assessing the patient

1. PATIENT ASSESSMENT
LESSON
6

2. INTRODUCTION
Patient assessment involves critical First
Responder skills
Act quickly to ensure scene is safe, assess
patient, and care for immediate threats to
life
Care provided is based on patient
assessment

3. SCENE SIZE-UP
While going to scene, consider factors that
may affect safety for you, bystanders,
and patient
Dispatcher’s information may alert you to
hazards or special precautions
Begin scene size-up before you exit your
vehicle and while approaching the
patient

4. BSI PRECAUTIONS
Put on medical exam gloves as you
approach patient
Observe scene/patient to determine
whether to use other personal
protective equipment:
Protective eyewear
Gown and mask
Turn-out gear
Follow standard precautions

5. SCENE SAFETY
Observe for any hazards
As you enter the scene
While approaching the patient

6. VEHICLE CRASH HAZARDS
Traffic hazards
Downed wires
Risk of fire or explosion
Unstable vehicles
Hazardous materials

7. POTENTIAL VIOLENCE
Crime scenes
Potentially violent patient or bystanders
Guard dogs, wild animals

8. ENVIRONMENTAL
DANGERS
Unstable surfaces
Water, ice
Weather extremes
Hazards within Structures
Low-oxygen areas
Toxic substances, fumes
Risk of collapse
Risk of fire or explosion

9. HAZARDS WITHIN STRUCTURES
Low-oxygen areas
Toxic substances, fumes
Risk of collapse
Risk of fire or explosion

10. PRINCIPLES OF SCENE SAFETY
Enter scene only if it is safe
If unsafe, make it safe or stay away
Protect bystanders and other rescuers
from hazards
Protect patient from environmental threats

11. MECHANISM OF INJURY
Often you will know from dispatcher
whether you have a trauma or medical
patient
With trauma patient, scene size-up
includes evaluating for clues about MOI
MOI may suggest serious injury or
presence of internal injuries

12. CONSIDER THE MECHANISM
What specifically caused the injury?
Was there an impact with a blunt or sharp
object?
What body area received the impact? What
organs may be injured?
How much force may have been involved?
Might the force have been transferred from
one body area to another?

13. EXAMPLES OF MECHANISM OF
INJURY
Vehicle collision may cause head /spinal
injuries
Fall from a height may cause extremity
fractures
Blunt impact to abdomen may cause
closed injury/ internal bleeding
Diving incident may cause spinal injury
Gunshot may cause extensive internal
damage not apparent from the
appearance of the outside wound
Fall forward onto a hand may transfer
force up arm and cause shoulder
dislocation

14. IMPORTANCE OF TIME
Quickly consider MOI during scene size-up
Do not delay assessment to examine
scene in detail
Consider MOI more fully while gathering
history/performing physical exam

15. CONSIDER NATURE OF ILLNESS
Consider nature of illness during scene size-up
Don’t stop to talk to family/bystanders until you are sure there is no
immediate threat to life
Observe patient’s position/demeanor for clues
Use all your senses
If patient is unresponsive, move immediately to initial assessment
If patient is responsive, ask patient, family members, or bystanders why
EMS was called

16. NUMBER OF PATIENTS
Determine how many patients are involved
Observe for clues and ask those present if everyone
is accounted for
Be certain you know how many patients are involved
Call for additional help immediately for multiple
patients
If more patients than responders, triage patients
first

17. ADDITIONAL RESOURCES
Scene size-up includes consideration of
whether additional resources may be
needed
If resources not already enroute, call
dispatch immediately
Describe injuries in detail, so an ALS
ambulance can be sent if needed

18. ADDITIONAL RESOURCES
Consider these factors:
Number of patients and types/seriousness of injuries
Possible need for air transport
Potential for fire or explosion
Potential presence of hazardous materials
Need for extrication
Need for law enforcement or traffic control
Damage to power lines or other utilities

19. INITIAL ASSESSMENT
Performed when you reach patient to identify any immediate threats to life
Rapid means to determine patient’s general condition and set initial
priorities for care
Begin with your initial impression of patient
Check patient’s responsiveness, airway, breathing, and circulation status

20. GENERAL IMPRESSION
Is the patient ill or injured?
What is chief complaint?
Does patient’s appearance give clues
about his/ her condition?
Are there signs of a serious problem?
Note patient’s sex and approximate age

21. RESPONSIVENESS
You may notice immediately whether patient is
responsive
Responsive means a person is conscious and
awake

22. RESPONSIVENESS
Patients who cannot talk may be able to move and
thereby signal responsiveness

23. RESPONSIVENESS
Patients who cannot talk/move may be paralyzed
but still able to respond with purposeful eye
movements or other signs

24. ASSESSING RESPONSIVENESS
Begin by speaking to the patient:
If patient isn’t speaking or moving, tap gently
and ask, “Are you okay?”
Be careful not to move patient in any way
Always suspect a spinal injury and take steps
to stabilize head and neck

25. UNRESPONSIVENESS
Unresponsiveness may be sign of life-
threatening problem or may result from a
less urgent problem
Continue the initial assessment
Unresponsiveness is considered life-
threatening emergency

26. DEGREE OF RESPONSIVENESS
Assessed with AVPU scale
AVPU scale useful for noting changes in a
patient’s responsiveness while providing
care and for communicating this
information
Make mental note of level of
responsiveness or write it down along
with time
A change in level of responsiveness,
generally indicates a serious condition

27. DEGREE OF RESPONSIVENESS
AVPU Scale
A = Alert
V = Responds to Verbal stimuli
P = Responds to Pain
U = Unresponsive to all stimuli

28. DEGREE OF RESPONSIVENESS
CONTINUED
Responsiveness in Pediatric Patients
Infants/young children may respond
differently from older children/adults
Look for age-appropriate responses
Assess unresponsive infant by flicking
bottom of feet and noting response

29. CHECKING THE ABCS
ABCs identifies immediate life threats that
must be corrected before patient assessment
continues.

30. CHECKING THE ABCS
After checking responsiveness, initial
assessment continues by checking ABCs:
A = Airway
B = Breathing
C = Circulation

31. AIRWAY
Airway is route air moves from mouth and
nose through pharynx to lungs
Airway may be blocked by a foreign body,
swollen airway tissues, or tongue
Airway must be patent
Confirm that it is open
Take action to open it
Clear an obstruction

32. AIRWAY CONTINUED
If patient is talking, crying, or coughing,
the airway is open
Patient with weak, wheezing cough may
have partially blocked airway

34. OPENING THE
AIRWAY
In unresponsive patient, you may need to open
the airway
If patient is lying supine, prevent tongue from
obstructing airway by positioning head

35. OPENING THE
AIRWAY
Open airway with head
tilt–chin lift or jaw thrust

36. HEAD TILT–CHIN LIFT
Tilting head back, lift chin to move tongue away from opening of throat
Use your fingers, not your thumb, to lift chin
Do not press deeply into the soft tissues of chin
Ensure mouth stays open

37. JAW THRUST
With possible spinal injury, lift jaw upward, using both hands
Jaw thrust is more difficult and fatiguing but is effective
If lips close, open lower lip with your gloved thumb
When in doubt, use jaw thrust
If jaw thrust does not open airway, switch to head tilt–chin lift method

38. TRAUMA OR VOMITING
With head trauma/vomiting, inspect mouth
for blood, loose teeth, vomit, or any
other obstruction
Use a gloved finger or suction if needed to
clear airway

39. AVOID UNNECESSARY
MOVEMENT
Don’t immediately roll unresponsive person
onto his/her back to open airway
Movement may cause additional injury
Determine whether airway is open by looking,
listening, feeling for breathing without
moving patient

40. AVOID UNNECESSARY
MOVEMENT CONTINUED
Patient who is breathing has an open airway
Don’t move patient unless necessary
If cannot determine whether patient is
breathing, move into supine position to open
airway, check for breathing
Support head/neck when moving trauma
patient

42. CHECK BREATHING
In a responsive adult, check for adequate
breathing
Inadequate Breathing
Difficult or labored breathing
Wheezing or gurgling sounds with breathing
Pale skin or a blue color of lips/nail beds
Respiratory rate ≤8 or ≥30 breaths/minute

43. CHECK FOR BREATHING
Look for rise and fall of chest
Listen for breathing
Feel for breath

44. IF NO BREATHING DETECTED
If no signs of breathing within 10 seconds,
assume the person is not breathing
Lack of breathing may be caused by an
obstructed airway or other causes
You must immediately give ventilations

45. ASSESSING A CHILD’S
BREATHING
It is difficult to assess a child’s adequacy
of respiration
Check instead for presence/absence of
breathing
Check the same as in an unresponsive
adult

47. CIRCULATION
After checking breathing, check for
circulation
If patient’s heart has stopped or patient is
bleeding profusely, vital organs are not
receiving enough oxygen to sustain life
If patient is responsive or breathing, heart
is beating

48. PULSE
CHECK
In responsive adult
or child, check
radial pulse

49. PULSE
CHECK
In an unresponsive adult, check carotid pulse

50. PULSE
CHECK
In an unresponsive child, check either carotid
pulse or femoral pulse
In an infant, use the brachial pulse in the
inside of the upper arm

51. PULSE CHECK IN INITIAL
ASSESSMENT
Do not take time to count pulse, note
whether it is irregular, very slow or very
fast—signs that patient may not be
stable
Lack of pulse along with absence of
adequate breathing signifies heart has
stopped or is not beating effectively
enough to circulate blood
If patient lacks a pulse and is not breathing
adequately, start CPR

52. CHECK FOR SERIOUS BLEEDING
Look for life-threatening bleeding
Arterial bleeding usually most serious
Bleeding from vein is generally slower

53. CHECK FOR SERIOUS BLEEDING
CONTINUED
Don’t remove clothing to check for
bleeding, but look for blood-saturated
clothing and blood pooling
During initial assessment, don’t address
minor bleeding or wounds
Control serious bleeding immediately with
direct pressure

54. SKILL: INITIAL
ASSESSMENT OF
AN
UNRESPONSIVE
PATIENT

55. PATIENT PRIORITY
Initial assessment determines whether a
critical condition is present and what
steps you need to take
Unresponsiveness or any problem with the
airway, breathing, or circulation is a high
priority
Continue to reassess and treat life-
threatening conditions while waiting for
additional EMS resources
Call EMS unit to update patient’s condition

56. REPORT TO EMS AFTER THE INITIAL
ASSESSMENT
Provide this information:
Number of patients
Patient age and gender
Patient’s chief complaint
Patient’s level of responsiveness
Patient’s airway, breathing, and circulation status
Ask responding unit their estimated time
of arrival
Continue to care for patient accordingly

58. PHYSICAL EXAMINATION
Follows the initial assessment
Question patient, family members, bystanders
Purpose is to find/assess signs/symptoms of
illness or injury

59. PHYSICAL EXAMINATION CONTINUED
Information gained from exam and history may
help you care for patient and be of value to
arriving EMS personnel
Complete rapid trauma assessment of
unresponsive patient or a patient with a
significant MOI
Perform focused physical exam of responsive
medical patient or a trauma patient with only
a minor injury

60. WHEN PERFORMING A PHYSICAL
EXAM
Allow responsive patient to remain in
position he/she finds most comfortable
Ask responsive patient for consent to do
physical examination
Don’t start with a painful area

61. WHEN PERFORMING A PHYSICAL
EXAM CONTINUED
Watch for facial expression/stiffening of
body part
In responsive patient, begin with area of
chief complaint and examine other body
areas only as appropriate
With an unresponsive patient, examine
patient from head to toe in a systematic
manner

62. WHEN PERFORMING A
PHYSICAL EXAM CONTINUED
A sign is an objective observation or
measurement such as warm skin or a
deformed extremity
A symptom is a subjective observation
reported by the patient, such as pain or
nausea

63. USE SYSTEMATIC HEAD-TO-TOE
APPROACH
Begin at head because injuries here are
more likely to be serious than injuries
elsewhere.
With responsive children, begin at feet and
work up the body.
Look and palpate for signs and symptoms
throughout the body,
Compare one side of body to other when
appropriate.

64. DOTS FOR TRAUMA PATIENTS
D = Deformities
O = Open injuries
T = Tenderness (pain)
S = Swelling

65. DCAP-BTLS MEMORY AID
D = Deformities
C = Contusions
A = Abrasions
P = Punctures
B = Burns
T = Tenderness
L = Lacerations
S = Swelling

66. CHECK HEAD AND NECK
Skull
Eyes
Ears
Nose
Breathing
Mouth
Neck

67. CHECK CHEST
Deformity?
Wounds?
Tenderness?
Bleeding?
Even
breathing?

68. CHECK ABDOMEN
Rigidity?
Pain?
Bleeding?

69. BACK
Unless head/spinal injury is suspected, roll
patient onto side to examine back
If head/neck injury is suspected, don’t
move patient but slide your gloved hand
under back
Sweep entire lower back, looking at
fingertips of your gloved hands for any
bleeding
Treat any tenderness, swelling, or
deformity of lower part of spine as a sign
of a spinal injury and don’t move patient

70. CHECK HIPS AND PELVIS
• Pain?
• Deformity?

71. CHECK LOWER EXTREMITIES
Bleeding?
Deformity?
Pain?
Normal movement,
sensation,
temperature?

72. CHECK UPPER EXTREMITIES
Bleeding? Deformity?
Pain?
Medial alert ID?
Normal movement,
sensation,
temperature?

73. VITAL SIGNS
Some First Responders
check patient’s vital signs
in the physical examination
Vitals signs assessed include:
Breathing rate, rhythm, depth, and ease
Pulse rate, rhythm, and strength
Skin color, temperature, and condition
Pupil size, equality, and reaction to light
Blood pressure

74. IMPORTANCE OF VITAL SIGNS
Vital signs reveal additional information about
condition
Changes in vital signs, from the baseline vital
signs, are important and should be
documented
Changes may show deterioration or
improvement with treatment
Vital signs vary significantly among different
individuals
Vital signs are affected by stress, activity, and
other variables

75. NORMAL VITAL SIGNS
Patient Normal
Respiratory
Rate at Rest
Normal
Pulse Rate
at Rest
Normal Blood
Pressure
(systolic/diastolic)
Infant 20 - 30 80 - 150 84-106 / 56-70
Child 18 - 30 70 - 130 98-124 / 50-80
Adult 12 - 20 60 - 100 118-140 / 60-90

76. ASSESSING
RESPIRATION
Don’t tell a responsive patient that
you are assessing breathing
Count respirations while holding
wrist draped across chest as if
taking a pulse. Observe or feel
for the chest rising and falling
(one cycle equals one breath)

77. ASSESSING
RESPIRATION
CONTINUED
Count number of breaths in 30
seconds and multiply by two
Note whether patient is making an
effort to breathe, is short of
breath, or is using abdominal
muscles in breathing

78. CHARACTERISTICS OF
RESPIRATORY DISTRESS
Gasping or wheezing
Very fast or slow respiratory rate
Very shallow or very deep breathing
Shortness of breath, difficulty speaking

79. ASSESSING PULSE
Have a responsive patient sit or lie down
Take a radial pulse in an adult or child. If no
radial pulse, take carotid pulse in an adult or
a brachial pulse in a child. Always take a
brachial pulse in an infant
Count the beats for 30 seconds and multiply by
two
Note strength of pulse (strong or weak)
Note rhythm of pulse (regular or irregular)

80. CHARACTERISTICS OF POSSIBLE
CIRCULATION PROBLEM
Very fast or very slow pulse
Very weak or strong, bounding pulse
Very weak and fast pulse (thready pulse)—
may indicate shock
Irregular rhythm—may indicate a cardiac
problem
Unequal pulses at different sites

81. ASSESSING SKIN TEMPERATURE
AND CONDITION
Assess skin temperature using back of
hand on skin
Assess skin color
Assess skin moisture
In a young child, assess capillary refill

82. SKIN CHARACTERISTICS THAT
MAY INDICATE A PROBLEM
Skin temperature
Unusual coloration
Skin condition
Capillary refill time ≥2 seconds may
indicate shock or diminished blood flow

83. ASSESSING PUPILS
Assess size of patient’s
pupils
Assess the pupils for
equality
Assess reactivity to light

84. ASSESSING PUPILS
Pupil Characteristics That
May Indicate a Problem
Dilated or constricted
pupils
Unequal pupils
Non-reactive pupils

85. BLOOD PRESSURE
Some First Responders
are trained to take blood
pressure
Blood pressure is force
of blood pressing
against arterial wall from
heart’s pumping action

86. BLOOD PRESSURE
When heart contracts,
pressure is higher
(systolic pressure)
Pressure falls lower
when heart relaxes
between beats (diastolic
pressure)
Blood pressure is
recorded as systolic
pressure over diastolic
pressure

87. SKILL: MEASURING BLOOD
PRESSURE BY AUSCULTATION

89. REPEATED BLOOD PRESSURE
It is difficult to interpret blood pressure
because of wide variation among
individuals
Repeated measurements may show a
possible trend in patient’s condition
A drop in blood pressure in shock usually
develops as a late sign

90. MEASURING BLOOD PRESSURE
BY PALPATIONIf you don’t have a stethoscope or scene is noisy, measure systolic blood
pressure by palpation
While palpating radial pulse, inflate cuff 30 mmHg beyond the point where
you stop feeling pulse
While watching gauge, open valve to slowly deflate cuff
Note the pressure when you feel radial pulse return
Record pressure as systolic pressure and include the word palpated (e.g.,
“130 palpated” or “130/Palp”)

92. PATIENT HISTORY
Patient’s history is gained from patient or
others
Although history focuses on specific injury
or chief complaint, it should be complete
With responsive medical patients, you may
take history before performing physical
exam
With trauma patients and any
unresponsive patient, perform physical
exam first

93. TAKING A HISTORY
Talk to a responsive patient
With an unresponsive patient, talk to family
members or bystanders about what they
know or saw
Look for medical alert insignia or other medical
identification.
In the home, look for medication bottles and a
Vial of Life

94. TAKING A HISTORY CONTINUED
With trauma patient, assess forces involved
When taking history of a responsive patient
with a sudden illness, ask fully about the
patient’s situation to learn possible causes

95. SAMPLE
S Signs and symptoms
A Allergies
M Medications
P Previous problems
L Last food or drink
E Events

96. ADDITIONAL GUIDELINES FOR
HISTORY
If patient is unresponsive, ask family
members or bystanders
Check scene for clues of what may have
happened
Consider environment
Consider patient’s age
When additional EMS personnel arrive,
give them information you gathered

98. ONGOING ASSESSMENT
Continue to assess while awaiting
additional EMS resources and giving
care
Calm and reassure patient while
reassessing ABCs and repeating
physical examination
Repeat initial assessment:
Every 15 minutes for a stable patient
Every 5 minutes for an unstable patient

99. PERFORMING THE ONGOING
ASSESSMENT
Reassess mental status
Maintain an open airway
Monitor breathing for rate and quality
Reassess pulse for rate and quality
Monitor skin color, temperature, and condition
Repeat the physical exam as needed

100. IMPORTANCE OF
ONGOING ASSESSMENT
Check that your
interventions are
effective
Perform additional
treatments as needed

101. HAND-OFF REPORT
Give EMS hand-off report with detailed
information about the patient’s:
Age and gender
Chief complaint
Responsiveness
Airway and breathing status
Circulation status

102. HAND-OFF REPORT CONTINUED
Also include:
Physical exam findings
Results of SAMPLE history
Interventions provided and the patient’s
response to them
You may also complete a written report
containing the same information