Patient Assessment Fundamentals:
Nuts and Bolts:
The patient assessment is broken into 4 basic components:
Scene assessment
Primary assessment
Secondary assessment
Ongoing assessment/reassessment
When done effectively, all 4 parts should be standardized but flexible enough to be adapted to varied clinical situations.
Scene assessment:
The scene assessment is performed on approaching and arrival on scene. We use EMCAP as the mnemonic device for this.
Environment: Look for any threats to your safety, and that of your allies, and the patient. Also look for clues as to the potential causes of patient injury/illness.
Mechanism: What is the mechanism of injury for your patient?
Casualties: How many patients are on scene?
Assistance needed: Do you require additional resources?
PPE: Apply PPE appropriate to the clinical situation.
Primary assessment:
The primary assessment begins as you approach your patient, with the formation of a general impression (a first glance), and follows a standard pathway assessing for and correcting life threats before moving on.
General impression: As you approach your patient, how do they look? -What is the patient's position? -How is skin colour and condition? -Does the patient appear to be in any respiratory distress? -Are they alert? -Do we note any LIFE THREATENING BLEEDING. If we do, we need to address it now before moving on.
LOA (level of awareness): Upon patient contact we assess using an AVPU scale. -Alert -Alert to verbal cues -Responsive to pain -Unresponsive
C-Spine precautions required? Does the patient's condition or MOI suggest the need for manual cervical spine stabilization.
Airway: We want to answer 3 questions: -Is the airway patent? -Doe we need to suction? -Do we need a basic or advanced adjunct?
Breathing: Assuming our airway is patent or problems have been corrected, we want to assess the patient's ventilatory status. We assess for respiratory rate, rhythm, and depth/volume. We need to ask ourselves: -Does the patient need supplemental oxygen? -Is assisted ventilation required?
Circulation: Next we want to assess our patient's perfusion status. We do this by assessing radial and carotid pulses, noting pulse rate, rhythm, and strength. We also want to assess our patient's skin condition, and capillary refill. We want to consider if our patient may be demonstrating signs of inadequate perfusion and shock. We use this consideration to determine if we may need IV cannulation during our treatment, and as an indication of patient stability.
If our patient initially presents unresponsive, we alter our order, performing it CAB instead of ABC. This is to determine if our patient is vital signs absent, so that we can begin taking appropriate measures. The primary assessment is to be completed in the order above, and you cannot move on until threats to life are corrected.
In trauma patients our primary assessment is extended to include the RAPID TRAUMA SURVEY. This is a systematic head to toe assessment in trauma patients, that is intended to identify and treat life threatening injuries prior to transport. In trauma patients the primary assessment and RTS are generally performed on scene and transport is initiated immediately afterward with the rest of the assessment and ongoing treatment performed enroute to the Trauma Centre. This may also be the case with unresponsive medical patients, when there is little information available on scene, and physical assessment is our primary tool.
In responsive medical patients we move on to the next step in the assessment.
Secondary assessment aka history and physical exam:
The secondary assessment is composed of of 4 parts:
The History Of Present Illness
Prior History
Physical assessment
Vital Signs
HPI: The history of present illness. This is a brief conversation where we attempt to uncover the reason for which the patient called 911, and the events surrounding the problem. For this we use the general format NOPQRST-ASPN. This stands for: -New: Is this a new problem or has the patient experienced it before? -Onset: When did the problem begin, and what was the patient doing when it started? Did symptoms appear suddenly or did they develop gradually? -Provocation/Palliation: Does anything make the problem better? Does anything make it worse? Has the patient taken any medications for the issue (ie: Tylenol for pain)? -Quality: How does the patient describe the problem/pain? -Radiation: Is the pain localized to one area, or does it radiate into other regions? -Severity: How bad is the pain on a scale from 0-10? -Time: Is the pain/problem constant or does it come and go? -ASPN: This stands for associated symptoms and pertinent negatives. Is the patient experiencing additional symptoms in addition to the primary complaint? Are there any additional symptoms you might expect that are not present?
Prior History: When assessing prior history we generally use the SAMPLE mnemonic, although the “S” is somewhat redundant as we have already covered symptoms in our HPI. So I generally prefer to use AMPLE. -Allergies: Does the patient have any known allergies or sensitivities? -Medications: What medications is the patient currently taking. Have there been any changes to medications and is the patient using them as prescribed. -Past medical history: Self explanatory. What medical conditions does the patient have? -Last ins/outs: Has the patient been eating and drinking normally? Any issues with bowel or bladder habits? -Events prior: This is a chance to recap everything you have covered with your patient and clarify any details.
Vital signs: Assuming you have a partner, they should have obtained a baseline set of vitals based on the presenting complaint. Review these and request any additional diagnostics you want.
Physical assessment: Perform a focused physical assessment on the systems involved in the presenting complaint.
Ongoing assessment: Following initiation of treatment and transport, the ABCs should be reassessed every time an intervention is performed. Vitals should be taken at minimum every 30 minutes, and more frequently depending upon patient stability.
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