Module 6 Patient Assessment

Patient Assessment

Mechanism of Injury (MOI) - trauma

In order for ECP to be able to provide best possible treatment, you need to have understanding of injuries are sustained
by look at MOI.
You are required to “search for clues” and be vigilant
E.g. MVA’s
 Steering wheel that is buckled or bent
o Thoracic trauma / fractures, neck, spinal, head trauma / fractures / injuries
 Front windshield damaged with a target looking shatter / crack / broken where windshield is damaged
o Head, neck, spinal, thoracic trauma / fractures
 Dashboard is damaged or crumbled
o Leg and pelvic fractures

Kinetic force:
When a car is driving at 120 km/p/h and has a head on collision with a brick wall, the car collides with the wall at
approximately 240km/p/h

Nature of illness (NOI) - medical

You are required to “search for clues” and be vigilant for clues on how the incident happened / occurred.
Pt. home – general appearance of living quarters can provide many clues.
Run-down messy apartment with liquor bottles scattered everywhere could give an indication of the type of pt. you are
about to treat.

1 Primary Survey
 Primary survey consists of
o BSI and then
o HHH ABC (conscious pt.) alternatively
o HHH CAB (unconscious pt.)
 Primary survey – most important starting point in pre-hospital pt. assessment in emergency care
 Even as you walking towards pt. and scene – critical assessment of ABC / CAB will determine pt. outcome
 Before primary survey – there are vital steps to be taken before pt. can be touched or treated
o That is Body Substance Isolation

1.1 Body Substance Isolation (BSI)

 Practice regarding ALL bodily fluids as being potentially infectious
 Always use BSI to protect yourself & partner from exposure to infectious disease/s
 Various ways to protect yourself from exposure to infectious disease/s
o Masks
o Gloves and eye protection
o Hand washing
o Disposal of used supplies
 NEVER leave medical equipment / dressing / bandages or anything used while treating the
pt. behind!!!!!!

Once BSI taken care of – primary survey can begin

Primary survey includes rapid assessment of pt. level of consciousness

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In almost every situation – following steps are excellent guidelines to follow:

H Hazards Is the scene safe to approach the pt.
H Help Send for help if needed – e.g. fire brigade
H Hello
A Airway Is pt. airway clear and free of debris?
B Breathing Is pt. breathing?
C Circulation Does pt. have pulse?
And or obvious bleeding?

 After primary survey is complete and all life-threatening injuries taken care of
o Proceed to finding out pt. history
 Primary survey must be continuously assessed on same pt.
o If ABC not re-assessed continuously – pt. condition may deteriorate without you being aware of it.
 SPEAK to your pt. NON-STOP
o GSC can easily be completed if pt. is speaking
o If pt. stops speaking you are immediately aware that the pt. has deteriorated.

2 Secondary survey
Integral part of the pt. overall approach
Secondary survey has sequence and manner – follow this

GENERAL APPEARANCE
 My provide clue in providing a diagnoses e.g. cold and clammy
PT. POSITIONING
 Foetal position could mean they are guarding an acute abdomen
 Trauma patients may lie in various positions depending on injuries sustained
BEHAVIOUR
 Pt. in pain may be crying or have various facial expressions
 Anxious pt. may look scared and wary of surroundings
 Be prepared for signs of restlessness
o May indicate pt. becoming hypoxic or has internal bleeding
o Restlessness in pt. must never be overlooked – can often indicate serious / potentially serious
condition.
OBVIOUS WOUNDS AND DEFORMITIES
 Look for areas of blood soaked clothing
 Or deformed / unnatural positioned extremities
SKIN
 Always observe the colour, temperature and abnormalities
 This will give you a good idea of the pt. perfusion
 Bright red skin – could be indication of:
o carbon monoxide poisoning – (gas heater, attempted suicide by exhaust fumes)
o allergic rash
o dilation of blood vessels
 Pale skin
o often associated with pt. in shock or normally pt. as being cold and clammy
 Bluish tinged skin
o can be indication of hypoxia / hypothermia
 Yellow skin
o Usually indication of jaundice – best seen in “whites” of eyes
o Jaundice most often due to liver disease – e.g. hepatitis
 Hives and urticarial – indication of allergic reaction

2.1 Pt. History

SAMPLE
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Signs and Symptoms Signs is something you see

Symptoms is what the pt. tells you
Allergies Ask – are you allergic to anything like medication like aspirin or food like peanuts
Medication Are you on chronic medication or taking medication for anything like flu or heart
problems
Past medical history This question needs to include the pt. as well as the pt. family
(pt. may not have past heart problems but pt. parents or family may have heart
problems)
Last meal When was the last time the pt. ate or had something to eat
Events leading up to the What was the pt. doing before the pain started
event

2.2 Chief Complaint

 This is main symptom that causes pt. to call for assistance e.g. difficulty breathing
 Always be alert to more serious underlying conditions even though
 Pt. might be complaining about specific wound e.g. pedestrian involved in MVA may complain of injured arm
 Physically examination may reveal internal abdominal bleed – possible ruptured spleen

2.2.1 History of Chief Complaint

 Obtain full as possible history from pt.
 Ask the flowing questions: O P Q R S T

Onset When did the pain start / begin?

Provokes What provokes the pain?
E.g. was the pt. exercising?
Quality What is the quality of pain?
Crushing / stabling / feels like someone is sitting on their chest
Radiation / Radiating Is the pain radiating?
i.e. to the jaw, arms, abdomen, back
Severity How sever is the pain?
Scale of 1 – 10? 10 being the worse the pt. has ever felt
Time How long has the pain lasted?
1 hour
And is the pain constant or does it come and go and for how long

VITAL SIGNS
At this point vitals MUST be taken
Signs – something you can see, hear, feel
Pt. may not be aware of them e.g. rate / rhythm / strength of pulse

 Pulse
 Respiration
 Air entry
 Haemoglucose test (HGT)
 Blood pressure
 Pupils
 Glasgow coma scale
 Revised trauma score
 Skin colour and temperature
 Capillary refill

2.3 Pulse
Palpated where an artery lies – close to surface skin – e.g. radial artery
When evaluating pulse: (things to consider)
Rate Number of beats per minute
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Rhythm Regularity of beats

Volume / strength Force / amplitude of each beat

Normal pulse rates per minute:

Adults 60 – 100 bpm
Children 80 – 100 bpm
Toddlers 100 – 120 bpm
New-borns 120 – 140 bpm

Extremely fit adult can have pulse rate as low as 40 – 60 bpm (unfit person has faster pulse)
Pulse rate only tell us little
Pulse rate with rhythm and strength could tell us lots
E.g. pt. pulse rate 120 bpm – regular but weak
Could indicate pt. that is in shock
E.g. pt. pulse rate 120bpm – regular but strong
Could indicate health pt. after exercising

When describing pulse – ALWAYS include rhythm, rate and strength / volume
Pulse can be located in many areas of the body:

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2.4 Respiration
When describing respiration rate – ALWAYS include rhythm, rate and depth and ANY abnormal sounds / smells if
present

Normal respiration rate:

Adult 12 – 20 bpm
Child 15 – 30 bpm
Infant 25 – 50 bpm

Groups of children Ages Normal respiratory rates

New-borns and infants Up to 6 months old 30-60 breaths/min
Infants 6 to 12 months old 24-30 breaths/min
Toddlers and children 1 to 5 years old 20-30 breaths/min
Children 6 to 12 years 12-20 breaths/min

 Cheyne stokes respiration

o Usually a sign of severe brain injury
o Breathing gets deeper and deeper then stops for some time and the cycle then repeats
 Depths of breaths may be affected by many factors
o Pt. rib fractures – pt. will find it difficult to breath and therefore decrease breathing in order to lessen
pain
o Overdose of narcotic drugs (respiration depressants) – may have shallow breathing
 Abnormal breathing sounds
o Snoring – obstructed airway
o Stridor – high pitched squeaking noise heard on IN-halation – caused by narrowing of airway
 Usually around larynx
o Gurgling – indicated collection of fluids in upper airway

 Total lung capacity

o 6000ml: Forced deep breathe - Volume of air in lung after a forceful inspiration
 Tidal volume
o 500ml: Normal breathing – volume of air inspire / expire during each respiratory cycle
o Normal breathing 12-20 breathes per minute)
 Dead air space
o 150ml: Air remaining in passages
 Minute volume
o Amount of air that moves in and out of the lungs per minute
o Tidal Volume x respiratory rate (12-20 bpm) = minute volume

o VT or tidal volume is the amount of air the lungs breathe in one breath,
o VE or minute volume is the number of breaths
o RR (respiratory rate or f=frequency) breathed in one minute times the tidal volume.
o Thus VT x RR = VE.
350ml x 12 breaths per minute = 4,2 L/min.

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[Link] Signs of abnormal breathing

 Slower the 8 breaths/min OR faster than 24 breaths/min
 Muscles retractions
 Pale / cyanotic skin (bluish coloured skin)
 Cool, damp (clammy) skin
 Shallow / irregular respirations
 Pursed lips
 Nasal flaring

2.5 Air entry

 Air entry is determined by auscultating both the left and right sides of the thoracic cavity
 Auscultating the thorax with a stethoscope
 It is used to determine equality of breath sounds on both sides of the chest
o Unequal air entry may suggest pneumothorax

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Auscultation:
Normal Abnormal
Sound Present & equal Diminished / unequal / absent
Expansion Adequate & equal Inadequate / unequal
Effort Unlaboured / normal Laboured / increased effort / uses accessory muscles / flail rib fractures /
subcutaneous emphysema

2.6 Blood Pressure

Two components to blood pressure measurements:
 Systolic (contraction of the heart)
 Diastolic (relaxation of the heart)

Blood Pressure = Cardiac Output x Peripheral resistance

Cardiac output = Stroke volume x Heart rate

Blood pressure is recorded: systolic over diastolic e.g. 120/80

Normal blood pressures:

Systolic: 100 – 140mmHG
Diastolic: 65 – 90mmHG

Male pt. Adult

Age + 100 = Systolic BP 40 + 100 = 140
Diastolic BP = 2/3 of systolic BP 90 - 100

Female pt. Adult

Age + 90 = Systolic BP 30 + 90 = 120
Diastolic BP = 2/3 of systolic BP 80

Blood pressure can be estimated by finding different pulses:

Pedal pulse: 90mmHG
Radial pulse: 80mmHG
Femoral pulse: 70mmHG
Carotid pulse: 60mmHG
RMB:
 BP only of many vital signs and must not be used in isolation
 e.g. pt. that has lost lots of blood may have normal BP
o this due to response of vasoconstriction by vessels and increase in heart rate and output to maintain
pressure
o By the time the pt. BP falls – pt. is already in sever hypovolaemic shock

2.7 Pupils
Remember: PEARL
Pupils equal and reactive to light

+- Normal size pupil 4mm

State of pupils may be indicator of cerebral perfusion and oxygenation of brain

Two main parameters:
 Size of pupils
 Reaction of pupils to light
In normal healthy person – pupils are equal size and shape

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Size of pupil is usually determined by amount of light entering the eye

 Bright light causes pupil to constrict
 Darkness causes pupils to dilate

When brain deprived of oxygen – pupils dilate

Use of drugs may affect pupils
Pt. who have dilated pupils but are alert and responsive – DON’T have problem with oxygenation to brain
Drug may have caused papillary response

Rate of reaction to light may give clues to states of brain

 Pupils slow to react – usually mean the brain or portion of the brain is hypoxic

2.8 Glasgow coma scale (value out of 15)

Derived from various responses to stimuli:
 Responses are:
o Opening of eyes
o Use of speech
o Ability to move

/15 Visual Response Verbal Ability Motor Skills

1 Eyes don’t open None No movement
2 Pain causes eyes to open Incomprehensible words / sounds Abnormal extension to pain
3 Voices cause eyes to open Inappropriate words Abnormal flexion to pain
4 Spontaneous Minimal / confused Withdraws from pain
5 -------------------- Orientated Localizes pain
6 -------------------- -------------------- Moves on command
Lowest score is 3

2.9 Revised Trauma Score

/1 GCS Systolic BP Resp. Rate
2
4 13 – 15 >90 10-29
3 9 – 12 76 – 89 >29
2 6–8 50 – 75 6–9
1 4–5 1 – 49 1-5
0 3 0 0
Lowest score is 3

2.10 Capillary refill

2 seconds to refill
Press nail bed – release and determine time it takes for nail bed to return to initial colour.

2.11 Haemoglucose test (HGT)

Haemoglucose test – done by assessing blood sugar level of pt.
Normal blood sugar level – 3.5 – 6.7 (or 7.4) mmol/L

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2.12 Head – to - Toe

Head Slide hands from neck upwards – to feel posterior scalp. Be extremely careful in trauma pt. NOT to move
head
DO NOT press hard on deformities – may push fragments of broken bone into brain
Feel for deformities, swelling and blood
Ears Look for ear damage
Blood and CSF (cerebra-spinal fluid) – may be oozing from ears - May be indication of skull fracture
Battle signs (bruising over mastoid process - May be indication of skull fracture
Nose Look for swelling, deformity or bruising
Blood and CSF (cerebra-spinal fluid) draining from nose - May be indication of skull fracture
Eyes Check external trauma – eyes and eyelids
Raccoon eyes (bruising around the eyes) – May sometimes be indication of skull fracture
Mouth 1st feel jaw for signs of fractures
Open mouth – check there is no foreign matter within e.g. broken teeth/dentures, vomits, blood etc.
Neck DO NOT move neck in trauma pt.
Gently examine neck for wounds, bruises, palpate for subcutaneous emphysema
Examine trachea – deviated or midline
Examine posterior and anterior aspects of neck for swelling and deformities.
Completion of neck examination – immobilize neck with neck brace
Chest Fully expose pt. chest when necessary. – be respectful and allow pt. to keep their dignity
Examine chest for stability, unity, bruising and wounds
Auscultate chest for unequal breath sounds or any abnormal breath sounds e.g. wheezing, rales
Lookout for medic-alert bracelet
Abdomen Ensure abdomen is exposed
Look for bruising, lacerations, bowel eviscerations
Palpate abdomen for tenderness, rigidity or guarding
Pelvis Locate crests of ilium (hips) and gently exert pressure
Instability or pain from this compression may indicated fracture of the pelvis
Genitalia Should not normally be done – unless obvious signs of injury i.e. blood soaking through clothing,
impalement of object
Always be sensitive and cautious when exposing genitalia – allow pt. maintain dignity – provide privacy
Very legal problems may be caused by this type of examination
Extremities Expose legs and arms if injury is expected
Examine for bleeding, deformity, bruising, abnormalities or abnormal positioning of limbs
Test pt. sensation – response to touch – BADINSKI REFLEX – normal movement toes curl – abnormal
movement toes pull up and away for touch.
Medical pt. look for swelling – sacral oedema and pericardial oedema and poor circulation (pulse)
Lookout for medic-alert bracelet
Completion of examining legs – examine arms in the same manor.

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3 Triage
 Triage is a French word – meaning sorting
 Defined as categorizing and sorting of pt. according to degree / severity of injuries / illness

 Assessment of injuries is conducted briefly – establishing

o Type of injuries sustained
o How severe injuries are
o Who is to receive priority in primary care
o And transportation to medical facility

 During this assessment ABC principle is applied

o Screaming, hysterical pt. usually NOT highest priority
 Pt. is conscious and has open airway
o Silent pt. usually have depressed level of consciousness
 Possible airway obstruction
 Possible breathing difficulty
 Possible haemorrhage – resulting in shock
 ECP responsible for triage MUST overcome desire to stop and treat individual pt. – ECP must complete ABC
 ECP should continue categorizing each pt.
 To enable arriving team to quickly identify pt. needs of immediate treatment

3.1.1 Prioritization of pts.

 ECP responsible for triage must ensure all pt. are closely monitored – triaging pt. may change
 Attention must be directed to priority 1 (/ highest priority) before treatment is administered to priority two pt. (/
lower priority pt.)
 Call centre must be updated of ALL events on continuous basis and any further assistance required
 Triage MUST be performed repeatedly (does not consist of one assessment)

[Link] Priority 1
Highest priority
Life threatening emergencies

Pt. in danger of asphyxia / hypoxia

 Obstructed airway
 Apnea
 Sucking chest wounds
 Tension pneumothorax
 Pt. in shock / impending shock
 Major external / internal bleeding
 Burns over more than 20% of body surface
 Cardiac tamponade

[Link] Priority 2
Second priority
Pt. seriously injured

 Visceral injuries WITHOUT shock

 Burns – less than 20%
o Including face / hands / feet / genitalia
 Spinal cord injuries
 Compound fractures / dislocations

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[Link] Priority 3
Third priority
Pt. with moderate to light injuries

 Soft tissue injuries WITHOUT shock

 Musculoskeletal injuries WITHOUT shock / WITHOUT loss of pulse / WITHOUT loss in sensation
 Minor injuries of the eyes
 Burns of other locations – less than 20%

[Link] Priority 4
These are dead pt.

Priority 4 pt. should be left where they are found and covered
SAPS will take over responsibility for removal of these victims

4 Pt. Effective interaction / communication

4.1 Effective interaction with patients
 Make and keep eye contact
 Use pt. proper name (if you forget pt. name – use sir/ma’am)
 Tell pt. truth
 Use language pt. can understand
 Be careful of what you say about pt. to others
 Be aware of own body language
 Speak slowly, clearly, distinctly (always)
 If pt. hearing impaired, speak clearly and face pt. when speaking
 Allow time for pt. to answer questions
 Act in calm, confident manner

4.2 Communicating with elderly pt.

 Determine pt. function age
 DO NOT assume elderly pt. senile / confused
 Allow pt. ample time to respond
 Watch for confusion, anxiety, impaired hearing / vision
 ALWAYS explain what is being done

4.3 Communicating with children

 Children are aware of what’s going on
 Allow people / objects that provide comfort to remain close
 Explain procedures to children truthfully
 Position yourself on their level

4.4 Communicating with hearing impaired pt.

 Always assume pt. has NORMAL intelligence
 Make sure you have paper and pen
 Face pt. and speak slowly, clearly and distinctly
 NEVER shout
 Learn simple phrases used in sign language

4.5 Communicating with visually impaired pt.

 Ask pt. if they can see at all
 Explain all procedures truthfully as being performed
 If guide dog present – transport guide dog also.

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4.6 Language barriers

 Use short, simple questions and answers
 Points to specific parts of body as you ask questions
 Learn common words and phrases – non-English language areas

4.7 Mentally disturbed pt.

 Interaction with mentally disturbed can be difficult at best of times
 Should be kept in mind – abnormal behaviour may be part and parcel of medical diseases, reaction to severe
stress, drug abuse
 NOT every pt. has specific mental (psychiatric) disorder.
 Pt. with hypoglycaemia or alcohol ingestion may appear mentally disturbed

5 Disruptive behaviour and drug abuse

Overview
 Drug defined as substance – can produce physical / mental effect on the body
 Every drug can have undesirable side effect or reaction
 Some reactions are life threatening and require emergency treatment
 Sometimes drugs misused and cause serious reactions
 Most drugs abused are done for mood altering effects
 Includes alcohol
 General misuse of drugs is termed as “substance abuse”

5.1 Drugs
Drug defined as substance – can produce physical / mental effect on the body
 Drug abuse is worldwide
 Varies from
 Simple minor overdoses of medically prescribed drugs
o Inhalation of intoxicating chemicals
o To major narcotic usage
 Cocaine powerful CNS stimulant
 Heroin CNS depressant – does have mood elevating effects
 LSD - One of most important and dangerous hallucinogenic drug
o Alters pt. awareness of themselves – can cause fatal situations when pt. believes they can leap off
buildings and fly.

5.2 Alcohol
 Alcohol – powerful CNS depressant
 Chronic alcoholics may be suicidal
 Drunken pt. may show aggression, inappropriate behaviour, fall easily / be combative
 Pt. who abuses alcohol and drugs usually have underlying personality disorder
o Pt. should always be approached in caring and understanding manner
 If pt. becomes too aggressive – call for assistance - SAPS

6 Death and terminal illness

6.1 SIDS (Sudden Infants Death Syndrome)
 Thousands of babies die from SIDS every year
 Usually occurs during sleep – in apparently healthy baby: 2 – 4 month old
 Also known as cot death

 Almost certainly encounter anguished, severely distressed pts.

 Always make effort to revive baby with basic life support – unless baby is cold and stiff
 Transport to hospital – even if baby seems dead to you

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o Be sure to examine baby

o Signs of child abuse – DO NOT make this obvious to the parents
 Evidence of child abuse MUST be reported to doctor at receiving hospital

6.2 Sudden death

 Often pt. will not have been previously ill / in danger – death will be a great shock to everyone
 Any doubts if the pt. is dead – full resuscitation should be carried out.
o When person obviously dead – support should be given to the family and friends
 Keep family informed of what you are doing
 Close relatives and friends should be allowed to see the body if desired
o BUT any mutilated areas should be covered
 NEVER raise false hopes – possible response to resuscitation if death is inevitable
 If possible, do not resuscitate pt. when family around; ask family to leave the room

6.3 Terminal illness

 Terminally ill pt. usually know / strongly suspect they are about to die
 May be little to do for terminally ill pt. – other than to make them comfortable
 Determine if pt. and family are aware that death is approaching
 Pt. should NOT die alone!!

7 Abuse
7.1 Child abuse
 Child abuse may take many forms
o Beatings
o Burns
o Rape
o Even attempted murder
 Anyone may be a victim of abuse – seen most often among family members
 Victims / pts. Of abuse may demonstrate anger / rage / withdrawal
 Victim may say little, appear not to care, may not want anyone near them
 If child abuse it suspected – make every effort to get child to hospital for doctors examination
o RMB to express your feelings to doctor – avoid confronting parents with suspicions

7.2 Adult abuse

 Commonly known as “wife beating” / “husband beating” (abuse of husbands also recognised)
 May be possible at times to quietly discuss problem with victim alone – who will often refuse help
 However – issue must NOT be forced – best course of action
o Attempt to persuade pt. to be taken to hospital

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