Detailed Lesson Plan
Chapter 13
Patient Assessment
500–600 minutes
Chapter 13 objectives can be found in an accompanying folder.These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines. /
Minutes / Content Outline / Master Teaching Notes /
5 / I. Introduction
A. During this lesson, students will learn about all of the components of the patient assessment procedures they will perform on every patient they encounter during their career as EMTs.
B. Case Studies
1. Present Dispatch and Upon Arrival information from the chapter.
2. Discuss with students how they would proceed. / Case Study Discussion: Call One
· Is the scene safe?
· What are some possible mechanisms of injury?
· What will you do first?
Case Study Discussion: Call Two
How will you respond to the daughter? Do any initial questions come to mind?
PART 1. SCENE SIZE-UP
20 / II. Scene Size-Up
A. Take necessary Standard Precautions.
B. Evaluate scene hazards and ensure scene safety.
1. Personal protection
2. Protection of the patient
3. Protection of bystanders
C. Determine the mechanism of injury or the nature of the illness.
1. Trauma patient
2. Medical patient
D. Establish the number of patients.
E. Ascertain the need for additional resources to manage the scene or the patients. / Teaching Tip
Use questioning to determine what students recall from your initial discussion of scene size-up.
Discussion Question
What are the purposes of the scene size-up?
PART 2. PRIMARY ASSESSMENT
5 / III. Primary Assessment
A. Purposes
1. Determine if the patient is injured or ill.
2. Identify and manage immediate life threats (PRIORITY).
3. Decide whether to transport immediately, or to proceed with further assessment and care on the scene.
B. Steps
1. Form a general impression of the patient.
2. Assess the level of consciousness (mental status).
3. Assess the airway.
4. Assess breathing.
5. Assess circulation.
6. Establish patient priorities. / Teaching Tip
Write the six steps of the primary assessment on the white board to give students a map for the upcoming information.
5 / IV. Form a General Impression of the Patient—Determine if the Patient Is Injured or Ill
A. Form a general impression as you approach the patient.
1. Age group and sex of the patient
2. Well or ill
3. Stable or unstable
4. Injured or uninjured
B. Immediately address obvious severe or life-threatening injuries.
1. If you suspect spine injury, stabilize the patient’s head and spine.
2. Control severe bleeding.
C. Remember that your general impression may change as you gather more information.
D. Be alert for general clues to the patient’s condition throughout the assessment.
E. Condition of an injured patient
1. Penetrating trauma: result of force that pierces the skin and body tissues
2. Causes include bullet, knife, or other hard and sharp object (screwdriver, ice pick, and so on).
3. Blunt trauma: a force that impacts the body without penetration
4. Causes include a blow, car crash, fall, fight, or collapse of a building.
F. Clues to an ill patient
1. Presence of pills in the room
2. Patient in bed/undressed in the daytime
3. Evidence of vomiting / Discussion Questions
· What are some initial indications that a patient is sick?
· What might indicate to you that a patient has been injured?
Critical Thinking Discussion
Why is it important to develop a general impression before proceeding with further assessment of the patient?
5 / V. Form a General Impression of the Patient—Obtain the Chief Complaint
A. Chief complaint is patient’s answer to the question “Why did you call us?”
B. If patient cannot answer, ask family or bystanders.
C. If no one knows, you will have to infer from observation.
D. Common categories of chief complaint
1. Pain
2. Abnormal function
3. EMT observation of something not right
E. Patient may be suffering more serious condition(s) than the chief complaint.
F. Ask additional questions that refine the chief complaint.
G. Use the information to make decisions about treatment and transport.
5 / VI. Form a General Impression of the Patient—Identify Immediate Life Threats During the General Inspection
A. Obvious life threats are those you can see right away as you first approach the patient.
B. Treat immediately before continuing assessment.
5 / VII. Form a General Impression of the Patient—Establish In-Line Stabilization
A. If you suspect spine injury
1. Place one hand on each side of the patient’s head.
2. Gently bring the head into a position in which the nose is in line with the navel.
3. Position the head neutrally so it is not tipped backward or forward.
B. Maintain manual in-line stabilization until patient is completely immobilized to a backboard. / Teaching Tips
· Emphasize the importance of establishing stabilization of the cervical spine in patients who may have spine trauma.
· Demonstrate in-line manual stabilization of the cervical spine.
5 / VIII. Form a General Impression of the Patient—Position the Patient for Assessment
A. If patient is prone (face down), quickly log roll him into a supine position (facing up).
B. Before performing the log roll, assess the following areas.
1. Posterior thorax and lumbar regions
2. Vertebral column
3. Buttocks
4. Posterior aspects of the lower extremities
C. Inspect and palpate for the following.
1. Major bleeding
2. Deformities
3. Open wounds
4. Bruises
5. Burns
6. Swelling or tenderness
D. Occlude any open wounds to posterior thorax quickly before log roll.
E. If you suspect spine injury, establish in-line stabilization before log rolling patient onto his back.
20 / IX. Assess Level of Consciousness (Mental Status)—Assess the Level of Responsiveness
A. Assess the patient using the AVPU mnemonic.
1. A: Alertness and orientation
a. Are the patient’s eyes open?
b. Is he able to speak to you?
c. Does he appear agitate, confused, or disoriented?
2. V: Responsiveness to verbal stimulus
a. Does the patient open his eyes and respond, or try to respond, only when you speak to him?
b. If he does not speak, does he obey your commands (such as “squeeze my fingers”)?
c. Does he stare off, talk inappropriately, mumble, or do nothing?
3. P: Responsiveness to painful stimulus
a. Central painful stimuli
i. Trapezius pinch
ii. Supraorbital pressure
iii. Sternal rub
iv. Earlobe pinch
v. Armpit pinch
b. Peripheral painful stimuli
i. Nail bed pressure
ii. Pinch to web between thumb and index finger
iii. Pinch to finger, toe, hand, or foot
c. Patient response
i. Purposeful movement: patient tries to remove stimulus or avoid pain (pushes you away, grabs your hand).
ii. Nonpurposeful movement: flexion or extension posturing
d. Problems with some types of painful stimuli
i. Always assess central painful stimuli, as peripheral painful stimuli are less accurate indicators of brain’s responsiveness.
ii. Sternal rub has been questioned as producing possibly inaccurate results and being too damaging to patient.
4. U: Unresponsiveness
a. No response to verbal or painful stimuli
b. Loss of gag and cough reflexes
c. Inability to control tongue and epiglottis
d. Priority for emergency care and transport
B. Document the level of responsiveness in very specific language (such as “made a facial grimace and grasped my hand”).
C. Take only a few seconds to assess patient’s mental status. / Teaching Tips
· Use examples from your experience to illustrate each level of responsiveness represented by AVPU.
· Explain that the purpose of applying a painful stimulus to a patient who is not alert and who has not responded to verbal stimuli is to assess the nervous system response, not to unnecessarily inflict discomfort.
· Show students (without actually inflicting pain) how each of the suggested methods for assessing response to pain is performed.
Discussion Questions
· What are acceptable ways of determining a patient’s response to painful stimuli?
· What are the differences between decorticate and decerebrate posturing?
· What are the concerns for patients who have an altered mental status?
Class Activity
Have students use one of the methods described to apply painful stimuli to themselves to increase their awareness of what it is they will be subjecting patients to.
Knowledge Application
Give several descriptions of patients and ask students to determine the level of consciousness for each patient.
Critical Thinking Discussion
What is the importance of determining the patient’s mental status early in the assessment process?
5 / X. Assess the Airway—Determine Airway Status
A. In the responsive patient
1. If alert patient is talking without difficulty, or crying, assume airway is patent and move on to assessment of breathing.
2. If alert patient has stridor, has difficulty speaking, is gasping, or is not speaking at all, examine for a partially blocked airway.
3. If you have any doubt at all that airway is open, open it.
B. In the unresponsive or severely altered mental status patient, check and open airway.
5 / XI. Assess the Airway—Open the Airway
A. Open and maintain airway with any or all of the following techniques.
1. Manual airway maneuvers
a. Head-tilt (if you do not suspect spine injury)
b. Chin-lift (if you do not suspect spine injury)
c. Jaw-thrust (if you suspect a spine injury)
2. Suction and/or finger sweeps
3. Airway adjuncts to maintain patient airway
4. Manual thrusts to abdomen, or chest thrust and back blows for infants
5. Positioning of patient without spine injury in a modified lateral position
5 / XII. Assess the Airway—Indications of Partial Airway Occlusion
A. Snoring
1. Indicates that tongue and epiglottis are partially blocking the airway
2. Use the head-tilt, chin-lift, or jaw-thrust maneuver to relieve the obstruction.
3. If you still hear snoring, insert an oropharyngeal airway (for unresponsive patient without gag reflex).
4. If patient gags
a. Remove oropharyngeal airway immediately.
b. Be prepared to suction.
c. Consider insertion of a nasopharyngeal airway.
B. Gurgling
1. Indicates that a liquid substance is in the airway
2. Open the patient’s mouth and suction out the contents.
3. If necessary, turn the patient onto his side and sweep out the mouth with your fingers.
4. Patient may unintentionally bite down on your fingers; place a bite stick between his teeth if necessary.
5. Be prepared and do not waste time; use whatever device or technique is most readily available to clear the airway.
C. Crowing and stridor
1. Indicates swelling or muscle spasms
2. Inserting anything (fingers or tools) into the patient’s mouth can cause dangerous spasms and total obstruction of airway.
3. Begin ventilation with a bag-valve-mask device with supplemental oxygen. / Discussion Questions
· What action should you take when a patient is snoring?
· What do gurgling sounds in the airway indicate?
· What should be suspected when stridor or crowing sounds are heard?
Critical Thinking Discussion
Why would using an oral or nasal airway be unlikely to improve the airway of a patient with stridor or crowing noises?
15 / XIII. Assess Breathing—Assess Rate and Quality of Breathing
A. Look at the chest for the following.
1. Inadequate tidal volume
2. Abnormal respiratory rate
3. Bradypnea (breathing too slowly) causes
a. Hypoxia (especially child or infant)
b. Drug overdose (depressants)
c. Head injury
d. Stroke
e. Hypothermia
f. Toxic inhalation
4. Tachypnea (breathing too rapidly) causes
a. Hypoxia
b. Fever
c. Pain
d. Drug overdose
e. Stimulant drug use
f. Shock
g. Head or chest injury
h. Stroke
i. Other medical conditions
5. Retractions
6. Use of the neck muscles
7. Nasal flaring
8. Excessive abdominal muscle use
9. Tracheal tugging
10. Pale, cool, clammy skin
11. Cyanosis
12. A pulse oximeter reading of less than 95 percent
13. Asymmetrical movement of the chest wall
B. Listen and feel for air movement and escape of warm, humidified air.
C. Absent or inadequate breathing: Immediately begin positive pressure ventilation with supplemental oxygen.
1. Absence of breathing
a. No chest wall movement
b. No sound of air moving in or out of nose or mouth
2. Inadequate breathing
a. Insufficient or ineffective respiratory rate
b. Inadequate tidal volume
c. Signs of inadequate oxygenation
d. Signs of serious respiratory distress
D. Adequate breathing
a. Chest is rising and falling adequately.
b. You hear and feel good air exchange.
c. Respiratory rate is adequate.
d. No evidence of serious respiratory distress.
e. Consider administering oxygen if adequately breathing patient is injured or ill.
E. Oxygen therapy in the patient with adequate breathing
1. Based on the following
a. Patient’s condition
b. Signs and symptoms of hypoxia, poor perfusion, or respiratory distress
c. SpO2 reading
2. Adminster oxygen at 15 lpm by nonrebreather mask if you have any doubt about whether patient needs it or if any of the following are present.
a. Shows deteriorating mental status
b. Becomes anxious, confused, sleepy, or disoriented
c. Exhibits hypoxia, poor perfusion, or respiratory distress
d. Complains of chest discomfort or shortness of breath
F. Adequate oxygen based on SpO2 reading of 95 percent or higher / Teaching Tip
Much of this section is review for students. Ask questions to determine students’ comprehension and retention of the material to guide your approach to the material.
Discussion Question
What are signs of inadequate oxygenation?
Knowledge Application
Describe the findings of breathing assessment for several patients. Ask students whether breathing is adequate or inadequate, and what interventions may be needed.
Discussion Questions
· What are ways in which EMTs can provide positive pressure ventilation for patients with inadequate breathing?
· What oxygen delivery device provides the highest concentration of oxygen for spontaneously breathing patients?
3 / XIV. Assess Circulation—Assess the Pulse
A. If you cannot feel a radial (wrist) pulse, check for carotid (neck) pulse.