Patient Assessment

 patient assessment process

Describe the ABCDE approach to intial patient assessment including:

*Airway 

*Breathing

*Circulation

*Disability

*Exposure/Envoriment

*State the component of the tool AVPU to assess level of conciousness

*Outline how to obtain a patient history using the acronyms SAMPLE,OPQRST and SOCRATES.

*Describe the in a 'head-to-toe' assessment.

Introduction

Once you have completed your scene assessment,the next step is to conduct a patient assessment.

Primary survey 

The primary survey is a swift patient assessment and mangement process, which can be completed within 60-90 seconds. It is designed to be a step-wise approach,meaning thats any abnormalities identified in one step should be addressed before moving on to the next.Patient who have suffered traumatic injuries should have a check for life-threatening (or catastrophic) haemorrhage, before you check the patient aorway. In addition,in this group of patients you should give consideration to the patient's cervical spine and avoid unnecessary movement of the head and neck .  

General Impression

The general impression is your first and immediate assessment of the patient and their current location, which will give you an early indicationas to how sick and/or injuried your patient is. Some of this information you will have already gethered from your scene assessment. However,now your focus is on the patient. Note the patient's approximate age,gender and ethnicity as your mangement and expectations of what the patient can do will vary. For example a 1-year-old child will not present in the same way as an adult. In addition ,patient positioning can give you early clues. This is also your chance to assess how responsive the patient is. If the patient is awake , introduce yourself with "hello,my name is..." And identify yourself as being from the ambulance service. Ask how they would prefer to be addressed. If the patient appears not to be awake or is unconcious , check for responsiveness by asking them if thy are alright , or try giving them a command like "open your eyes". If they do not responed,gently shake the patient's shoulders. Patient who fail to responed are critically ill until proven otherwise.

  Airway 

Assessment of the airway involves three steps:

•Look for sign of airway obestruction

•Listen for noisy or absent breathing

•Feel for air movement as the patient breathes.

Remeber, the primary assessment proceeds in a step-wise manner. Any signs of obestruction such as snoring or gurgling sounds need to be addressed now, before moving on to breathing. You will learn how to deal with airway problems.

 Breathing 

Once you have a patient (open) airway , you are ready to move on to breathing. As with the airway ,you will adopt a look,listen,feel approach. The first question you should ask is whether the patient is breathing. If they aren't than you will have to provide breaths for the patient, i.e. ventilate them. If they are breathing you will need to decide whether it is adequate. You can start with respiratory rate and depth of breathing( indicated by chest movement)

Circulation 

In the medical patients, circulation is yhe next step following airway and breathing. You can obtain a good idea of the patient's circulation by looking at the colour of their limbes( usually the hands as they are nost accessible and normally visible) . Feeling for a pulse is a skill ;it can tell you the heart rate and adequacy of the cardic output , particularly if distal pulses such as the wrist are absent when a central pulse ( such as found in the neck) is palpable. Clearly, a patient who does not have a pulse needs CPR immediatly! 

Disability

Disability in the primary assessment refer to the patient's level of consciousness, or how awake they are. During the primary assessment , you will need to check three thing to assess the patient's disability

•Level of consciousness

•Pupils

•Blood sugar.

Level of consciousness

A rapid assessment of the patient's level of the consciousness can be undertaken using the acronym AVPU:

•A alert 

•V responds to verbal stimulus

•P Responds to pain

•U Unresponsive

Pupils

 when looking at a patient's pupils, you are interested in whether they are of equal size and react to light. They are a number of reasons why this may not the case and you'll find out about it.

Blood sugar

hypoglycaemia,or low sugur ,is a cause of reduced level of consciousness, which can usually be corrected by the administration of glucose,either orally(by mouth) or intravenously. In addition ,there are drugs which can mobilise the body's own glucose store.

 Expose/Environment

You will unertake a full 'head-to-toe' assessment later on in the patient assessment process, but a quick look early in will provide you with clues to obvious illness/injury thats needs to be manged quickly. For example , some types of rashes(e.g non-blancing) signal serious illness such as sepsis or anaphylaxis . It also provides a chance to identify sites of hidden bleeding thats you did not pick up on earlier on in your assessment . Working out of hospital , however, yod do need to be mindful about maintenance of patient privacy by not unnecessarily exposing them in public as well as ensuring thats they do not lose body heat. This is particularly important in trauma as patients are three time more likely to die if they are hypothermic( their body temperature is below 35°c).

History taking 

Presenting complaint 

The majority of presenting complaints fall into the categories of pain, discomfort and/or abnormal body function . Sometime this explicit(" i have terrible chest pain") but can be vegue,particularly in the elderly( "i just don't feel right today") . Avoid using words like problem or complaint when finding out the reason for the emergency call.

History taking 

-Presenting complaint

 -SAMPLE history 

SAMPLE history 

•S sign and symptoms of the presenting complaint 

•A allergies (particularly to medication,food allergies might be relevent) 

•M medications

•P past medical history 

•L last oral intake

•E event that led to the current illness or injury.

Note: that when you are working with clinician, such as paramedics,you may find that they use and document a different method , made up of the following components

•history of presenting complaint

•past medical history

•drug history

•family history

•social history

•systematic enquiry.

Signs and symtoms of the presenting complaint

To help you organise the signs and symptoms of the presenting complaint, there are two acronyms thats can use :OPQRST and SOCRATES.  

These were orgionally designed with assessment of pain in mind, but can be helpful for other presenting complaints.

OPQRST:

•O onset,when did it( the presenting complaint ) start?

•P procation/palliation.what makes it worse/better? Include self-treatment such as taking analgesia

•Q Quality . how does the patient describe their symptoms, particularly pain? Is it sharp or dull, for example?

•R Region /radiation/referral.In the case of pain, does it stay in one place (can the patient ponit point to it with one fingre) or does it go elsewhere?

•S severity . On a scale of 0 to 10, where 0 is no pain and 10 is the wrost pain imaginable, what score does the patient give it now?

•T Time . How long has the patient had it and if it has been relieved , what time was this ? In the case of pain , also consider whether the pain is intermittent( comes and goes). 

SOCRATES is very similar:

•S Site

•O Onset

•C character. Same as quality above

•R radiation

•A association.are there any o

•T timing

•E exacerbating/relieving factors. Same as provocation/palliation above

•S severity.

Allergies and medication

Allergies 

The range of drug that you can administer as an SW is limited and thess are typically safe. However,you should always ask the patient about any allergic reaction to medication they have received in the past. It is also a good idea to ask about ither allergies,such as those caused by food,animals,or metal.

Medication 

Write down all of the patient's medication including the doose and frequency of administration. Just writing 'drug with patient' or similiar is not acceptable. It is also a good idea to ask about any over-the-counter medicines(i-e. Those not prescribed by a doctor , but obtained from pharmacist or supermarkeet),as well as herbal and homeopathic remdies.

Strictly specking there no drugs called 'over-the-counter'. They are either general sales list medications,which can be sold without the supervision of a pharmacist,or pharmacy medicines, which,as the name suggests, require a pharmacist to oversee the purchase,usually because it is necessary to check that they are appropriate for the patient.

Past medical history 

You will probally cover some of the patient's medical history while obtaining the history of the presenting complaint, but the following questions will help you uncover other medical illness or surgery that may prove helpful

•have you had any illnesses thats you saw you GP about?

•have you had to take any time off work because of ill health?

•have you had any operations?

•have you been admitted to hospital, and if so, why?

•have you suffered any injuries? 

 Last oral intake and events leading to illness/injury

Last oral intake 

Find out when the patient last had anything to eat or drink. This information is useful for patients who are uniconsious or deteriorrate on the way to hospital , or who may require surgery , as patient with a full stomach are at risk of aspiration . Also , you may be able to identify the onset of food posioning and/or food allergies.

Event leading to the illness or injury

This is also known as the history of the presenting complaint and if you have used either of the OPQRST or the SOCRATES acronyms, you will have already obtained most the information required.

Additional information that is useful to obtain includes .

•associted symptoms: for example, does the patient have shortness of breath and nausea with their chest pain? 

•pervious episodes: find out what happened last time . Including any diagnoses made or hospital admissions

•effect on daily living:Does the presenting complaint interfere with getting to the toilet or making a cup of tea , for example? 

secondary Survey

The secondary survey is often tailored to your finding from the primary survey and history . For example, if the presenting complaint is shortness of breath, then you are going to ensure that you obtain a respiratory rate and oxygen saturations , and ausculatate the lunges. 

•Vital sign

•head-to-toe assessment

Vital signs

If you have not already been instructed to do so, now is the time to obtain some physiological observation from the patient, or obtain vital signs. Your ambulance service may a specified minimum set of observations to obtain, but this generally include:

•respiratory rate 

•oxygen saturations

•pulse rate 

•blood pressure

•glasgow coma scale score( Often just referred to as GCS) 

•Blood sugur 

•temperature

Depending on the patient's presenting complaint and the mangment plan, you may also obtain an electrocradiogram(ECG).

Being able to record vitak signs accurately is a fundamental skill of the SW and these will be explored in depth in next lessons.

'Head-to-toe' assessment

It is not always appropriate to perform a head-to-toe body examination for every patient, but in cases of multiple injury, or is cases when the patient is found collapsed and the history is limited for non-existent,it can be helpfull to identify sign of injury, or illness. The assessment outlined here is a rapid full-body assessment which should take around 60-90 seconds to complete. Cilnicians thats you work with are likely ro perform more thorough assessment on specific area of the body depending on the presening complaint.

Procedure

Take the following step to perform a head-to-toe assessment :

1Look at the face for obvious injuries such as lacerations, bruising , fluid and deformities.

2.inspect the area around the eyes and eyelides .

3.check the eyes for redness and the presence of contact lenses.

4.assess the puplis with a pen torch,to ensure that they react to light.

5.look behind the ears for bruising and in the ear for sign of fluid or blood leaking out.

6.look for bruising , lacerations and deformity around the head and then gently feel for tenderness and depressions of the skull.

7.feel the cheekbones for tenderness , symmetry and instability.

8.feel the maxilla ( the bone just below the nose) .

9.check the nose for blood and fluid leaking out .

10.feel the jaw.

11.assess the mouth and nose for cyanosis(blue-tinged skin), foriegn bodies( including loose teeth and/or dentures), bleeding , lacerations and dormities.

12.smell the patient's breath for specific odours ( such as pear-drops,which can be present in some diabetic patients)

13.look at the neck and note any obvious lacerations,bruises and/or deformity. Look for bulging veins in the neck and feel and trachea to ensure it is centerally located

14.feel the back of the neck for tenderness and deformity.

15.look at the chest for any obvious injury and watch the chest rise and fall as the patient breathes.

16.gently feel the ribes to ensure they arw intact and to identify if they are tender . Don't press over any obvious bruising or fractures.

17.listen for breath sounds.

18. If safe to do so log roll the patient and listen to the back of the chest. Also ,look for injuries and feel for deformities and tenderness.

19.check the abdomen and pelvis for obvious injury and gently feel the abdomen, which should be soft and non-tnder

20. Look at the pelvis for signs of injury , then gently feel the iliac crests for signs of instability, tenderness kf crepitus. Do not compress the pelvis ( sometimes called 'sprining')

21. Check the extermities (arms and legs) for lacerations , bruises,swelling,deformities and the presnce of medical bracelets. Feel for distal pulses and check motor and sensory function. Compare the right and left sides.

Reassessment 

The first thing you'll probably notice about the reassessment section is thats it contains many of the thing you have already undertaken as part of the patient assessment process. As with scene safety , a patient's clinical condition is dynamic and frequently changes. Either due to the illness and/or injury they have acquired,or as a result of an intervation you have performed, such as defibrillation,or drug administration. Frequent reassessment will mean that you will not miss these changes.

Reassessment 

-primary survey

-presenting complaint

-review treatment 

-moniter patient condition