paramedic

1. Copyright © 2023 by Jones & Bartlett Learning, LLC, an Ascend Learning Company and the American Academy of Orthopaedic Surgeons.
Patient
Assessment
CHAPTER 11

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Surgeons.
Introduction (1 of 2)
 One of the most important skills you will develop is the ability to assess a
patient.
 Combines a number of steps:
 Assessing the scene
 Obtaining chief complaint and medical history
 Performing a secondary assessment
 Process leads to:
 Differential diagnosis
 Working diagnosis

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Introduction (2 of 2)
 Your job is to quickly:
 Identify your patient’s problem(s).
 Set your care priorities.
 Develop a patient care plan.
 Execute your plan.

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Sick Versus Not Sick
 Determine whether the patient is sick or not sick.
 Every time you assess a patient:
 Qualify whether your patient is sick or not sick.
 Quantify how sick the patient is.

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Establishing a Field Impression
 A determination of what you think is the patient’s current problem
 You must be able to communicate and ask the right questions.
 Develop your own style.

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Is This a Medical Emergency or Trauma?
 Medical patients
 Identify chief complaint and sift through medical history.
 Trauma patients
 Medical history may have less impact.
 Requires a modified approach

7. Copyright © 2023 by Jones & Bartlett Learning, LLC, an Ascend Learning Company and the American Academy of Orthopaedic Surgeons.
Scene Size-up

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Surgeons.
Scene Size-up (1 of 2)

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Scene Size-up (2 of 2)
 Looking around and evaluating the overall safety and stability of the scene
 Safe and secure access into the scene
 Ready egress out of the scene
 Specialty resources needed

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Scene Safety (1 of 6)
 Ensure the safety and well-being of your EMS team and any other responders.
 If the scene is not safe, do what is necessary to make it safe.
 Requires constant reassessment

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Scene Safety (2 of 6)
 Crash-and-rescue scenes often
include multiple risks.
 Wear a high-visibility public safety
vest.
 Consider specialty reflective
gloves, coats, and boots. © Matt Jonas/Digital First Media/Boulder Daily
Camera/Getty Images.
© Nancy G Fire Photography, Nancy
Greifenhagen/Alamy Stock Photo.

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Scene Safety (3 of 6)
 Ensure that your team can safely gain access to the scene and the patient.
 Consider a snatch and grab.
 Establish a safe perimeter to keep bystanders out of harm’s way.
 Formulate a basic plan with your team.

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Scene Safety (4 of 6)
 Be wary of toxic substances and toxic environments.
 Proper body and respiratory protection
Courtesy of Tempe Fire
Department.

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Scene Safety (5 of 6)
 Potential crime scenes
 Law enforcement should enter first.
 Formulate an escape plan.
 Be aware of violence from
bystanders or patient.
 Patients who abuse
methamphetamines can be a
serious threat.
© Miro Vrlik Photography/Shutterstock.

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Scene Safety (6 of 6)
 Environment risks include:
 Unstable surfaces
 Snow and ice
 Rain
 Consider stability of structures
around you.
 Ensure safety of bystanders next.
© A_Lesik/Shutterstock.

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Mechanism of Injury or Nature or Illness (1 of 2)
 Mechanism of injury (MOI)
 Forces that act on the body to cause damage
 Nature of illness (NOI)
 General type of illness a patient is experiencing

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Mechanism of Injury or Nature or Illness (2 of 2)
 Multiple patients or obese patients may warrant additional resources.
 Multiple patients must be triaged.
 Be familiar with specialized resources.
 Assess the need for spinal immobilization.

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Standard Precautions (1 of 3)
 Your first priority is your own safety and the safety of other EMS team
members.

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Standard Precautions (2 of 3)
 Treat all patients as potentially infectious.
 Wear properly sized gloves.
 Wear eye protection.
 Wear a HEPA or N95 mask.
 Wear a gown.
 Err on side of caution.

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Standard Precautions (3 of 3)
 Personal protective equipment (PPE)
 Steel-toe boots
 Leather gloves
 Helmet
 Heat-resistant outerwear
 Self-contained breathing apparatus

21. Copyright © 2023 by Jones & Bartlett Learning, LLC, an Ascend Learning Company and the American Academy of Orthopaedic Surgeons.
Primary Survey

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Primary Survey

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Examination Techniques
 You may use three exam techniques:
 Inspection
 Palpation
 Auscultation

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General Impression (1 of 3)
 Based on initial presentation and chief complaint
 Make conscious, objective, and systematic observations.
 Is the patient in stable or unstable condition?
 Is the patient sick or not sick?

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General Impression (2 of 3)
 Observe level of consciousness (LOC).
 Decide whether to implement spinal immobilization procedures.
 Determine your priorities of care.
 Identify age and sex of the patient.

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General Impression (3 of 3)
 Treat life threats as you find them.
 What additional care is needed?
 What needs to be done on scene?
 When to initiate transport?
 Which facility is most appropriate?
 Assess mental status by using AVPU scale.

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Assess the Airway (1 of 2)
 Is airway open and patent?
 Crying or talking indicates airway adequacy.
 Move from simple to complex:
 Position
 Obstruction

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Assess the Airway (2 of 2)
 Possibility of spine injury determines how to open airway.
 Mechanical means requires an airway adjunct.
 If patient cannot maintain airway, use more invasive technique.

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Assess Breathing (1 of 2)
 Is the patient breathing?
 Is the breathing adequate?
 Expose chest and inspect for injuries.
 Consider minute volume.

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Assess Breathing (2 of 2)
 Also consider:
 Breathing rate
 Work of breathing
 Chest rise and fall
 Lung sounds

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Assess Circulation (1 of 5)
 Perform full-body scan.
 Look for major hemorrhage or life-threatening injury.
 Check for pulse.
 Evaluate the skin.
 Assess and control external bleeding.
 Perform rapid exam to identify any major external bleeding.

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Assess Circulation (2 of 5)
 Palpate the pulse.
 Count the number of beats in 30 seconds and multiply by 2.
 Normal pulse rate for adults is 60–100 beats/min.
 Bradycardia: Rate less than 60 beats/min
 Tachycardia: Rate higher than 100 beats/min

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Assess Circulation (3 of 5)
 Quality
 Normal pulse is easy to feel.
 Weak pulse is thready.
 Bounding indicates hypertension.
 Rhythm
 Normal rhythm is regular.
 Irregular: Beats come early or late, or are skipped.
 Report your findings.

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Assess Circulation (4 of 5)
 Assess the skin to evaluate
perfusion.
 Color
 Temperature
 Condition
Courtesy of Rhonda Hunt.

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Assess Circulation (5 of 5)
© Jones & Bartlett Learning. © Jones & Bartlett Learning.

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Restoring Circulation (1 of 2)
 If a patient has inadequate circulation:
 Restore or improve circulation.
 Control severe bleeding.
 Improve oxygen delivery to the tissues.

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Restoring Circulation (2 of 2)
 If you cannot feel a pulse, begin CPR until an AED or manual defibrillator is
available.
 Follow standard precautions.
 Evaluate cardiac rhythm of any patient in cardiac arrest.
 Oxygen delivery is improved through the administration of supplemental
oxygen.

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Assess the Patient for Disability (1 of 2)
 Perform a neurologic evaluation.
 AVPU scale and pupils
 Quick assessment for neurologic deficits
 Glasgow Coma Scale (GCS)

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Assess the Patient for Disability (2 of 2)
 Assess for any gross neurologic deficits.
 Have the patient move all extremities.
 Assess for motor strength and weakness.
 Assess grip strength.
 Assess for loss of sensation.

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Expose Then Cover
 Visually inspect areas being examined.
 You cannot assess what you cannot see!

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Make a Transport Decision
 Identify priority patients.
 Do only what is necessary at the scene, and handle everything else en route.

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Priority Patients
 Suspected AMI with ECG showing
STEMI
 Suspected stroke
 Uncontrolled bleeding
 Severe pain anywhere
 Multiple injuries
 Abdominal injuries
 Severe hypotension
 Inability to move
 ALTE
 Include:
 Patients receiving CPR
 Poor general impression
 Unresponsiveness
 Responsive, but cannot follow
commands
 Difficulty breathing
 Hypoxia not corrected in 1–2
minutes
 Hypoperfusion or shock
 Complicated childbirth
 Chest pain w/systolic BP < 100
mm Hg

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History Taking

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History Taking

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Purpose
 Gain information about the patient and the events surrounding the incident.
 Ask open-ended questions.
 Avoid leading questions.
 Ask age-appropriate questions.
 Be patient.
 Use opportunities for patient teaching.

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Patient Information
 Name and chief complaint are the most important pieces.
 Obtain other information in whatever order is most conducive to good patient
care and most convenient.

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Techniques for History Taking (1 of 2)
 Appearance and demeanor
 Clean, neat, and professional
 Project a good attitude.
Courtesy of Rhonda Hunt.

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Techniques for History Taking (2 of 2)
 Note taking
 Let the patient know that you will
be writing information down.
 Position yourself at eye level.
 Maintain good eye contact.
© CJ GUNTHER/EPA-EFE/Shutterstock.

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Communication Techniques (1 of 3)
 Introduce yourself and partner.
 Identify your service.
 Be familiar with the cultural groups in your area.
 Ask about feelings.

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Communication Techniques (2 of 3)
 Communicate empathy.
 Offer reassurance.
© CJ GUNTHER/EPA-EFE/Shutterstock.

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Communication Techniques (3 of 3)
 Read nonverbal cues.
 Encourage dialogue.
 Avoid medical terminology.

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Dealing With Sensitive Topics (1 of 3)
 Social history
 Not typically gathered in prehospital setting
 Provides valuable information about overall health and helps to identify risk factors
for various disease processes

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Dealing With Sensitive Topics (2 of 3)
 Alcohol and drug misuse
 Alcohol can mask signs and symptoms.
 Patients may give an unreliable history.
 Keep a professional attitude.

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Dealing With Sensitive Topics (3 of 3)
 Sexual history
 Talk to the patient in private.
 Keep your questions focused.
 Do not interject opinions or biases.
 Treat with compassion and respect.

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Domestic Violence and Sexual Assault or Rape
 Physical abuse, domestic abuse, and sexual assault
 Required to report
 Look for clues.
 Always call law enforcement.
 Maintain evidence per protocol.

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Handling Physical Attraction to Patients
 It is never appropriate for a clinician to act on feelings of attraction to a patient.
 If a patient becomes seductive or makes sexual advances, firmly make it clear
that your relationship is professional.
 Keep someone else in the room at all times.

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Ensuring Confidentiality
 Maintain confidentiality of the patient’s information.
 Be familiar with relevant laws:
 HIPAA
 State laws

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Protecting the Patient’s Privacy
 Interview patients in a private setting.
 Obtain information that patient may be reluctant to share.
 Do not hesitate to ask nonessential personnel to leave the room or to step
back.

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Gathering Information From Third Parties (1 of 2)
 If patients cannot provide information, other sources on scene may need to be
used.
 The further from primary source, the greater the chance of inaccuracies.
 Family and friends often filter information.
 They may be able to describe the patient’s chief complaint, history, and possibly
current health status.

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Gathering Information From Third Parties (2 of 2)
 Law enforcement personnel and bystanders can also provide information.
 For routine transfers, take a few moments to review transfer paperwork.
 Evaluate your sources for reliability.

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Cultural Competence (1 of 3)
 Common barriers to communication
 Race
 Ethnicity
 Age
 Gender
 Language
 Education
 Religion
 Geography
 Economic status

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Cultural Competence (2 of 3)
 Respect ideas and beliefs.
 Consider dietary practices.
 Obtain consent.
 Provide best possible care for all patients.
 Research prevalent groups in your area.
 Remember the importance of manners.

63. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Cultural Competence (3 of 3)
 Facilitating cross-cultural
communication
 Identify an interpreter.
 Use a certified medical interpreter
if possible.
 Consider manners, hand gestures,
and body language.
© John Moore/Getty Images News/Getty Images.

64. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Special Challenges in History Taking (1 of 2)
 Overly talkative patients
 Silence
 Anxious patients
 Depression
 Situational
 Chronic
 Anger and hostility
 Don’t take it personally.
 Be attentive to risks.
 Retreat and call police if needed.

65. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Special Challenges in History Taking (2 of 2)
 Confusing history or bizarre behavior
 Consider medical causes.
 Sensory or developmental challenges
 Limited education or intellectual challenges
 Hearing loss, low vision, or blindness

66. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Managing Age-Related Considerations (1 of 4)
 Pediatric patients
 Include child in the history-taking process.
 Be sensitive to the fears of the parents.
 Pay attention to the parent-child relationship.

67. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Managing Age-Related Considerations (2 of 4)
 Pediatric patients (cont’d)
 Tailor your questions to the age of the child.
 Neonates/infants
 3 to 5 years
 Adolescent
 Gather an accurate family history.

68. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Managing Age-Related Considerations (3 of 4)
 Geriatric patients
 Present a variety of medical and traumatic conditions not seen in other patients
 Accommodate sensory losses.
 Patients tend to have multiple problems.
 Multiple chief complaints
 Multitude of medications

69. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Managing Age-Related Considerations (4 of 4)
 Geriatric patients (cont’d)
 Symptoms may be less dramatic.
 Consider including a functional assessment.
 Assessment of mobility
 Upper extremity function
 Activities of daily living

70. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Responsive Medical Patients (1 of 9)
 Chief complaint
 Reason someone called 9-1-1
 Should be recorded in patient’s
own words
 Determine patient’s alertness.
 Ask about events to begin
elaborating on chief complaint.
 Look for clues on scene.
Courtesy of Rhonda Hunt.

71. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Responsive Medical Patients (2 of 9)
 History of illness
 OPQRST
 SAMPLE

72. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Responsive Medical Patients (3 of 9)
 “What made you call 9-1-1?”
 If the patient’s behavior is inappropriate, consider:
 Hypoxia
 Medical issue
 Low blood glucose or hypothermia
 Psychiatric emergency
 Drug or alcohol ingestion

73. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Responsive Medical Patients (4 of 9)
 Current health status
 Made up of unrelated pieces of information
 Ties together past history with history of current event
 Focuses on environmental and personal habits

74. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Responsive Medical Patients (5 of 9)
 Current health status (cont’d)
 Examples of questions to ask:
 What prescription medicines do you take?
 Are you allergic to anything?
 Do you drink beer, wine, or cocktails?
 Do you smoke?
 Decide which items to explore.

75. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Responsive Medical Patients (6 of 9)
 Family history
 Helps establish patterns and risk factors for potential diseases
 Information should be related to the patient’s current medical condition.

76. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Responsive Medical Patients (7 of 9)
 Social history
 Patient’s occupation may indicate possible toxic exposures.
 Environment indicates lifestyle and chronic exposures.
 Travel history may be relevant.
 Questions regarding diet may be appropriate.

77. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Responsive Medical Patients (8 of 9)
 Past medical history
 Should include:
 Current medications and dosages
 Allergies
 Childhood illnesses and immunizations
 Adult illnesses
 Past surgeries
 Past hospitalizations and disabilities

78. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Responsive Medical Patients (9 of 9)
 Past medical history (cont’d)
 Patient’s emotional affect provides insight into overall mental health.
 Determine whether the patient has ever experienced the problem.

79. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Unresponsive Patients
 Rely on:
 Head-to-toe physical examination
 Normal diagnostic tools

80. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Trauma Patients (1 of 4)
 Life-threatening MOIs:
 Falls
 Greater than 20 feet for adults
 Greater than 10 feet for children
 High-risk motor vehicle crash
 Intrusion
 Ejection
 Death of another occupant
 Vehicle-pedestrian/bicyclist collision
 Motorcycle/ATV crash

81. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Trauma Patients (2 of 4)
© Enigma/Alamy Stock Photo © Corbis/Getty Images © Joseph Eid/AFP/Getty Images
© simonkr/E+/Getty Images;
© Jack Dagley
Photography/Shutterstock
Larry St. Pierre/Shutterstock © micheal ledray/Shutterstock © Jones & Bartlett Learning.

82. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Trauma Patients (3 of 4)
 High-priority infant or child MOIs:
 Falls from more than 2–3 times
child’s height
 Fall of less than 10 feet with loss of
consciousness
 Medium- to high-speed vehicle
crash
 Bicycle collision
 Medium- to high-speed MVC
© Jones & Bartlett Learning. © Jones & Bartlett Learning.
© Jones & Bartlett Learning.

83. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Trauma Patients (4 of 4)
 Multiple MOIs often come into play
during a traumatic event.
 In a MVC, determine whether seat
belts and/or air bags were involved.
© Thinkstock/Getty Images.

84. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Review of Body Systems (1 of 12)
 Pertinent negatives
 General symptoms
 Ask questions regarding:
 Fever
 Chills
 Malaise
 Fatigue
 Night sweats
 Weight variations

85. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Review of Body Systems (2 of 12)
 Skin, hair, and nails
 Rash, itching, hives, or sweating
 Musculoskeletal
 Joint pain, loss of range of motion (ROM), swelling, redness, erythema, and
localized heat or deformity

86. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Review of Body Systems (3 of 12)
 Head and neck
 Severe headache or loss of consciousness
 Eyes and ears
 Eyes: visual acuity, blurred vision, diplopia, photophobia, pain, and flashes of light
 Ears: hearing, loss, pain, discharge, tinnitus, and vertigo

87. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Review of Body Systems (4 of 12)
 Nose, throat, and mouth
 Nose: sense of smell, rhinorrhea, obstruction, epistaxis, postnasal discharge, and
sinus pain
 Throat and mouth: sore throat, bleeding, pain, dental problems, ulcers, and
changes to taste sensation

88. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Review of Body Systems (5 of 12)
 Endocrine
 Enlargement of the thyroid gland
 Temperature intolerance
 Skin changes
 Swelling of hands and feet
 Weight changes
 Polyuria, polydipsia, polyphagia
 Changes in body and facial hair

89. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Review of Body Systems (6 of 12)
 Chest and lungs
 Dyspnea and chest pain
 Coughing, wheezing, hemoptysis, and tuberculosis status
 Previous cardiac complaints
 Pain or discomfort
 Orthopnea, edema, and past cardiac testing

90. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Review of Body Systems (7 of 12)
 Hematology and lymph nodes
 Anemia, bruising, and fatigue
 Tender and enlarged lymph nodes

91. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Review of Body Systems (8 of 12)
 Gastrointestinal
 Ask about:
 Appetite and general digestion
 Food allergies and intolerances
 Heartburn, nausea and vomiting, diarrhea
 Hematemesis
 Bowel irregularity, changes in stool, flatulence,
 Jaundice
 Past GI evaluations and tests
 Consider GI bleeding and urinary habits.

92. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Review of Body Systems (9 of 12)
 Genitourinary
 Ask about sexually transmitted diseases.
 For women ask:
 If menstrual cycle is regular
 When last period was
 If she has dysmenorrhea
 When last sexual intercourse was
 Whether she has had multiple partners
 What kind of contraception she uses
 Whether she has ever been pregnant

93. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Review of Body Systems (10 of 12)
 Genitourinary
 For men:
 Ask about erectile dysfunction, fluid discharge, and testicular pain.
 When most recent sexual encounter was
 If they use condoms
 About the characteristics of any discharge or lesions

94. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Review of Body Systems (11 of 12)
 Neurologic
 Seizures or syncope, loss of sensation, weakness in extremities, paralysis, loss of
coordination or memory, and muscle twitches
 Facial asymmetry
 If you suspect stroke or TIA, use appropriate stroke assessment tool.

95. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Review of Body Systems (12 of 12)
 Psychiatric
 Depression, mood changes
 Difficulty concentrating
 Anxiety, irritability
 Sleep disturbances, fatigue
 Suicidal or homicidal tendencies

96. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Critical Thinking
 Goal of assessment:
 Figure out most likely reason for patient’s chief complaint and how best to address
it.
 Five aspects of critical thinking:
 Concept formation
 Data interpretation
 Application of principles
 Reflection in action
 Reflection on action

97. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Clinical Reasoning
 Combines knowledge of anatomy, physiology, pathophysiology, and patient’s
complaints
 Pay attention to signs or symptoms that are inconsistent with working
diagnosis.
 Differential diagnosis—a working hypothesis of the nature of the problem

98. Copyright © 2023 by Jones & Bartlett Learning, LLC, an Ascend Learning Company and the American Academy of Orthopaedic Surgeons.
Secondary Assessment

99. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Secondary Assessment (1 of 4)

100. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Secondary Assessment (2 of 4)
 Process by which quantifiable, objective information is obtained from a patient
about their overall state of health
 Consists of two elements:
 Obtaining vital signs
 Performing a systematic physical exam

101. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Secondary Assessment (3 of 4)
 Prehospital setting may determine how secondary assessment is performed.
 Identifying abnormalities requires direct, hands-on experience.
 Factors in starting exam:
 Stability of patient
 Chief complaint
 History
 Communication ability
 Potential for unrecognizes illness or injury

102. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Secondary Assessment (4 of 4)
 Not every aspect will be completed in every patient.
 Factors to consider:
 Location
 Positioning of the patient
 The patient’s point of view
 Maintaining professionalism

103. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Physical Exam of Priority Patients
 The physical exam performed depends on patient needs.
 If traditional physical exam is not possible, rapid full-body scan may be
required.
 A 60- to 90-second nonsystematic review and palpation of the patient’s body
 Inspect the soft tissue, look for open or closed wounds, and palpate for pain or
tenderness.
 Refer to Skill Drill 11-1: Performing a Rapid Full-Body Scan.

104. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Assessment Techniques (1 of 3)
 Inspection
 Palpation
 Pulses: Use finger
 Skull: Use palms
 Skin: Use back of hand © Jones & Bartlett Learning.
© Jones & Bartlett Learning.

105. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Assessment Techniques (2 of 3)
 Percussion
 Striking surface of the body, typically where it overlies various body cavities
 Detects changes in the densities of the underlying structures
 Refer to Skill Drill 11-2: Performing Percussion.

106. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Assessment Techniques (3 of 3)
 Auscultation
 Measured with a stethoscope
 Requires:
 Keen attention
 Understanding of what “normal” sounds like
 Lots of practice

107. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Vital Signs (1 of 8)
Pediatric data from: American Heart Association (AHA). Vital signs in children. In:
AHA. Pediatric Advanced Life Support. Dallas, TX: AHA; 2020.

108. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Vital Signs (2 of 8)
 Baseline
 Serial vital signs to establish trends for later comparison
 Pulse
 Assess rate, presence, location, quality, regularity.
 To palpate, gently compress an artery against a bony prominence.
 Count for 30 seconds and multiply by 2.
 Check for central pulse in unresponsive patients.

109. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Vital Signs (3 of 8)
© Jones & Bartlett Learning. © Jones & Bartlett Learning. © Jones & Bartlett Learning.
© Jones & Bartlett Learning. © Jones & Bartlett Learning. © Jones & Bartlett Learning.

110. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Vital Signs (4 of 8)
 Respiration
 Assess rate by inspecting the patient’s chest.
 Evaluate quality of the respiratory effort.
 Recognize when patients exhibit:
 Tripod positioning
 Accessory muscle use
 Retractions

111. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Vital Signs (5 of 8)
© Jones & Bartlett Learning.

112. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Vital Signs (6 of 8)
 Blood pressure
 Product of cardiac output and peripheral vascular resistance
 Systolic pressure
 Diastolic pressure
 Measured using a cuff
 Ideally should be auscultated

113. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Vital Signs (7 of 8)
 Temperature
 When measuring the tympanic membrane temperature:
 External auditory canal must be free of cerumen.
 Position the probe so the infrared beam is aimed at the tympanic membrane.
 Wait 2–3 seconds until temperature appears.

114. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Vital Signs (8 of 8)
 Pulse oximetry
 Should never be used as an absolute indicator of the need for oxygen
 Measures percentage of hemoglobin saturation
© Jones & Bartlett Learning.

115. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Equipment Used in the Secondary Assessment (1 of 2)
 Stethoscope
 Blood pressure cuff
(sphygmomanometer)
 Pulse oximeter
 Capnography
 Glucometry
 Reflex hammer
 Reliable light source
 Gloves
 Sheet or blanket

116. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Equipment Used in the Secondary Assessment (2 of 2)
 Stethoscope
 Acoustic
 Electronic
 Blood pressure cuff
 Ophthalmoscope
 Otoscope
© Denis Pepin/Shutterstock.
© WizData, Inc./Shutterstock.

117. Copyright
©
2023
by
Jones
&
Bartlett
Learning,
LLC,
an
Ascend
Learning
Company
and
the
American
Academy
of
Orthopaedic
Surgeons.
Physical Examination (1 of 2)
 Look for signs of significant
distress.
 Other aspects:
 Dress
 Hygiene
 Expression
 Overall size
 Posture
 Unusual odors
 Overall state of health
© ALEX EDELMAN/AFP/Getty Images.

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Surgeons.
Physical Examination (2 of 2)
 Terms to describe the degree of distress:
 No apparent distress
 Mild
 Moderate
 Acute
 Severe
 Terms to describe the general state of a patient’s health:
 Chronically ill
 Frail
 Feeble
 Robust
 Vigorous

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Orthopaedic
Surgeons.
Full-Body Exam
 A systematic head-to-toe examination
 Patients who should receive:
 Sustained a significant MOI
 Unresponsive
 Critical condition
 Refer to Skill Drill 11-3: Performing the Full-Body Exam.

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Orthopaedic
Surgeons.
Focused Exam
 Performed on patients who have sustained insignificant MOIs and are
responsive
 Based on the chief complaint
 Most common complaints involve:
 Head
 Heart
 Lungs
 Abdomen

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Orthopaedic
Surgeons.
Mental Status (1 of 2)
 For any patient with a “head” problem, assess and palpate for signs of trauma.
 Assess the patient in four areas:
 Person
 Place
 Day of week
 The event
 Refer to Skill Drill 11-4: Using a Glucometer to Assess Blood Glucose
Level.

122. Copyright
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Academy
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Orthopaedic
Surgeons.
Mental Status (2 of 2)
 Use the Glasgow Coma Scale.
 Conduct a mental status examination:
 General appearance
 Speech and language patterns
 Mood
 Thoughts and perceptions
 Information relevant to thought content
 Insight and judgment
 Cognitive function (attention and memory)

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Surgeons.
Skin (1 of 4)
 Perhaps the quickest and most reliable way to assess overall distress
 In cold and hot environments:
 Transmits information from the environment to the brain
 Protects the body from the environment
 Regulates the temperature of the body

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Surgeons.
Skin (2 of 4)
 Examine:
 Color
 Temperature
 Condition (moisture and texture)
 Turgor
 Significant lesions or obvious deformities
 Evidence of diminished perfusion:
 Pallor
 Cyanosis
 Diaphoresis
 Vasodilation (flushing)

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Skin (3 of 4)
 Pallor: poor red blood cell perfusion to the capillary beds
 Vasoconstriction: indicated by pale skin
 Cyanosis: low arterial oxygen saturation
 Mottling: severe hypoperfusion and shock

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Surgeons.
Skin (4 of 4)
 Ecchymosis: localized bruising or blood collection within or under the skin
 Turgor: relates to hydration
 Skin lesions: may be only external evidence of a serious internal injury

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Surgeons.
Hair
 Examine by inspection and palpation.
 Note:
 Quantity
 Distribution
 Texture
 Recent changes in growth or loss of hair

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Nails (1 of 2)
 Note:
 Color
 Shape
 Texture
 Presence or absence of lesions
 Normal nail should be firm and
smooth.
© Biophoto Associates/Science Source.

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Nails (2 of 2)
© Jones & Bartlett Learning.

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Surgeons.
Head (1 of 2)
 Inspect and feel the entire cranium.
 Deformity
 Asymmetry
 Warm, wet areas
 Tenderness
 Shape and contour
 Scars or shunts
© E. M. Singletary, MD. Used with permission.

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Head (2 of 2)
 Evaluate the face.
 Color
 Moisture
 Expression
 Symmetry and contour
 Swelling or apparent areas of injury
 Refer to Skill Drill 11-5: Assessing the Head.

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Eyes (1 of 3)
 Assess functions of CNS.
 Anterior and posterior chambers
 Assessed from front to back
 Inspect and palpate the upper and lower orbits.

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Eyes (2 of 3)
 Assess visual acuity.
 Snellen (“E”) chart
 Light/dark discrimination
 Finger counting
© German Ariel Berra/Shutterstock.

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Surgeons.
Eyes (3 of 3)
 Assess pupils.
 Normally round and equal size
 Pupils should react instantly to
change in light level.
 Check for size, shape, and
symmetry, and reaction to light.
 Evaluate muscle movement.
 Refer to Skill Drill 11-6:
Examining the Eye.
© American Academy of Orthopaedic Surgeons.
© Jones & Bartlett Learning.

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Surgeons.
Ears (1 of 2)
 Involved with hearing, sound perception, and balance control
 Includes:
 Outer portion
 Middle portion
 Inner portion

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Surgeons.
Ears (2 of 2)
 Assess for:
 Changes in hearing perception
 Wounds
 Swelling
 Drainage
 Assess mastoid process of the skull for discoloration and tenderness.

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Nose (1 of 2)
 Nasal cavity is divided into two
chambers.
 Each chamber contains three
layers of bone.
 Assess anteriorly and inferiorly.
© Jones & Bartlett Learning.

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Nose (2 of 2)
 Look for:
 Asymmetry
 Deformity
 Wounds
 Foreign bodies
 Discharge or bleeding
 Tenderness
 Evidence of respiratory distress

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Surgeons.
Throat (1 of 5)
 Evaluate mouth, pharynx, and neck.
 Prompt assessment is mandatory in patients with altered mental status.
 Assess for a foreign body or aspiration.

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Surgeons.
Throat (2 of 5)
 Mouth
 Lips
 Symmetry
 Gums
 Look for cyanosis around the lips.
 Inspect airway for obstruction.

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Throat (3 of 5)
 Tongue
 Size
 Color
 Moisture
 Maxilla and mandible
 Integrity
 Symmetry

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Throat (4 of 5)
 Oropharynx
 Discoloration
 Pustules
 Unusual odors on the breath
 Fluids that might need suctioning
 Edema and redness

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Throat (5 of 5)
 Neck
 Symmetry
 Masses
 Venous distention
 Palpate carotid pulses.
 Palpate the suprasternal notch.
 Refer to Skill Drill 11-7: Examining the Neck.

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Surgeons.
Cervical Spine (1 of 3)
 Consider MOI.
 Evaluate for:
 Pain
 Altered mental status
 Loss of consciousness at the time
of the event
© Augustino/Shutterstock.

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Surgeons.
Cervical Spine (2 of 3)
 Indications for spinal immobilization:
 Tenderness on palpation of spinal column
 Complaint of pain in spine
 Altered mental status
 Inability to communicate effectively
 GCS of less than 15
 Evidence of a distracting injury
 Paralysis or other neurologic deficit or complaint

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Surgeons.
Cervical Spine (3 of 3)
 Inspect and palpate.
 Stop exam if pain, tenderness, or tingling results.
 Assess range of motion when there is no potential for serious injury.
 Passive motion
 Active motion

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Surgeons.
Chest (1 of 7)
 Three phases of exam
 Chest wall exam
 Pulmonary evaluation
 Cardiovascular assessment
 Refer to Skill Drill 11-8:
Examining the Chest.
© Iasha/Shutterstock.

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Surgeons.
Chest (2 of 7)
 Check for:
 Signs of abnormal breathing
 Ventilatory fatigue
 Accessory muscle use (respiratory distress)
 Chest deformities

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Chest (3 of 7)
 Palpate abnormal areas of the chest wall.
 Chest wall percussion
 Listen over five discrete lobes.
 Deep breath through open mouth

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Chest (4 of 7)
 Auscultate breath sounds.
 Normal
 Tracheal
 Bronchial
 Bronchovesicular
 Vesicular
 Adventitious
 Wheezing, crackles, rhonchi, stridor, pleural friction rubs

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Chest (5 of 7)
© Jones & Bartlett Learning. © Jones & Bartlett Learning. © Jones & Bartlett Learning.

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Chest (6 of 7)
© Jones & Bartlett Learning.

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Surgeons.
Chest (7 of 7)
 Are sounds:
 Dry or moist?
 Continuous or intermittent?
 Coarse or fine?
 Are breath sounds diminished or absent?
 In a portion of one lung or entire chest?
 If localized, assess transmitted voice sounds.

154. Copyright
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Cardiovascular System (1 of 10)
 Circulates blood throughout the body
 Blood flows through two circuits:
 Systemic circulation
 Pulmonary circulation

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Cardiovascular System (2 of 10)
 Cardiac cycles involves:
 Cardiac relaxation (diastole)
 Filling
 Contraction (systole)

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Cardiovascular System (3 of 10)
 The contraction and relaxation of
the heart generates heart sounds.
© Jones & Bartlett Learning.

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Cardiovascular System (4 of 10)
 Splitting: Events on the right of the heart usually occur later than those on the
left.
 Korotkoff sounds: Related to blood pressure
 There are five (first and fifth are significant):
 Phase I: Clear, faint, tapping sounds; correlates to systolic contraction
 Phase V: All sounds disappear; correlates to diastolic pressure

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Cardiovascular System (5 of 10)
 Use the point of maximum impulse (PMI) to assess apical pulse.
 Bruit: abnormal “whooshing” sound
 Turbulent blood flow through narrowed artery
 Murmur: abnormal “whooshing” sound
 Turbulent blood flow around a cardiac valve

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Cardiovascular System (6 of 10)
 Arterial pulses are an expression of systolic blood pressure.
 Palpable where artery crosses bony prominence
 Venous pressure tends to be low.
 Assess extremities for signs of obstruction or insufficiency.

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Cardiovascular System (7 of 10)
 Jugular venous distention (JVD)
 With penetrating left chest trauma, may indicate cardiac tamponade
 With pedal edema, consider heart failure.

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Cardiovascular System (8 of 10)
 An older patient’s ability to compensate for cardiovascular insult may be
compromised.
 Arterial atherosclerosis and diabetes
 Medications, such as for high blood pressure

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Cardiovascular System (9 of 10)
 Pay attention to arterial pulses.
 Obtain blood pressure and repeat.
 Note history and category of
hypertension.
Reproduced with permission from Whelton PK, Carey RM, Aronow WS, et al. 2017
ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the
prevention, detection, evaluation, and management of high blood pressure in
adults: A report of the American College of Cardiology/American Heart Association
Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018 May
15;71(19):e127-e248. doi:10.1016/j.jacc.2017.11.006.

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Cardiovascular System (10 of 10)
 Palpate and auscultate carotid arteries.
 For a suspected heart problem, assess:
 Pulse
 Skin
 Breath sounds
 Baseline vital signs
 Extremities

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Abdomen (1 of 13)
 Divided into quadrants
 Diaphragm is at top of abdominal
cavity.
 Pelvis is at bottom of abdominal
cavity.
© Jones & Bartlett Learning.

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Abdomen (2 of 13)
 Abdomen can also be divided into ninths.
© Jones & Bartlett Learning.

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Abdomen (3 of 13)
 Abdomen contains:
 Almost all of the organs of digestion
 Organs of the GU system
 Significant neurovascular structures
 Peritoneum: well-defined layer of fascia made up of parietal and visceral
peritoneum
 Intraperitoneal organs
 Extraperitoneal organs

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Abdomen (4 of 13)
 Three basic mechanisms produce pain.
 Visceral pain
 Inflammation
 Referred pain

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Abdomen (5 of 13)
 Orthostatic vital signs (tilt test)
 Blood pressure and pulse are taken in the supine and sitting or standing positions.
 Determines extent of volume depletion

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Abdomen (6 of 13)
 Orthostatic vital signs (tilt test) (cont’d)
 Generally considered positive if:
 Decrease in systolic pressure
 Increase in diastolic pressure of 10 mm Hg
 Increase in pulse rate by 20 beats/min
 Documentation

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Abdomen (6 of 13)
 For inspection:
 Make patient comfortable.
 Proceed in systematic fashion.
 Refer to Skill Drill 11-9: Examining the Abdomen.
 Abdomen can be described as:
 Flat
 Rounded
 Protuberant (bulging)
 Scaphoid (hollow or boat shaped)
 Pulsatile (pulsing/throbbing)

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Abdomen (7 of 13)
 Ascites
 Fluid within the peritoneal cavity
 Abdomen may appear markedly distended.
 A visible or palpable fluid wave may be evident.
 Shifting dullness to percussion
 Cullen sign or Grey Turner sign
 Indicates ruptured ectopic pregnancy or acute pancreatitis

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and
the
American
Academy
of
Orthopaedic
Surgeons.
Abdomen (8 of 13)
 Auscultation
 May have limited utility in prehospital setting
 Setting must be quiet to hear bowel sounds.
 Note presence or absence of bowel sounds.
 Bruits

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Surgeons.
Abdomen (9 of 13)
 Palpation
 Palpate each quadrant gently but firmly.
 Guarding
 Rebound tenderness
 Localized guarded tenderness may indicate a more visceral problem.

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Surgeons.
Abdomen (10 of 13)
 Palpation (cont’d)
 To palpate the liver:
 Place left hand behind patient, parallel to right 11th and 12th ribs.
 Place right hand on right abdomen below rib cage.
 Ask patient to take a deep breath.
 Try to feel the liver edge.

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Surgeons.
Abdomen (11 of 13)
 Palpation (cont’d)
 To palpate the gallbladder:
 Use same technique as for liver.
 Response indicating pain may mean possible inflammation.
 When patient takes deep breath, move fingers under liver edge.

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Surgeons.
Abdomen (12 of 13)
 Palpation (cont’d)
 To palpate the spleen:
 With left hand, reach over and around patient.
 Press forward lower left rib cage and adjacent soft tissues.
 With right hand below costal margin, press toward the spleen.

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Surgeons.
Abdomen (13 of 13)
 Aortic aneurysm
 May be seen pulsating in the upper midline
 Do not palpate an obvious pulsatile mass.
 Hernia
 Place patient in supine position and raise the head and shoulders.
 Bulge of hernia will usually appear.

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Learning,
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Surgeons.
Female Genitalia (1 of 2)
 Limited and discreet assessment
 Reasons to examine include:
 Life-threatening hemorrhage
 Imminent delivery in childbirth
 Assessment includes:
 Palpating the bilateral inguinal regions
 Palpating the hypogastric region

179. Copyright
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Surgeons.
Female Genitalia (2 of 2)
 Reasons for pain on palpation include:
 Ectopic pregnancy
 Complications of third trimester pregnancy
 Nonpregnant ovarian problems
 Pelvic infections

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Surgeons.
Male Genitalia
 Limited exam with partner present.
 Assess for bleeding, injury, or
fracture.
 Note inflammation, discharge,
swelling, or lesions.
 Priapism: prolonged erection
 Look for evidence of urinary
incontinence.
© Jones & Bartlett Learning.

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Surgeons.
Anus
 Often evaluated at same time as genitalia
 Examined in limited circumstances
 Assess for need of bleeding control or another intervention.
 Examine sacrococcygeal and perineal areas.

182. Copyright
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Surgeons.
Musculoskeletal System (1 of 9)
 Joints: areas where bone ends abut each other and form a kind of hinge
 Skeletal muscles: used to flex and extend joints

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Surgeons.
Musculoskeletal System (2 of 9)
 Common injuries:
 Fractures
 Pathologic
 Traumatic
 Sprains
 Strains
 Dislocations
 Contusions
 Hematomas
 Open wounds

184. Copyright
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Surgeons.
Musculoskeletal System (3 of 9)
 Note:
 Structure and function
 Limitation or pain in range of motion
 Bony crepitus
 Inflammation or injury
 Obvious deformity
 Diminished strength
 Atrophy
 Asymmetry
 Pain
 Refer to Skill Drill 11-10: Examining the Musculoskeletal System.

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Orthopaedic
Surgeons.
Musculoskeletal System (4 of 9)
 Problems with the shoulders can
often be determined by noting
posture.
 Assess:
 Sternoclavicular joint
 Acromioclavicular joint
 Subacromial area
 Bicipital groove
© Dr. P. Marazzi/Science Source.

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Surgeons.
Musculoskeletal System (5 of 9)
 Assess range of motion:
 Ask patient to raise arms above the head.
 Have patient demonstrate external rotation and abduction.
 Perform internal rotation.

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Surgeons.
Musculoskeletal System (6 of 9)
 Inspect elbows.
 Palpate between the epicondyles
and olecranon.
 Range of motion:
 Flex and extend passively and
actively.
 Pronate the forearms while the
elbows are flexed.
© Jones & Bartlett Learning.

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Surgeons.
Musculoskeletal System (7 of 9)
 Inspect hands and wrists.
 Palpate the hands.
 Palpate the carpal bones.
 Range of motion:
 Make fists, then extend fingers.
 Flex/extend wrists.
 Move hands laterally and medially.
© Jones & Bartlett Learning.

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Surgeons.
Musculoskeletal System (8 of 9)
 Inspect knees and hips.
 Range of motion:
 Ask patient to bend each knee and
raise toward chest.
 Assess for rotation and abduction
of hips.
 Palpate each hip.
 Palpate pelvis.
© Jones & Bartlett Learning.
© Jones & Bartlett Learning.

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Surgeons.
Musculoskeletal System (9 of 9)
 Observe ankles and feet.
 Palpate feet and ankles.
 Assess range of motion:
 Have patient plantar flex, dorsiflex,
and invert and evert ankles and
feet.
 Inspect, palpate, and check
forefoot and toes.
© Jones & Bartlett Learning.

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Surgeons.
Peripheral Vascular System (1 of 5)
 Comprises aspects of circulatory
system.
 Lymphatic system: network of
nodes and ducts dispersed
throughout the body
 Lymph nodes: larger
accumulations of lymphatic tissues
© Jones & Bartlett Learning.

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Surgeons.
Peripheral Vascular System (2 of 5)
 Perfusion occurs in the peripheral circulation.
 Diseases of the peripheral vascular system are often seen in patients with other
underlying medical conditions.

193. Copyright
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Surgeons.
Peripheral Vascular System (3 of 5)
 During assessment, pay attention to upper and lower extremities.
 Signs of acute or chronic vascular problems
 Refer to Skill Drill 11-11: Examining the Peripheral Vascular System.

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Peripheral Vascular System (4 of 5)
 Assessment
 Inspect upper extremities.
 Five Ps of acute arterial insufficiency:
 Pain
 Pallor
 Paresthesia
 Paresis
 Pulselessness

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Peripheral Vascular System (5 of 5)
 Assessment (cont’d)
 Inspect lower extremities.
 Palpate lower extremities.
 Note temperature of feet and legs.
 Attempt to palpate edema.
 Palpate superficial inguinal lymph nodes.

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Spine (1 of 4)
 Consists of 33 individual vertebrae
 Inspect the back.
 Lordosis
 Kyphosis
 Scoliosis

197. Copyright
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Spine (2 of 4)
© Jones & Bartlett Learning. © Dr. P. Marazzi/Science Source. © Southern Illinois University/Science Source.

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Spine (3 of 4)
 Palpate the spine.
 Check back for any other findings.
 Tap over costovertebral angles.
 Palpate scapulae, paraspinal
areas, and base of neck.
 Check the buttocks.
© Living Art Enterprises/Science
Source.

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Surgeons.
Spine (4 of 4)
 Range of motion:
 Never evaluate passively.
 If any pain or tingling is elicited, stop the exam and immobilize the spine.
 Refer to Skill Drill 11-12: Examining the Spine.

200. Copyright
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Surgeons.
Nervous System (1 of 8)
 Nervous system is divided into:
 Voluntary nervous system
 Involuntary (autonomic) nervous system
 Sympathetic
 Parasympathetic

201. Copyright
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Surgeons.
Nervous System (2 of 8)
 Reflexes
 Involuntary motor response to specific sensory stimuli
 Primitive reflexes
 Babinski reflex test may be used to check neurologic function.
 Do not perform on a patient with lower-extremity injuries.

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Surgeons.
Nervous System (3 of 8)
 Neurologic exam
 Mental status (AVPU)
 Cranial nerve function
 Distal motor function
 Distal sensory function
 Deep tendon reflexes

203. Copyright
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Learning,
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Surgeons.
Nervous System (4 of 8)
 Mental status exam
 COASTMAP
 Consciousness
 Orientation
 Activity
 Speech
 Thought
 Memory
 Affect (mood)
 Perception

204. Copyright
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Nervous System (5 of 8)
 Cranial nerve examination
 Determines presence and degree of disability
 Can be performed in less than 3 minutes

205. Copyright
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Surgeons.
Nervous System (6 of 8)
 Evaluation of the motor system
 Posture and body position
 Involuntary movements
 Muscle strength
 Coordination
 Proprioception
 Refer to Skill Drill 11-13:
Examining the Nervous System.
Courtesy of Rhonda Hunt.

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Surgeons.
Nervous System (7 of 8)
 Check sensory function.
 Bilateral
 Assess primary and cortical
sensory functions.
 Dermatomes
 Evaluate deep tendon reflexes.
 Refer to Skill Drill 11-14:
Evaluating Deep Tendon
Reflexes. © Jones & Bartlett Learning.

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Surgeons.
Nervous System (8 of 8)
 Results of the neurologic exam
 Delirium
 Consistent with an acute sudden change in mental status
 Dementia
 Representative of deterioration of cognitive cortical functions

208. Copyright
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Surgeons.
Secondary Assessment of Unresponsive Patients (1 of 2)
 After ruling out trauma, position in recovery position.
 If trauma, position in neutral alignment.
 Perform a thorough assessment of the body and look for signs of illness.

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Secondary Assessment of Unresponsive Patients (2 of 2)
 Perform at least two sets of vital signs.
 Always assess the posture of an unresponsive patient

210. Copyright
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Secondary Assessment of Trauma Patients (1 of 2)
 Two classifications of trauma patients:
 Isolated injury
 Multisystem trauma
 High visibility factor
 Do not become distracted by obvious but non–life-threatening injuries.

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Secondary Assessment of Trauma Patients (2 of 2)
 Patient who is unresponsive or has altered mentation is considered high risk.
 Perform rapid exam.
 When time and condition permit, perform physical examination.

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Recording Secondary Assessment Findings
 Should be orderly and concise
 Document using the forms recommended by your medical director.
 Note:
 Objective signs
 Pertinent negatives
 Similar relevant information

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Limits of the Secondary Assessment
 Not everything can be discovered in the secondary assessment.
 Keep total time in field to a minimum.
 Evaluation by trained physician coupled with laboratory and radiographic
studies may be needed for a definitive diagnosis.

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Surgeons.
Monitoring Devices (1 of 6)
 Continuous ECG monitoring
 Purpose is to establish a baseline.
 Electrodes must be placed
properly.
 The leads are usually colored and
labeled to help with placement.
© Jones & Bartlett Learning.

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Monitoring Devices (2 of 6)
 12-lead ECG monitoring
 Patient should be supine.
 Prepare the skin.
 Connect electrodes.
 Connect and apply the precordial
leads.
 Record the ECG.
© Jones & Bartlett Learning.

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Surgeons.
Monitoring Devices (3 of 6)
 Carbon dioxide monitoring
 Capnometry
 Measures carbon dioxide output
 Capnography
 Measures carbon dioxide output and provides a waveform

217. Copyright
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Monitoring Devices (4 of 6)
 Blood glucometer
 Can obtain reading in two ways in the field:
 From the hub of an IV catheter
 From a finger stick
 Most take only a few seconds.
 Should be calibrated regularly

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Monitoring Devices (5 of 6)
 Cardiac biomarkers
 Used to assess presence of damage to cardiac muscle
 May take several hours following a myocardial infarction for the cardiac biomarkers
to become elevated

219. Copyright
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Monitoring Devices (6 of 6)
 Other blood tests
 i-STAT handheld device
 Basic and complete metabolic
profile (CHEM 7 and CHEM 12)
 Brain natriuretic peptide (BNP) test
© Abbott Point of Care Inc.

220. Copyright © 2023 by Jones & Bartlett Learning, LLC, an Ascend Learning Company and the American Academy of Orthopaedic Surgeons.
Reassessment

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Reassessment (1 of 2)

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Reassessment (2 of 2)
 Stable patients should be reassessed every 15 minutes.
 Unstable patients should be reassessed every 5 minutes.

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Reassessment of the Primary Survey
 Compare LOC with baseline assessment.
 Review the airway.
 Reassess breathing, circulation, pulse.

224. Copyright
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Reassessment of Patient Care and Transport Priorities (1 of 2)
 Have you addressed all life threats?
 Do priorities need to be revised?
 Is initial transport decision appropriate?
 Obtain another complete set of vital signs and compare with expected
outcomes.
 Priority patients: minimum three sets

225. Copyright
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Reassessment of Patient Care and Transport Priorities (2 of 2)
 Look for trends.
 Revisit patient complaints.
 Document all of your findings.