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Patient Assessment

Beginning the Physical Examination:

Scene Size-Up, General Survey, Vital Signs, and Pain

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Scene Size-Up

1. Scene Safety 2. BSI 3. MOI/NOI 4. # Patients 5. Additional Help? 6. C-Spine?

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Initial Assessment

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Initial /Primary Assessment

1. General Impression Age, Sex, Race, CC, Environment

2. Mental Status AVPU

3. Airway (C-Spine) 4. Breathing 5. Circulation

Pulse – Skin - Bleeds

6. Determine Priority

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Components of General Survey

General Appearance/Impression

Height and Weight

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General Appearance - Description

Apparent state of health Acute or chronically ill, frail

Level of consciousness Awake, alert, responsive or

lethargic, obtunded, comatose

Signs of distress Cardiac or respiratory; pain;

anxiety/depression Skin color and obvious

lesions

Dress, grooming, and personal hygiene Appropriate to weather

and temperature Clean, properly

buttoned/zipped Facial expression

Eye contact, appropriate changes in facial expression

Odors of body and breath Posture, gait, and motor

activity

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Mental Status and Behavior Terminology

To appreciate the differences in mental status and behavior, you must learn the terminology

Level of consciousness: how aware the person is of his environment

Attention: the ability to focus or concentrateo Alert: the patient is awake and awareo Lethargic: you must speak to the patient in a

loud forceful manner to get a responseo Obtunded: you must shake a patient to get a response o Stuporous: the patient is unarousable except

by painful stimuli (sternal rub)o Coma: the patient is completely unarousable

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Height and Weight Height

Short or tall Build: slender and lanky, muscular, or stocky Body symmetry Note general body proportions and any deformities

Weight Emaciated, slender, plump, obese If obese, is fat distributed evenly or concentrated

over trunk, upper torso, or around the hips? small – medium – large?

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Initial Assessment?

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What next

Health form History

http://videos.med.wisc.edu/videos/33744

Secondary Assessment: Detailed exam Focused exam

Ongoing exam

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Health History: subjective Changes in weight

Rapid or gradualo Rapid changes over a few days suggest changes in fluid, not tissue

Weight gain: nutrition vs. medical causes

Weight loss: medical vs. psychosocial causes

Fatigue and weakness Fatigue: a sense of weariness or loss of energy

Weakness: a demonstrable loss of muscle power

Medical vs. psychosocial causes

Fever, chills, and night sweats Ask about exposure to illness or any recent travel

Some medications may cause elevated temperature

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Question

A patient presents with a 6-day history of rapid weight gain, and increasing fatigue. The most likely explanation is:

a. Dysphagia

b. Excessive absorption of nutrients

c. Diabetes mellitus

d. Accumulation of body fluids

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Answer

d. Accumulation of body fluids

Rapid changes over a few days suggest changes in fluid.

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Vital Signs

Blood pressure

Heart rate and rhythm

Respiratory rate and rhythm

Temperature

Pain

SaO2

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QuestionA patient’s vital signs are recorded as follows:

T 98.4 F, HR 74, R 18, BP 180/98What would be the MOST appropriate action related to this patient’s vital signs?

a. The blood pressure should not be repeated

b. Repeat the blood pressure and verify in contralateral arm

c. Check the heart rate again to see if it is regular

d. Listen to the patient’s lungs for adventitious sounds

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Answerb. Repeat the blood pressure measurement

and verify in the contralateral arm

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Pain

Assess OPQRST

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Pain

Types of pain Nociceptive or somatic – related to tissue damage

Neuropathic – resulting from direct trauma to the peripheral or central nervous system

Psychogenic – relates to factors that influence the patient’s report of paino Psychiatric conditionso Personality and coping styleo Cultural normso Social support systems

Idiopathic – no identifiable etiology

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Examination Techniques

Inspection Palpation Percussion Auscultation

System with cc: function / physiology System above and below

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Thoracic Landmarks—Anterior Chest

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Shoulders and Related Structures

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Percussion and Auscultation of Chest

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Thoracic Landmarks—Posterior Chest

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Spine

Inspection Cervical, thoracic, and

lumbar curves Lordosis (swayback) Kyphosis (hunchback) Scoliosis (razorback)

Height differences of shoulders

Height differences of iliac crest

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Breath Sounds

Fig. 11-26Fig. 11-26

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Pulse

Auscultate for: Frequency (pitch) Intensity (loudness) Duration Timing in cardiac

cycle

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Abdomen

four quadrants

Inspect Auscultate Percuss Palpate

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Abdomen—Inspection

Skin Umbilicus Contour Abdominal

movement

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Pelvis

Pelvic structural integrity Hands on anterior iliac

crests Press down and out

Heel of hand on symphysis pubis

Press down

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Ankles and Feet

Range of motion Dorsiflexion Plantar flexion Inversion Eversion

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Ongoing Assessment

Components Repeat initial assessment

Stable patient: every 15 minutes Unstable patient: every 5 minutes (minimum)

Reassess mental status Reassess airway Monitor breathing for rate and quality Reassess circulation Reestablish patient priorities