Putting it all together- Patient Assessment
BSI (Body Substance Isolation) / PPE (Personal Protective Equipment):
· Gloves should be worn on every call
· Since the Covid-19 pandemic, surgical or N95 masks are required on every call, consider HEPA mask when tending to a patient with potential/known tuberculosis
· Consider goggles when suctioning, childbirth, droplet precautions, etc.
· Consider a gown when tending to patients with droplet precautions, MRSA with open wounds, clostridium difficile (c. diff), any patient in active labor, or any call in which body fluid exposure is possible
· Traffic vests should be worn on all motor vehicle calls
Scene safety considerations:
· Maintain crowd control during public events
· Police should be present on any potential/known calls involving violence
· Police should be present on any calls involving potential/known intoxication or overdoses
· Fire department and police should be present on all traffic accidents
· Reflective traffic vests should be worn on all calls involving public roads, no matter the time of day
· Take extra precaution during events involving severe weather
· Assure any animals on scene are secured in another location
· Follow all site protocols when responding to construction/warehouse incidents.
· HAZMAT should be present during incidents involving chemical exposures
Nature of illness/mechanism of injury (NOI/MOI): What you have been dispatched for. Examples include chest pain, traffic crash, breathing problem, general illness, fall, etc.
Number of patients: The total number of patients present on scene. Consider calling for extra resources when dealing with more than one patient. If you are the first to respond to a mass casualty incident, begin triaging the patients involved.
Additional resources: Call for additional resources when dealing with any incident involving scene safety hazards. Request a lift assist from dispatch when dealing with patients in difficult positions / those that are too heavy for you to safely lift on your own.
C-spine precautions: Stabilize your patient’s cervical spine during any incidents involving potential spinal compromise. Examples include motor vehicle collisions, falls in which there was a loss of consciousness or injuries to the head/neck/back, and with any patients who are unconscious from an unknown origin. Be sure to palpate the back of the cervical spine (looking for any deformities/instability/step-off) prior to applying a cervical collar.
General impression: Is your patient sick or not sick, injured or not injured. How is your patient presenting; what position they were found in, are they in obvious distress, what is the patient’s current affect or mood?
Level of consciousness / AVPU (Alert, Verbal, Pain, Unconscious):
· Alert: Is your patient immediately aware of your presence upon arrival? If so, your patient is Alert. When you have a patient who is alert, you must establish a level of orientation. This is done by asking 4 objective questions that most people would reasonably be expected to answer correctly. Examples include who is the current president, what is the current year or month, the city in which the patient currently is, what has happened, how many quarters make a dollar, who a family member present on scene is, etc. Avoid asking questions involving color identification as some patients may be color blind. As well, avoid asking your patient what the current date is. If your patient is able to answer all four questions correctly, they are alert and oriented x 4. This is written out A&Ox4. If your patient is only able to answer 3 questions correctly, they are A&Ox3, and so on. If your patient is unable to answer any questions correctly, they are A&Ox0, or alert and disoriented.
· Verbal: If your patient is not immediately aware of your presence upon arrival, attempt speaking to them to attract their attention. If they respond to your presence when you speak, they are alert to Verbal stimulation.
· Pain: If your patient does not respond to your presence when you speak, attempt to gain their attention by squeezing the trapezius muscle or apply firm pressure to the patient’s fingernail with a pen. If your patient responds to pain, they are alert to Painful stimulation.
· Unconscious: If your patient does not respond to any verbal or painful stimuli, they are Unconscious.
Chief complaint / apparent life threats: The chief complaint differs from the MOI/NOI as this is the complaint that the patient verbalizes to you, as opposed to dispatch’s call nature of illness/mechanism of injury. For example, you are dispatched for chest pain. Upon arrival, the patient states that they are experiencing a burning sensation in their chest. The nature of illness would be chest pain, whereas the chief complaint would be a burning sensation in the chest.
Airway, breathing, and circulation: life threats
Airway: Does your patient have a patent airway? How do you know? Are they snoring/gurgling/apneic, or speaking to you in full and complete sentences?
· If you have an airway compromise, first try to reposition the head. With no suspected spinal injury, this would be done with a head-tilt, chin-lift. With a suspected spinal injury, this would be done with a jaw thrust maneuver.
· Look in the mouth for any visible airway obstructions. For a partial obstruction, encourage your patient to keep coughing. With a full airway obstruction, perform abdominal thrusts and prepare to begin CPR.
· If you hear your patient gurgling, look in the mouth for fluids and prepare to suction.
· If you hear your patient snoring, reposition the head and consider an airway adjunct.
· Consider an adjunct to maintain a patent airway. Examples include oropharyngeal airways (OPA), nasopharyngeal airways (NPA), or a supraglottic airway (King, LMA, iGel, Combitube, etc)
Breathing: Asses your patient’s breathing. Are they breathing adequately to sustain life? Do you need to provide rescue ventilations?
· If your patient is breathing at an inappropriate rate or depth, consider providing rescue ventilations with a bag valve mask (BVM)
· Attempt to coach patients that are hyperventilating due to stress or anxiety back into a normal breathing rate.
· Consider CPAP for CHF or COPD patients with breathing difficulties, ONLY if they are conscious and able to follow directions while also maintaining their own airway.
Oxygenation: Place a pulse oximeter on the patient’s finger to record an SpO2 reading. Remember: if the patient has fake nails or nail polish, turn the pulse oximeter sideways on the patient’s finger.
· If your pulse oximeter reads above 94%, your patient does not need supplemental oxygen
· If you pulse oximeter reads 90-93%, your patient requires low flow oxygen. This is provided with a nasal cannula (NC) at a rate of 2-6 liters per minute (LPM)
· If your pulse oximeter reads <90%, your patient requires high flow oxygen. This is provided with a non-rebreather mask (NRB) at a rate of 10-15 LPM
*Please note the difference between oxygenation and ventilation: the need for oxygenation is shown in the patient’s skin condition/perfusion and SpO2 reading. The need for ventilation is shown in the patient’s breathing rate and depth. If oxygen levels are low but the patient has an appropriate rate and depth of breathing, they ONLY require supplemental oxygen. If the patient’s oxygen levels are low and they are breathing at an inappropriate rate and depth, they require manual ventilation with a bag valve mask at 25 LPM*
*You must have an open airway to be able to appropriately breathe. You must be able to appropriately breathe to have adequate oxygenation. You must have good oxygenation to have adequate perfusion*
Circulation: How is the patient’s perfusion? Are there any exsanguinating bleeds? Remember, when dealing in trauma with significant bleeds, the ABCs should be performed as CAB.
· Asses your patients pulse rate. If they are a conscious adult, assess the radial pulse. For an unconscious adult, assess the carotid pulse. In infants, assess the brachial pulse. How does the pulse feel? Is it fast/slow/bounding/weak? Describe the pulse.
· Asses the patient’s skin condition. Determine the temperature, color, condition, and capillary refill time. Normal, healthy skin should be pink, warm, dry, and have a capillary refill of less than 2 seconds. If the skin is pale, cool, and clammy with an extended capillary refill time, prepare to treat for shock.
· Find and control any major bleeding. Do a full body blood sweep to locate any unseen bleeds. For any bleed found, immediately apply direct pressure. If direct pressure fails to control the bleed, apply more gauze pads and harder pressure. If this doesn’t work, consider packing the wound or applying a tourniquet.
· Shock treatment includes applying high flow oxygen via a NRB, laying the patient supine, and maintaining their body heat with a blanket.
Determine patient priority and transport decision: If the patient has any compromise involving their ABC’s, they are a high priority and must be transported as soon as the life threat has been controlled. If the patient does not have any immediate life threats, you are able to stay on scene and stabilize any further issues as you find them. Remember to spend as little time on scene as possible.
*Vital signs should be performed as soon as is appropriate during your assessment. Vital signs include blood pressure, pulse rate, breathing rate, blood glucose level, and temperature. *
History taking and differential diagnoses
During your secondary assessment, you will begin establishing a patient history. There are two acronyms to help you remember the information to obtain: SAMPLE and OPQRST. SAMPLE questions are focused towards establishing your patient’s medical history and events leading up to the emergency at hand. OPQRST questions are focused on your patient’s current signs, symptoms, and pain level. These questions can help you begin to form a differential diagnosis regarding your patient’s current condition. A differential diagnosis is a working hypothesis of the nature of the current problem. (AMLS, NAEMT.)
SAMPLE will be used in both medical and trauma scenarios, whereas OPQRST only applies to medical scenarios.
S: Signs and symptoms. Signs are objective- they are what you can see. Symptoms are subjective- they are what your patient is feeling. For example, you arrive on scene for an abdominal pain emergency. Your patient is in the fetal position (a sign) and states that they are having extreme lower abdominal pain (a symptom.)
A: Allergies. Establish if your patient has any medication or environmental allergies. Be sure to ask your patient what occurs when they encounter their specific allergens- do they go into anaphylaxis or is it a simple allergic reaction? Allergy information will help you add to your differential diagnosis. For example, you are tending to a patient with a history of asthma and seasonal allergies. It is the springtime, and your patient has been working outside in their garden for several hours and is now experiencing shortness of breath with wheezing. One could reasonably assume the cause of the current distress is an asthma attack due to prolonged allergen exposure.
M: Medications. Establish what medications your patient currently takes. As well as asking what the patient takes, you will need to know whether they take their medications when they should. This is called medication compliance. You will also need to establish if any of their medications have been recently prescribed, as a new medication may cause unfamiliar side effects for the patient. If you don’t know what a certain medication is, ask the patient what they take it for.
P: Pertinent medical history. Establish your patient’s medical history that could potentially relate to the problem at hand. For example, if your patient is currently experiencing chest pain, it is pertinent to ask about any cardiac or respiratory history. As well, if your patient is experiencing altered mental status, it is pertinent to ask about a history of diabetes, stroke, or behavioral issues. It would not, however, be pertinent to ask about any behavioral issues with a patient experiencing chest pain. It is also pertinent to ask about any recent hospital stays or surgeries.
L: Last oral intake. This refers to the last thing the patient ingested. This includes food, drink, drugs, alcohol, and prescription medications. It is always pertinent to ask when the patient last ate, and whether they have been keeping hydrated. This is especially important for patients experiencing a diabetic crisis. With patients who have recently ingested drugs or alcohol, it is important to ask what, when, and the amount of drugs or alcohol ingested.
E: Events leading up. Establish the conditions in which the patient was in when their current problem began. For example, before the patient began experiencing chest pain, were they exerting themselves? Before having a seizure, was the patient exposed to any bright, flashing lights? You are attempting to establish the potential causes of the patient’s current problem.
O: Onset. Ask your patient when their current symptoms began. What were the conditions surrounding the beginning of this issue? Did it come on suddenly or gradually?
P: Provocation / Palliation. Does anything make the problem worse? (Provocation.) Does anything help to alleviate symptoms of the problem? (Palliation.) These could refer to body positions, medications, activities, temperature therapy, etc. For example, some patients with respiratory difficulties may find it difficult to exert themselves (provocation) and may find leaning forward in a tripod position helps them to breathe more effectively (palliation.)
Q: Quality. Ask the patient to describe to you how their pain feels. Some frequently used descriptors include sharp, dull, stabbing, burning, crushing, throbbing, nauseating, shooting, twisting, and stretching. Remember to ask this as an open-ended question. Document how the patient describes their pain in quotation marks. For example, if your patient is experiencing chest pain, ask, “What does the pain in your chest feel like?” If your patient says, “It feels like something is crushing the center of my chest,” you would document the patient’s quality of pain as “feeling like something is crushing the center of [their] chest.”
R: Radiation. This refers to the localization or distribution of the patient’s pain. In the example above, your patient states that they have crushing pain in the center of their chest. It is pertinent to ask whether the pain stays localized to the center of their chest, or if it moves (radiates) to a different location. Remember that some conditions cause referred pain to another part of the body. This is when the pain is perceived in a location other than the site of the painful stimulus/origin. For example, the spleen is in the upper left side of the abdomen, next to the stomach and behind the left ribs. However, pain from a ruptured spleen can be felt in the left shoulder (Kehr’s sign.)
S: Severity. Ask your patient to rate the pain on a scale of 1-10. A rating of 1 would be minimal pain that is hardly noticeable, whereas a 10 would be pain that is so severe the patient is unable to move; the worst pain they have ever felt in their life. This scale can also be applied to breathing difficulties. A rating of 1 would indicate mild breathing difficulty, whereas a 10 would indicate severe, life-threatening breathing difficulty. To assess a pediatric patient’s pain level, use the Wong-Baker Faces Pain Rating Scale.
T: Time. Establish a timeline of your patient’s current problem, beginning at the onset of their symptoms to when they called 911, then from when they called 911 to your arrival on scene. Determine if they called 911 at the start of their symptoms, or if they called 911 when their symptoms began getting progressively worse/did not improve after a reasonably expected amount of time. Ask your patient whether they have had or were hospitalized for this problem before, and how this current instance compares to the previous.
Clarifying questions: Clarifying questions are questions not listed in your OPQRST or SAMPLE that you feel could be beneficial for your patient care and documentation, or potentially add to your differential diagnosis.
*Remember to ask these questions in plain language and avoid using medical terminology. *
Full body assessment (DCAP-BTLS)
In traumatic situations, a full body assessment should be performed to locate any secondary injuries. Each area of the body should be individually assessed as such for for Deformities, Contusions, Abrasions, Punctures/Penetrations, Burns, Tenderness, Lacerations, and Swelling (DCAP-BTLS)
Scalp: Examine for any bleeding or DCAP-BTLS by palpating the skull
Ears: Look inside the ear for any blood or CSF, behind the ears for Battle’s signs, palpate the mastoid process
Eyes: Palpate the orbital bones, look for raccoon eyes, determine pupil size and reaction with pen light
Facial areas: Palpate the mandible and maxilla
Oral: Look inside the mouth for any fluids or foreign objects
Nasal: Palpate the bridge of the nose and look inside for any fluid or foreign objects
Posterior: Palpate cervical spine for step-off
Anterior: Look for tracheal deviation
Lateral: Look for jugular vein distention
*Make sure to palpate the cervical spine prior to applying a c-collar *
Inspect: Look for flail chest, sucking chest wounds, unequal respirations, etc.
Palpate: Clavicles, shoulders, sternum, ribs
Palpate: All four quadrants separately using your flat palm in a rolling motion
Inspect: Do you note any pulsating masses/rebound tenderness/swelling
Palpate: Push inwards then downwards, noting any instability *If you feel any instability when you push inwards, DO NOT PUSH DOWN*
Verbalize: Checking genitalia with palm facing upward
Palpate: Palpate the entire extremity from most proximal joints downwards. Use a cup-like motion with your hands to feel both the anterior and posterior sides.
Pulse: Radial/dorsalis pedis/posterior tibial
Motion: Test your patient’s ability to squeeze, push, pull, or wiggle fingers/toes
Sensation: Can the patient feel and differentiate between which hand/foot is being touched
Palpate: The posterior spine looking for step-off, instabilities, or deformities
*Make sure to palpate the spine prior to rolling a patient onto a backboard*
Assessment of body systems
To help further your differential diagnosis, it is imperative to continue your assessment through secondary exams. These can be accomplished by assessing and testing body systems. Consider testing multiple body systems, as many illnesses may have secondary problems that do not present themselves in your primary assessment.
· Asses your patient’s radial pulses. Does the pulse feel regularly regular, irregularly regular, irregularly irregular? Do the pulses feel the same in both arms?
· Run a 12 lead EKG on your patient. At the BLS level, you will not be able to interpret the heart rhythm, but it will be helpful for the hospital to compare to their testing upon arrival.
· Listen to lung sounds, as many cardiac issues relate to the pulmonary system as well.
· Auscultate your patient’s lungs. Do you hear any adventitious breath sounds? In which lobes did you hear adventitious sounds?
· Utilize capnography to assess your patient’s end-tidal carbon dioxide or ETCO2 (the amount of carbon dioxide exhaled with each respiration)
· Take your patient’s temperature. A tympanic thermometer is preferred in adult patients. An axillary temperature measurement will be the least accurate.
· Asses your patient’s skin for urticaria (hives), unusual bruising, abnormal lumps or bumps, or injuries in different stages of healing.
· Ask your patient if they have been experiencing nausea, vomiting, diarrhea, constipation, or unusual bowel movements.
· In the case of diarrhea or vomiting, ask the patient to describe the color and consistency of the excrement or vomit.
· Palpate all four quadrants of the abdomen separately. If your patient is experiencing pain in one abdominal quadrant, end your palpation at the affected quadrant.
· Ask your patient about their urine output. With infants, ask the parent or guardian the number of wet diapers the infant has gone through since the start of the issue.
· Ask your patient if they are experiencing any pain or burning when urinating.
· Ask your patient if they have experienced any abnormal discharge.
· Assess any affected body parts for DCAP-BTLS.
· Assess the movement and sensation in the affected body parts.
· Ask your patients if there is any possibility that they could be pregnant and when their last menstrual cycle was.
· If the patient is pregnant, ask about any prenatal care, complications with the current or previous pregnancies, current trimester, and due date.
· You will need to establish the number of times your patient has been pregnant before, whether the pregnancy was carried to term. The number of pregnancies is referred to gravidity.
· You will need to establish the number of births of a fetus at >24 weeks, whether it was a live birth or stillborn. This is referred to as parity.
· For example, a pregnant patient with three children would be documented as G4P3
· First and foremost, ensure that your patient is non-violent or has been securely restrained prior to establishing patient contact.
· Ask your patient whether they are seeing/hearing/feeling anything that others are not.
· Ask your patients if they have any intention of hurting themselves or others.
Management of secondary injuries: Bleeding control, splinting, full spinal immobilization, etc.
Treatments: Document any treatments or therapies used during your patient care. Examples include medications, repositioning, temperature therapy, supplemental oxygenation, manual ventilations, or anything else you did to improve your patient’s condition and what effect your therapies had.
Radio report: Prior to your arrival, you will need to perform a radio report to the receiving hospital. This report should contain the only following information and be limited to approximately 30-45 seconds.
· Your unit number and level of care (ALS or BLS)
· Your patient’s age and gender
· Chief complaint / mechanism of injury
· Mental status and vital signs
· Treatments performed and patient responses
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