and this measures the level of glucose or sugar in the bloodstream and that's on skill drill 10-6 okay then we're going to do the nbp measurement and that's non-evasive blood pressure measurement okay and then finally the very last thing we're going to reassess the patient all right so we're going to reassess the patient we're going to perform that reassessment at regular intervals during the assessment process the first purpose of that reassessment is to identify and treat changes in the patient's condition so repeat the primary assessment we're reassessing vital signs and we're going to compare the baseline vitals obtained during the primary assessment with any and all of the subsequent vital signs okay so we're looking for trends did the blood pressure go up did the blood pressure go down did the heart rate go up we're looking for trends and then we're reassessing the chief complaint then we're going to recheck our interventions okay and we're going to identify and treat the patient's condition so any we're going to document any changes and whether it was positive and negative and then we're reassessing so when we have when we talk about unstable patients we're going to reassess them every five minutes it's just a continuous reassessment continuous okay and as i said the reassessment is the last part of the patient assessment so this concludes chapter 10 patient assessment lecture now we're going to go to the review questions to see how much we've learned okay all right here we go so during the scene size up you should routinely determine all of the following except all right so accept i think it's going to be the ratio of pediatric patients to adults right we're just looking for the number of patients all right b is the answer you arrive at the scene of an injured person as you exit the ambulance you see a man laying on the front porch of his house he appears to have been shot in the head and is laying in a pool of blood what should we do okay i think it's going to be a retreat to a safe place and wait for law enforcement to arrive of course because we can't enter an unsafe scene right we don't want to become part of the problem okay number three findings such as inadequate breathing or an altered level of consciousness should be identified in the oh goodness all right so not breathing good or altered that's the primary the primary very fast and we need to try and fix those okay we're going to identify those life threats which of the following would not detect would we not detect while determining our initial general impression all right so we're going to see the cyanosis we'll probably hear gurgling severe breathing ah rapid heart rate maybe that's not the initial general we need to check the abcs to do that all right yep indeed the general impression we're not going to be um palpating that for the pulse yet okay your primary assessment of an elderly woman who fell reveals an altered loc and a large hematoma on our forehead uh-oh after protecting her c-spine and giving her oxygen what are we gonna do what are we gonna do so let's see i think they want us to do a rapid exam right or are we going to do a focus assessment on her head i think we're doing a rapid exam to see if there's any life threats perfect so be rapid exam okay a semi-conscious patient pushes our hand away when you pinch his earlobe you should describe this level of responsive to pain right see so they are responsive to pain it puts you away assessment of an unconscious patient breathing begins by how does it begin it's going to begin when we open the airway so if it's trauma remember trauma we're going to do that jaw thrust non-trauma it's head tilt chin lift opening the airway is going to begin our assessment okay your 12 year old patient can speak only two or three words without pausing to take a breath this is two to three word dipstine yup b two to three word dipsneh all right you should determine a pulse and an unresponsive eight-year-old how are we going to do that remember anybody one year or above we're doing the an unresponsive we're doing the carotid pulse in the neck right one year or above one year and under it's going to be that brachial okay so d one year and above when assessing your patient's pain you say it started in his chest but it has spread to his lungs oops spread to his legs sorry this is an example of which part of the opqrst pneumonic so this is region or radiation all right so the opq st all right so this concludes chapter 10 of the patient assessment if you like this chapter go ahead and subscribe to the channel because we're going to be going through the whole book all right thanks have a great night