Emergency Medical Responder, Fifth Edition Chapter 8: Patient Assessment
Chapter 8
Patient Assessment
Unit Summary
After students complete this chapter and the related coursework, they will understand the scope, sequence, and phases of patient assessment. This chapter is divided into five sections: Scene Size-up, Initial Assessment, Physical Examination, Patient’s Medical History, and Ongoing Assessment. Mastery of the skills in this chapter is essential to provide a foundation for learning subsequent skills presented in this book.
National EMS Education Standard Competencies
Assessment
Use scene information and simple patient assessment findings to identify and manage immediate life threats and injuries within the scope and practice of the emergency medical responder (EMR).
Scene Size-Up
• Scene safety (pp 164–165)
• Scene management (pp 164–165)
o Impact of the environment on patient care (p 164)
o Addressing hazards (pp 164–165)
o Violence (p 164)
o Need for additional or specialized resources (pp 165–166)
o Standard precautions (p 166)
Primary Assessment
• Primary assessment for all patient situations (p 168)
o Level of consciousness (p 168)
o ABCs (pp 169–170)
o Identifying life threats (p 169)
o Assessment of vital functions (p 169)
• Begin interventions needed to preserve life (pp 169–170)
History Taking
• Determining the chief complaint (p 172)
• Mechanism of injury/nature of illness (p 165)
• Associated signs and symptoms (p 172)
Secondary Assessment
• Performing a rapid full-body scan (p 175)
• Focused assessment of pain (p 175)
• Assessment of vital signs (p 180)
Reassessment
• How and when to reassess patients (p 186)
Knowledge Objectives
1. Discuss the importance of each of the following steps in the patient assessment sequence:
§ Scene size-up (p 164)
§ Primary assessment (p 168)
§ History taking (p 172)
§ Secondary assessment (p 175)
§ Reassessment (p 186)
2. Discuss the components of a scene size-up. (pp 164–166)
3. Explain why it is important to get an idea of the number of patients at an emergency scene as soon as possible. (p 166)
4. List and describe the importance of the following steps of the primary assessment:
§ Forming a general impression of the patient (p 168)
§ Determining the patient’s level of responsiveness (p 168)
§ Performing a rapid scan, including:
· Assessing the patient’s airway (p 169)
· Assessing the patient’s breathing (p 169)
· Assessing the patient’s circulation (pp 169–170)
§ Updating responding EMS units (p 170)
5. Describe the differences in checking airway, breathing, and circulation when the patient is an adult, a child, or an infant. (pp 170, 180–181)
6. Explain the purpose for obtaining a patient’s medical history. (p 172)
7. Discuss the SAMPLE approach to obtaining a patient’s medical history. (pp 172–173)
8. Explain the difference between a sign and a symptom. (p 175)
9. Describe the sequence used to perform a full-body secondary assessment. (pp 175–180)
10. List the areas of the body that you should examine during the secondary assessment. (pp 175–180)
11. Explain the significance of the following signs: respiration, circulation, blood pressure, skin condition, pupil size and reactivity, level of consciousness. (pp 180–184)
12. List the information that should be obtained during reassessment. (p 186)
13. List the information about the patient’s condition that should be addressed in your hand-off report. (p 186)
14. Explain the differences between performing a patient assessment on a medical patient and performing one on a trauma patient. (p 187)
Skills Objectives
1. Demonstrate the following five steps of the patient assessment sequence:
a. Scene size-up (p 164)
b. Primary assessment, including:
i. Forming a general impression of the patient (p 168)
ii. Assessing the patient’s responsiveness (p 168)
iii. Assessing the patient’s airway (p 169)
iv. Assessing the patient’s breathing (p 169)
v. Assessing the patient’s circulation (including severe bleeding) (pp 169–170)
vi. Updating responding EMS units (p 170)
c. Obtaining the patient’s medical history using the SAMPLE format (pp 172–173)
d. Performing a secondary assessment, including:
i. Performing a full-body examination (pp 175–180)
ii. Identifying and measuring a patient’s vital signs (pp 180–184)
e. Performing an ongoing reassessment (p 186)
Readings and Preparation
Review all instructional materials, including Emergency Medical Responder, Fifth Edition, Chapter 8, and all related presentation support materials.
• Review any local protocols on patient assessment for EMR personnel.
• Practice your own assessment skills, paying particular attention to the DOT progression, prior to teaching this lesson.
• This EMS1 web site includes an article written by Brian Potter on patient assessment for new providers:
o www.ems1.com/ems-products/education/articles/507226-Patient-Assessment-Tips-from-the-Field-for-NewProviders/
Support Materials
• Lecture PowerPoint presentation
• Skill Drill PowerPoint presentations
o Skill Drill 8-1, Performing a Secondary Assessment PowerPoint presentation
• Equipment needed to perform the psychomotor skills presented in this chapter.
• Patient assessment template from the beginning of Chapter 8 of the text (several copies)
• Skill Evaluation Sheets
o Skill Drill 8-1, Performing a Secondary Assessment
Enhancements
• Direct students to visit the companion web site to the Tenth Edition at www.EMR.EMSzone.com for online activities.
• Contact a local EMS agency for information on local standards of care and protocols for performing patient assessment.
• This web site includes sobering and tragic accident scene incidents involving EMS and fire fighters injured while attending to victims. Consider having students visit this web site to reinforce the importance of scene safety for emergency responders:
o www.lionvillefire.org/hwy_safety/Highway_Incident_Summary_1997-2002.pdf
Teaching Tips
• Before teaching this section, make sure you are proficient and comfortable with the sequence and components of all aspects of patient assessment as organized by the DOT.
• Remember to maintain a valid student-to-instructor ratio during all practical sessions. A ratio of one instructor to six students is recommended.
• Emphasize the different sections of the patient assessment using the flowcharts provided in the textbook. Help students see the skill from the whole perspective. Consider using the color codes shown in the flowcharts to create larger diagrams for display in the classroom. Students may want to add their own signs and symptoms to these larger flowcharts using color-coded index cards to help in organizing new information as it is learned.
Unit Activities
Writing assignments: Distribute a patient assessment template to each student and assign him or her a specific medical condition or trauma scenario. Students will then need to research the assigned condition and fill out the assessment with appropriate findings one would expect with such a patient. Collect the completed templates, review them, and use them for the activity described in the Group Activities section.
Student presentations: As an alternative to the written assignment, distribute completed assessment scenarios, one to each student group, allowing each group a few minutes to discuss roles and approach. Groups will then take turns presenting their scenarios to the class. The observing students will use blank templates to evaluate the thoroughness of the assessment of each presenting group. Stress the importance of constructive comments only, and ask students to hold all comments until the scenario is completed.
Group activities: Prepare several manikins (one for each group) ahead of time by dressing them in old (unwanted) clothing after securing various index cards to the body indicating injuries and/or assessment findings. Write each finding on a separate card, fold it, number it in order of required discovery, and tape it in place. Dress the manikin, covering as many of the cards as is reasonable. Students must “discover” each symptom or sign as they perform the assessment. Students may not take clues out of order even if they are visualized. Also, students may not take clues without completing that part of the assessment in which the findings would be expected to be discovered. For example, if the student does not verbalize or perform auscultation of lung sounds, he or she should not be allowed to take the index card indicating lung sound findings. Be sure to place the cards on body parts that would necessitate log roll or exposure to find them.
Medical terminology review: Prepare a patient assessment narrative ahead of time using longer descriptive definitions in place of correct medical terminology. Distribute the narrative to student groups for a timed exercise in which they need to replace the definitions with correct medical terminology. For example, the assessment narrative might state, “While examining the patient, a grinding, grating sensation was palpated over the proximal tibia” or “The delicate membrane that lines the patient’s eyelids was found to be very pale.” Underlined words must be replaced with the correct terminology (ie, crepitus and conjunctiva, respectively).
Visual thinking:
• Have students create a life-size “patient” by outlining a team member using several large pieces of poster paper. Assign a disease or trauma scenario to each group, and have the team display the picture of their patient on the wall. Each group should label its patient’s signs and symptoms in the proper body location. Students can add to these posters as they learn more about each condition in subsequent lessons.
• Collect several photos of accident scenes, interiors of homes, large events, and so forth from the Internet or other source. Arrange the photos in a PowerPoint presentation. Have students write down scene hazards, possible mechanisms of injury/illness, and their general impression for each photo. Display each photo for a limited amount of time (10–20 seconds). Discuss findings and the importance of good observation skills.
Pre-Lecture
You are the Provider
“You are the Provider” is a progressive case study that encourages critical thinking skills.
Instructor Directions
1. Direct students to read the “You are the Provider” scenario found throughout Chapter 8.
2. You may wish to assign students to a partner or a group. Direct them to review the discussion questions at the end of the scenario and prepare a response to each question. Facilitate a class dialogue centered on the discussion questions.
3. You may also use this exercise as an individual activity and ask students to turn in their comments on a separate piece of paper.
Lecture
I. Introduction
A. EMRs are the first trained EMS providers at many emergency scenes.
1. Your assessment of the scene and the patient will affect the level of care requested for the patient.
2. It is important that you are able to perform a systematic patient assessment to determine whether your patient has a medical condition or has sustained injuries from trauma.
B. The patient assessment sequence consists of five steps:
1. Perform a scene size-up.
2. Perform a primary assessment.
3. Obtain the patient’s medical history.
4. Perform a secondary assessment.
5. Perform a reassessment.
C. This sequence allows you to systematically gather the information you need.
D. The skills and knowledge presented in this chapter follow an assessment-based care model.
1. With assessment-based care, the treatment rendered is based on the patient’s symptoms.
2. Assessment-based care requires you to conduct a careful and thorough evaluation of the patient so that you can provide appropriate care.
II. Patient Assessment Sequence
A. The patient assessment sequence provides a framework so that you can:
1. Safely approach an emergency scene
2. Determine the need for additional help
3. Examine the patient to determine if injuries or illnesses are present
4. Obtain the patient’s medical history
5. Report the results of your assessment to other EMS personnel
III. Scene Size-up
A. The scene size-up is a general overview of the incident and its surroundings.
B. Review dispatch information.
1. Anticipate possible conditions by reviewing and understanding the dispatch information.
2. Your dispatcher should have obtained the following information:
a. Location of the incident
b. Main problem or type of incident
c. Number of people involved
d. Safety level of the scene
3. Other factors can also affect your actions:
a. Time of day
b. Day of the week
c. Weather conditions
4. Think about the resources that may be needed and mentally prepare for other situations you may find when you arrive on the scene.
5. If you should come across a medical emergency, notify the emergency medical dispatch center by using your two-way radio.
a. If you do not have a two-way radio, use a cellular phone or send someone to call for help.
C. Ensure scene safety.
1. Park your vehicle so that it helps secure the scene and minimizes traffic blockage.
2. Scan the scene to ensure that you are not putting yourself in danger and make the following determinations:
a. Extent of the incident
b. Possible number of people injured
c. Presence of possible hazards
3. Hazards can be visible or invisible.
a. Visible hazards include:
i. Scene of a crash
ii. Fallen electrical wires
iii. Traffic
iv. Spilled gasoline
v. Unstable buildings
vi. Crime scene
vii. Weather
viii. Crowds
ix. Unstable surfaces such as slopes, ice, and water
b. Invisible hazards include:
i. Electricity
ii. Biologic hazards
iii. Hazardous materials
iv. Poisonous fumes
4. Note hazards, consider your ability to manage them, and decide whether to call for assistance.
5. If a scene is unsafe, keep people away until specially trained teams arrive.
6. Identify potential exit routes from the scene in the event a hazard becomes life threatening, and wear appropriate personal protective equipment.
D. Determine the mechanism of injury or nature of illness.
1. Look for clues that may indicate how the accident happened.
2. If you can determine the mechanism of injury (MOI) or nature of illness (NOI), you can sometimes predict the patient’s injuries.
3. Ask the patient, family members, or bystanders for additional information.
4. Do not rule out any injury without conducting a full-body physical assessment of the patient.
E. Take standard precautions.
1. Before arriving at the scene, prepare yourself by anticipating the types of standard precautions for infectious diseases that may be required.
2. Always have gloves readily available.
3. Consider whether the use of additional protection, such as eye protection, gowns, or masks, may be necessary.
4. Wash your hands thoroughly after contact with a patient or contaminated materials.