principles of patient assessment in ems

Barry Kidd 2010Barry Kidd 2010 11

Principles of Patient Principles of Patient Assessment in EMSAssessment in EMS


Baseline & Serial Vital SignsBaseline & Serial Vital Signs


ObjectivesObjectives

Describe the difference between a sign Describe the difference between a sign and a symptom and provide examples of and a symptom and provide examples of each.each.

List the devices EMS providers use to List the devices EMS providers use to measure signs.measure signs.

Describe the method for assessing a Describe the method for assessing a patient’s mental status using AVPU.patient’s mental status using AVPU.

Describe five abnormal breathing patterns Describe five abnormal breathing patterns and the typical causes of each.and the typical causes of each.

Specify the significance of assessing a Specify the significance of assessing a distal pulse versus a central pulse.distal pulse versus a central pulse.


Objectives Objectives (continued)(continued)

Describe the difference between a blood Describe the difference between a blood pressure taken with a stethoscope and one pressure taken with a stethoscope and one taken without a stethoscope and when it is taken without a stethoscope and when it is appropriate to use either technique.appropriate to use either technique.

List examples of abnormal skin C,T,T and the List examples of abnormal skin C,T,T and the possible indications or conditions for each.possible indications or conditions for each.

Define the mnemonic PEARL and explain the Define the mnemonic PEARL and explain the consensual light reflex and normal consensual light reflex and normal accommodations of the pupils.accommodations of the pupils.



Describe the principle of capillary refill in a Describe the principle of capillary refill in a pediatric patient.pediatric patient.

Describe the principle of pulse oximetry Describe the principle of pulse oximetry and provide examples of when a reading and provide examples of when a reading may be unreliable.may be unreliable.



Distinguish between a baseline set of vital Distinguish between a baseline set of vital signs and serial vital signs.signs and serial vital signs.

Explain how the EMS provider develops Explain how the EMS provider develops trends examining serial sets of vital signs.trends examining serial sets of vital signs.


IntroductionIntroduction Patient injuries and conditions are often Patient injuries and conditions are often

described in terms of signs and symptoms.described in terms of signs and symptoms.

Traditional vital Traditional vital signs include: signs include: Mental statusMental status RespirationsRespirations PulsePulse Blood pressureBlood pressure TemperatureTemperature

Additional signs Additional signs include:include: Pupil responsePupil response Pulse oximetryPulse oximetry


Signs & SymptomsSigns & Symptoms Signs can be measured by hand or with a Signs can be measured by hand or with a

device.device. Symptoms are subjective, such as:Symptoms are subjective, such as:

PainPain NauseaNausea VertigoVertigo

Sometimes the findings may be both signs Sometimes the findings may be both signs and symptoms:and symptoms: Dyspnea and the observable signs of Dyspnea and the observable signs of

respiratory distressrespiratory distress


Vital Signs (VS)Vital Signs (VS)

Often considered the starting point or Often considered the starting point or gauge of a patient’s health status.gauge of a patient’s health status.

Normal vitals are charted in ranges due to Normal vitals are charted in ranges due to fluctuations.fluctuations.

VS are to be included in the “big picture” VS are to be included in the “big picture” and not to be taken out of context.and not to be taken out of context.


Mental Status (MS)Mental Status (MS)

The most important VSThe most important VS Assess MS using AVPU:Assess MS using AVPU:

Alert – knows the big 3 (person, place, Alert – knows the big 3 (person, place, and day)and day)

Verbal – does not know all of the big 3Verbal – does not know all of the big 3 Painful – response to painful stimulusPainful – response to painful stimulus UnresponsiveUnresponsive


RespirationsRespirations

Evaluate rate, regularity, and quality Evaluate rate, regularity, and quality (adequacy)(adequacy)

Refer to ranges in each age group:Refer to ranges in each age group: AdultAdult ChildChild InfantInfant


Abnormal Respiratory Abnormal Respiratory PatternsPatterns

Cheyne-Stokes – Gradually increasing rate Cheyne-Stokes – Gradually increasing rate and tidal volume, which increases to a and tidal volume, which increases to a maximum, then gradually decreasesmaximum, then gradually decreases

Biot’s – Irregular pattern and volume, with Biot’s – Irregular pattern and volume, with intermittent periods of apnea. intermittent periods of apnea.

Agonal – Slow, shallow, irregular Agonal – Slow, shallow, irregular respirationrespiration


Abnormal Respiratory Abnormal Respiratory PatternsPatterns

Kussmaul’s – Deep grasping respirations, Kussmaul’s – Deep grasping respirations, representing hyperventilation, “blowing representing hyperventilation, “blowing off” of excess carbon dioxide and off” of excess carbon dioxide and compensation for an abnormal compensation for an abnormal accumulation of metabolic acids in the accumulation of metabolic acids in the bloodblood

Central neurogenic hyperventilation – Central neurogenic hyperventilation – Deep, rapid, regular respirationDeep, rapid, regular respiration


PulsePulse

Pulse is evaluated in terms of rate, Pulse is evaluated in terms of rate, regularity, and qualityregularity, and quality

If irregular count for 1 full minuteIf irregular count for 1 full minute Refer to ranges in each age group:Refer to ranges in each age group:

AdultAdult ChildChild Infant Infant


Pulse Pulse (continued)(continued)

The quality of the pulse may be described The quality of the pulse may be described as:as: WeakWeak ThreadyThready BoundingBounding StrongStrong


Pulse Pulse (continued)(continued)

Location of pulse checks:Location of pulse checks: Unconscious patient – carotid “quick Unconscious patient – carotid “quick

check”check” Infants – brachial artery in the upper Infants – brachial artery in the upper

armarm Adults – radial pulseAdults – radial pulse Distal vs. proximalDistal vs. proximal


Blood PressureBlood Pressure

Assessed by auscultationAssessed by auscultation Assessed by palpationAssessed by palpation Systolic - peak pressure in the Systolic - peak pressure in the

arterial system as the left ventricle arterial system as the left ventricle contractscontracts

Diastolic - residual pressure left in Diastolic - residual pressure left in the system as the left ventricle the system as the left ventricle relaxesrelaxes


How’s Your Blood Pressure?How’s Your Blood Pressure?

Refer to ranges in each age groupRefer to ranges in each age group Hypotension – a BP of:Hypotension – a BP of:

Systolic < 100 mmHgSystolic < 100 mmHg Diastolic < 60 mmHg Diastolic < 60 mmHg

Hypertension - a BP of:Hypertension - a BP of: Systolic >150 mmHgSystolic >150 mmHg Diastolic > 100 mm HgDiastolic > 100 mm Hg


Skin SignsSkin Signs Color, temperature, and condition (C,T,T)Color, temperature, and condition (C,T,T)

Observe the color of the nail beds, lips, and Observe the color of the nail beds, lips, and eyeseyes

Temperature:Temperature: Rectal – most accurateRectal – most accurate OralOral AxillaryAxillary TympanicTympanic


Skin Signs Skin Signs (continued)(continued)

Normal temperature – 37 C (98.6 F)Normal temperature – 37 C (98.6 F) Critically high > 40.6 C (105 F)Critically high > 40.6 C (105 F) Critically low < 30 C (86 F)Critically low < 30 C (86 F) Temperature is especially important in:Temperature is especially important in:

ChildrenChildren ElderlyElderly


Abnormal Skin ConditionsAbnormal Skin Conditions

Cool or cold and moist skin could be Cool or cold and moist skin could be caused by shock or the body may be caused by shock or the body may be losing heatlosing heat

Cold and dry skin may be caused by Cold and dry skin may be caused by exposure to cold, hypothermia, or poor exposure to cold, hypothermia, or poor peripheral circulationperipheral circulation

Hot and dry or moist skin may be caused Hot and dry or moist skin may be caused by high fever or heat exposureby high fever or heat exposure


Abnormal Skin ConditionsAbnormal Skin Conditions

Piloerection and shivering may be caused Piloerection and shivering may be caused by chills, exposure to cold, communicable by chills, exposure to cold, communicable disease, pain or feverdisease, pain or fever

Tenting of the skin may be caused by Tenting of the skin may be caused by dehydrationdehydration


Additional SignsAdditional Signs

Complete the overall assessment by Complete the overall assessment by considering additional signs:considering additional signs: PupilsPupils Capillary refillCapillary refill Pulse oximetryPulse oximetry


PupilsPupils Normal – equally round (3-5 mm)Normal – equally round (3-5 mm) Difference of > 1 mm is abnormalDifference of > 1 mm is abnormal Normal response is to constrict to lightNormal response is to constrict to light Consensual light reflexConsensual light reflex


Pupils Pupils (continued)(continued)

Accommodation Accommodation (turning the eyes inward)(turning the eyes inward)

Divergence Divergence (outward movement of both eyes away from each (outward movement of both eyes away from each other) other)

Conjugate gaze Conjugate gaze (inability of both eyes to(inability of both eyes to move in the move in the same direction at the same time)same direction at the same time)

Convergence Convergence (the simultaneous inward movement of both (the simultaneous inward movement of both eyes toward each other)eyes toward each other)

PEARL PEARL ( pupils equal and reacting to light)( pupils equal and reacting to light)


Capillary RefillCapillary Refill Reliable indication of poor circulation in Reliable indication of poor circulation in

childrenchildren Greater than 2 seconds is considered Greater than 2 seconds is considered

delayeddelayed Assess on nail beds or bottom of foot in Assess on nail beds or bottom of foot in

small childrensmall children


Pulse OximetryPulse Oximetry Non-invasive technique using an infrared Non-invasive technique using an infrared

light beam to measure oxygen saturation light beam to measure oxygen saturation of the bloodof the blood

Normal reading – 95% or moreNormal reading – 95% or more Pulse oximetry probes can be placed on Pulse oximetry probes can be placed on

fingers, toes, earlobes, or nosefingers, toes, earlobes, or nose Not reliable on all patientsNot reliable on all patients


Pulse Oximetry Pulse Oximetry (continued)(continued)

False readings may occur in:False readings may occur in: Cardiac arrestCardiac arrest Hypovolemia (shock)Hypovolemia (shock) HypothermiaHypothermia Carbon monoxide poisoningCarbon monoxide poisoning AnemiaAnemia Nail polishNail polish


Baseline vs. Serial Vital Baseline vs. Serial Vital SignsSigns

Baseline are the first full setBaseline are the first full set Serial are additional sets taken to Serial are additional sets taken to

establish trendsestablish trends Frequency of repeat VS is based on Frequency of repeat VS is based on

priority (stable or unstable)priority (stable or unstable) Stable every 15 to 30 minutesStable every 15 to 30 minutes Unstable every 5 minutesUnstable every 5 minutes


ConclusionConclusion

Analysis of trending is more helpful Analysis of trending is more helpful than one set of vital signs.than one set of vital signs.

Look at the entire assessment Look at the entire assessment picture before reacting to one set of picture before reacting to one set of abnormal vital signs. abnormal vital signs.


QUESTIONS ?QUESTIONS ?

1: 1: The normal pulse rate for a The normal pulse rate for a toddler/small child toddler/small child (between 1 and (between 1 and 10 years of age)10 years of age) is approximately is approximately how many beats per minute?how many beats per minute?A:A: 60 to 100 60 to 100

B: 70 and 120B: 70 and 120 C: 100 to 120C: 100 to 120 D: 100 plus the child's ageD: 100 plus the child's age


AnswerAnswer

1: 1: The normal pulse rate for a child The normal pulse rate for a child is approximately how many beats per is approximately how many beats per minute? minute?

B: B: 70 and 12070 and 120

Reason:Reason: The normal pulse rate for a The normal pulse rate for a child is approximately 70 t0 120 child is approximately 70 t0 120 beats per minute. beats per minute.


QuestionQuestion

2: 2: Pulse volume, often described as Pulse volume, often described as thready or bounding, is a general thready or bounding, is a general indicator of the:indicator of the:A:A: heart's rhythm. heart's rhythm.

B:B: temperature of the blood. temperature of the blood.

C:C: amount of blockage in the arteries. amount of blockage in the arteries.

D:D: strength of the heart's contractions. strength of the heart's contractions.


AnswerAnswer

2: 2: Pulse volume, often described as Pulse volume, often described as thready or bounding, is a general thready or bounding, is a general indicator of the: indicator of the:

D:D: strength of the heart's contractions. strength of the heart's contractions.Reason:Reason: Pulse volume is considered a Pulse volume is considered a

rough indicator of the strength of the rough indicator of the strength of the heart's contractions heart's contractions


QuestionQuestion

3: 3: Skin color changes may be seen Skin color changes may be seen in patients with deeply pigmented in patients with deeply pigmented skin by observing the:skin by observing the:A:A: earlobes. earlobes.

B:B: abdomen. abdomen.

C:C: knuckles. knuckles.

D:D: fingernail beds. fingernail beds.


AnswerAnswer

3: 3: Skin color changes may be seen in patients Skin color changes may be seen in patients with deeply pigmented skin by observing the: with deeply pigmented skin by observing the:

D:D: fingernail beds. fingernail beds.

Reason:Reason: The fingernail beds, the mucous The fingernail beds, the mucous membranes, inside the mouth, and the sclera membranes, inside the mouth, and the sclera (whites) of the eyes of patients with deeply (whites) of the eyes of patients with deeply pigmented skin will show changes in skin color. pigmented skin will show changes in skin color.


QuestionQuestion

4: 4: The state of the pupils is a rapid The state of the pupils is a rapid reflection of:reflection of:A:A: circulation. circulation.

B:B: blood pressure. blood pressure.

C:C: retinal pressure. retinal pressure.

D:D: central nervous system injury or central nervous system injury or disease.disease.


AnswerAnswer

4: 4: The state of the pupils is a rapid reflection The state of the pupils is a rapid reflection of: of:

D:D: central nervous system injury or disease. central nervous system injury or disease.

Reason:Reason: The state of the pupils, especially The state of the pupils, especially any progressive change, is a rapid reflection any progressive change, is a rapid reflection of central nervous system injury or disease. of central nervous system injury or disease.


QuestionQuestion

5: 5: The appropriate way to assess a The appropriate way to assess a systolic blood pressure by auscultation systolic blood pressure by auscultation is to note the point on the gauge at is to note the point on the gauge at which:which:A:A: the needle starts moving. the needle starts moving.

B:B: the needle stops moving. the needle stops moving. C:C: you first hear a strong sound. you first hear a strong sound. D:D: the sound disappears or changes the sound disappears or changes

in quality.in quality.


AnswerAnswer

5: 5: The appropriate way to assess a systolic The appropriate way to assess a systolic blood pressure by auscultation is to note the blood pressure by auscultation is to note the point on the gauge at which: point on the gauge at which:

C:C: you first hear a strong sound. you first hear a strong sound.

Reason:Reason: The point at which you first hear The point at which you first hear the sound of a pulse wave is the patient's the sound of a pulse wave is the patient's systolic blood pressure. The diastolic blood systolic blood pressure. The diastolic blood pressure is noted when the sound pressure is noted when the sound disappears. disappears.


QuestionQuestion

6: 6: In a stable patient, you should In a stable patient, you should reassess and record vital signs at reassess and record vital signs at least every:least every:A:A: 2 to 10 minutes. 2 to 10 minutes.

B:B: 5 to 12 minutes. 5 to 12 minutes.

C: C: 15 to 30 minutes.15 to 30 minutes.

D:D: 45 to 60 minutes. 45 to 60 minutes.


AnswerAnswer

6: 6: In a stable patient, you should reassess In a stable patient, you should reassess and record vital signs at least every: and record vital signs at least every:

D:D: 15 to 30 minutes. 15 to 30 minutes.

Reason:Reason: In a stable patient, you should In a stable patient, you should reassess and record vital signs at least reassess and record vital signs at least every 15 to 30 minutes. In an unstable every 15 to 30 minutes. In an unstable patient, you should reassess and record patient, you should reassess and record vital signs at least every 5 minutes. vital signs at least every 5 minutes.


QuestionQuestion

7: 7: A sign differs from a symptom in A sign differs from a symptom in that a sign is:that a sign is:A:A: reported by the physician. reported by the physician.

B:B: a condition described by the a condition described by the patient.patient.

C:C: a condition displayed by the a condition displayed by the patient that you observe.patient that you observe.

D:D: recorded in the medical record, recorded in the medical record, whereas a symptom whereas a symptom


AnswerAnswer

7: 7: A sign differs from a symptom in A sign differs from a symptom in that a sign is: that a sign is:

C:C: a condition displayed by the a condition displayed by the patient that you observe.patient that you observe.Reason:Reason: A sign is something that A sign is something that you observe in a patient, such as you observe in a patient, such as bleeding or a contusion. bleeding or a contusion.


QuestionQuestion

8: 8: You should take a patient's You should take a patient's carotid pulse if the:carotid pulse if the:A:A: radial pulse is bounding. radial pulse is bounding.

B:B: patient is unresponsive. patient is unresponsive.

C:C: patient has a head injury. patient has a head injury.

D:D: patient has traumatic chest patient has traumatic chest injuries.injuries.


AnswerAnswer

8: 8: You should take a patient's carotid You should take a patient's carotid pulse if the: pulse if the:

B:B: patient is unresponsive. patient is unresponsive.

Reason:Reason: The carotid pulse should be The carotid pulse should be taken if the patient is unresponsive. The taken if the patient is unresponsive. The radial pulse should be taken if the patient radial pulse should be taken if the patient is responsive. is responsive.


QuestionQuestion

9: 9: Which of the following signs is Which of the following signs is seen in respiratory arrest?seen in respiratory arrest?A:A: Rapid, shallow respirations Rapid, shallow respirations

B:B: Deep, labored, noisy respirations Deep, labored, noisy respirations

C:C: Strong airflow at the nose and Strong airflow at the nose and mouthmouth

D:D: Little or no movement of the chest Little or no movement of the chest and abdomenand abdomen


AnswerAnswer

9: 9: Which of the following signs is seen in Which of the following signs is seen in respiratory arrest? respiratory arrest?

D:D: Little or no movement of the chest and Little or no movement of the chest and abdomenabdomen

Reason:Reason: With respiratory distress or With respiratory distress or arrest, there is little or no movement of arrest, there is little or no movement of the chest and abdomen. There is also little the chest and abdomen. There is also little or no airflow felt or heard at the nose and or no airflow felt or heard at the nose and mouth. mouth.


QuestionQuestion

10: 10: Which of the following statements Which of the following statements about temperature is FALSE?about temperature is FALSE?A:A: The skin will feel cold when the patient The skin will feel cold when the patient is in profound shock.is in profound shock.

BB:: When the patient has hyperthermia, the When the patient has hyperthermia, the skin feels hot to the touchskin feels hot to the touch

C:C: Body temperature must be measured Body temperature must be measured with a thermometer.with a thermometer.

D:D: Normally, the skin is warm to the Normally, the skin is warm to the touch.touch.


AnswerAnswer

10: 10: Which of the following statements Which of the following statements about temperature is FALSE? about temperature is FALSE?

C:C: Body temperature must be measured Body temperature must be measured with a thermometer.with a thermometer.

Reason:Reason: In the field, feeling the patient's In the field, feeling the patient's forehead with the back of your hand is forehead with the back of your hand is usually adequate to determine whether usually adequate to determine whether the patient's temperature is elevated or the patient's temperature is elevated or depresseddepressed

principles of patient assessment in ems

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