Patient Assessment Plan: Steps, Phases, and Vital Signs

OBJECTIVES:

Upon completion of this lesson, you will be able to:

1. List the five general procedures a medical first responder should complete when arriving at the scene.
2. List the six phases of the patient assessment plan.
3. List the six steps of the initial assessment.
4. Demonstrate a complete physical examination as defined in this lesson.

The sections of this lesson constitute the six phases of the ASSESSMENT PLAN. MFR insignia having six corners actually denotes six phases of the patient assessment plan. The Assessment Plan begins with information received on dispatch.

1. Scene Size-up

1.1 Arrival on the Scene

When arriving on the scene as a medical first responder, you should:

1. Ensure your own personal safety (includes the use of body surface isolation and securing the scene). Wear appropriate PPE and confirm the area is safe.
2. Ensure patient safety. Remove the patient from any immediate dangers, if necessary.
3. Establish a general impression of the scene (determine mechanism of injury) and begin your initial assessment of the patient (if responsive, identify yourself). Observe the surroundings for potential hazards and assess the patient’s condition.
4. Identify and treat life-threatening injuries. Check for airway, breathing, and circulation issues and manage them immediately.
5. Stabilize and continue to monitor the patient. Provide necessary care and reassess their condition regularly.

1.2 Identify Yourself

1. State your name and organization. “My name is [Your Name], and I am with [Your Organization].”
2. Identify yourself as a medical first responder. “I am a certified medical first responder here to assist you.”
3. Ask the patient if you may help him/her (obtain consent). “May I help you? I need your consent to provide care.”

1.3 Immediate Sources of Information

1. The scene itself (observe, plan, react): Observe for hazards, plan your actions, and react appropriately to ensure safety and effective response.
2. Patient (if responsive): Communicate directly, ask questions, and assess their condition based on their responses and visible signs.
3. Relatives or bystanders: Gather additional information about the patient’s condition, history, and events leading to the situation.
4. The mechanism of injury (forces that caused the injury – kinematics): Analyze the cause of injury (e.g., fall, collision) to anticipate potential internal or external trauma.
5. Any remarkable deformity or obvious injury: Identify visible deformities, wounds, fractures, or swelling that may require immediate attention.
6. Any signs or characteristics of certain types of injury or illness: Note symptoms such as difficulty breathing, discoloration, or other indicators of specific conditions or injuries

2. Initial Assessment

Definition: A process used to identify and treat conditions that pose an immediate threat to the patient’s life.

1) Steps of the Initial Assessment

The steps of the initial assessment are as follows, in order of importance:

1. Form a general impression: Assess the patient’s condition, their level of distress, and the environment to determine the severity of the situation.
2. Determine if the situation is trauma or medical: Evaluate the cause of the emergency (e.g., injury from an accident or a medical condition like a heart attack) to guide further assessment and treatment

Neck: Examine front and back (covered later in this lesson). Apply a cervical collar if needed. You will learn how to select and apply a cervical collar in Lesson 12. For trauma cases with suspected cervical spine injury, before continuing, immediately immobilize the cervical region to prevent paralysis.

2) Check for responsiveness.

Gently shake the patient’s shoulders and shout, “Are you okay?” This is important for many reasons (for example, a patient with altered mental status may need airway care or other life-saving aid).

There are four levels of responsiveness commonly used to classify patients: A, V, P, U often referred to as “A.V.P.U.”

• A = Alert: A patient who is alert, responsive, and oriented (e.g., aware of surroundings, approximate time and date, and his/her name). Commonly referred to as being responsive to person, place, and date-oriented (x3 ~ AADx3).
• V = Verbal: A patient who responds only when spoken to. We say he/she is responsive to verbal stimulus.
• P = Painful: The patient responds only to painful stimulus.
• U = Unresponsive: The patient does not respond to any stimulus. Does not open eyes, respond verbally, or even flinch when pain is applied. A deeply unconscious person is unquestionably in need of airway and other supportive care.

3) Ensure adequate airway.

Depends on the patient’s response.

Responsive Patient: Determine if the patient can speak clearly. Gurgling or similar sounds may indicate airway obstruction.

Unresponsive Patient: Needs aggressive airway maintenance immediately — make sure the airway is open and the patient is breathing adequately.

4) Verify breathing

look, listen, and feel for air exchange (3-5 seconds). Respirations must be adequate. Adequate breathing is characterized by three factors:

• Full rise and fall of the chest
• Easy breathing
• Normal respiratory rate

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• Inadequate breathing is characterized by:
• Insufficient rise and fall of the chest
• Increased respiratory effort
• Cyanosis (bluish/gray discoloration of skin, lips, or nail beds)
• Mental status changes
• Inadequate respiratory rate (<8 in adults, <10 in children, <20 in infants)

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Apply oxygen as needed. Select the appropriate delivery system and accessories. Administering oxygen will be covered fully in Lesson 8.

Oxygen is used for both medical and trauma patients.

5) Assess circulation.

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Responsive patient: In verbally responsive adults, check the radial pulse. Check the brachial pulse for an infant. Check rate and rhythm.

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Unresponsive patient: Check the pulse of an unresponsive adult at the carotid artery. In children, check carotid/femoral pulses, and in infants the brachial artery.

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Control serious external bleeding: Identify and treat life threats. Do not let minor wounds sidetrack you.

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6) Patient status update:

Inform responding EMS units of your findings.

• If more resources will be needed, request them.
• If the patient has life-threatening injuries or illness, let responding units know.
• If the patient is stable with minor injuries, advise responding units.

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The initial assessment should be completed, and all life-threatening conditions treated before proceeding to the physical exam.

3. Physical Exam

Background

• The initial assessment is designed to help you identify and treat life-threatening conditions.

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• The physical exam is a thorough survey of the patient’s entire body. It is meant to reveal any signs of illness or injury.

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• The physical exam proceeds in a logical order, usually from head to toe, but may vary from patient to patient.

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The main purpose of the physical exam is to reveal any injury or medical problem that could be a threat to patient survival if left untreated.

3.1 Principles of Patient Assessment

Patient assessment is a skill and must be practiced. The patient assessment process involves the use of your senses. Three methods are used during your patient assessment:

• Inspection (looking): A method of examination that involves looking for signs of injury or illness. Simply make an overall observation of your patient, then an observation of the body.

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• Auscultation (listening): A method of examination that involves listening for signs of illness or injury. The most important listening you will do is for air entering and leaving the lungs to determine respiratory status.

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• Palpation (feeling): A method of examination that involves feeling for signs of illness or injury. Palpating, or feeling with your fingertips, is usually done last in the exam, because it may cause pain. Actual pressure applied depends on the area and type of problem you suspect.

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3.2 Conducting an Exam

Medical vs. Trauma Patients

An examination of the trauma patient is different from an examination of the medical patient. Physical signs of an injury can be observed and palpated. Medical problems are felt by the patient. In order to provide emergency care, you must ask questions to encourage the patient to describe their symptoms.

When conducting an exam, look for the following signs of injury. You can use the mnemonic “D.O.T.S.” to remember them:

• D = Deformities
• O = Open injuries
• T = Tenderness
• S = Swelling

Some signs may be obvious. Others, such as abdominal tenderness caused by internal injuries, are not as obvious and are potentially serious.

As you proceed, listen to your patient. Listening shows you care and will usually enable you to gather important information.

3.3 PHYSICAL EXAM — HEAD TO TOE

1) Examination of the Head

• • Scalp and skull: Check for deformities, open injuries, tenderness, and swelling.
  • Ears and nose: Look for blood or cerebrospinal fluid (CSF) in or around openings.
  • Pupils: Usually symmetrical (unless otherwise due to prior condition or injury, consider possible artificial eye). Abnormal findings include no reactivity to light, pupils that remain constricted, or unequal pupils.
  • Mouth: Check for deformities, open injuries, tenderness, and swelling. Check for possible airway obstructions such as foreign objects, loose teeth, etc.

2) Examination of the Neck

• Always go front to back (anterior to posterior).
• Check for deformities, open injuries, tenderness, and swelling.
• Check trachea for mid-line position.
• Palpate vertebrae.
• Open injuries (bandage immediately with occlusive dressing).
• (Prevent air from entering veins).
• Check for a medical alert necklace.

3) Examination of the Chest Any injury may involve the vital organs or major blood vessels.

• If trained to use the stethoscope, assess lungs for equal breath sounds.
• Check for deformities, open injuries, tenderness, and swelling.
• Feel rib for deformities all the way to spine.
• Palpate the sternum.

4) Examination of the Abdomen

Abdominal organs may be injured without external signs.

• Check for rigidity (hardness) or distention.
• Cuts, scrapes (lacerations and abrasions), penetrating wounds, protruding organs. Potential bleeding and infection.
• May indicate underlying injury. Palpate quadrant with pain as your last step.
• Swelling or discoloration.

5) Examination of the Pelvis

• Composed of the left and right ilium, ischium, and pubic bone.
• Pelvic or hip fracture could result in blood loss of ___4___ liters or more.
• Internal organs, blood vessels, and nerves pass through the pelvic area.
• Spinal injury possible.
• Genital region: priapism in males
• Deformities are not always obvious. Palpate iliac crest (pelvic wings) and pubic bones.
• Open injuries may occur, but are uncommon. Penetrating injuries are possible.
• Assess for tenderness.

6) Examination of the Lower Extremities
Common sites of injury – do not rush your examination.

• Check for deformities, open injuries, tenderness, and swelling.
• Check distal pulse.
• Check for motion – wiggle fingers/toes.
• Check for sensation – gently squeeze one extremity, then another. Ask the patient “Can you feel this?” or “Does this hurt?”
• When do you remove the patient’s shoes?

7) Examination of the Upper Extremities
Common sites of injury – do not rush your examination.

• Check for deformities, open injuries, tenderness, and swelling.
• Check radial pulse.
• Check for motion – wiggle fingers.
• Check for sensation – gently squeeze one extremity then another. Again, ask the patient, “Can you feel this?” or “Does this hurt?”
• Check for medic-alert bracelet.

8) Examination of the Back

• Check chest wall for deformities that may indicate broken ribs.
• Check for obvious deformities and/or tenderness along the entire length of the spine that may indicate spinal cord injury.
• As with chest injuries, check for sucking wounds, penetrating injuries, cuts, etc.
• Blood accumulation in the flanks and/or tenderness may indicate abdominal injury.

3.4 Measuring Vital Signs

A patient’s vital signs include:

• Respiration
• Pulse
• Skin
• Pupils
• Blood pressure

At the conclusion of the lesson, we will practice measuring vital signs. You can assess and monitor most vital signs by looking, listening, and feeling.

Proper Equipment to Measure Vital Signs

• Wristwatch – count seconds
• Penlight – examine pupils
• Stethoscope – respiration and blood pressure
• Pen and notebook – take notes
• Blood pressure cuff (sphygmomanometer) – measure BP

More important than just measuring vital signs is measuring changes over time. It is important to establish baseline vital signs. For example, if pulse on the initial reading is 80 and later becomes 120, this indicates a possibly serious condition developing.

Age Definitions

• Infant: Under 1 year
• Child: One to 8 years
• Adult: 9 and older

Respiration

Normal Respiratory Rates

Age Group	Respirations per Minute
Infant	25-50 rpm
Child	15-30 rpm

To count respirations, count the number of times the chest or abdomen rises and falls in 30 seconds, then multiply by 2. Pretend to count pulse or do something so the patient is unaware.

When respirations are all the same frequency and depth (shallow or deep breathing), breathing is considered regular. If frequency or rate is different, breathing is irregular (rhythm).

Unusual noises (snoring or wheezing) can indicate an obstructed airway.

Abnormal breathing conditions:

• Poor rise and fall of the chest
• Increased effort
• Cyanosis

Pulse

The pulse is the pressure wave in the arteries generated by the heartbeat. It directly reflects the rate, rhythm, and strength of heart contractions. Each time the heart beats, arteries expand and contract. You can feel the pulse by pressing on an artery over a bony prominence.

Normal Pulse Rates

Age Group	Pulse Rate per Minute
Infant	120-150 ppm

Skin Temperature

Normal body temperature: 98.6°F (37°C)

Method: Place the back of your hand against the patient’s skin. This is called relative skin temperature. It is not an exact measurement but can tell you if it is high or low.

Skin Coloration

Skin coloration can be characterized by:

• Paleness
• Redness
• Blueness
• Yellowness
• Black and blue mottling
• In people with darker skin, you can also check for color changes in specific areas.

Skin Condition

Reported as dry, moist, or wet with respect to the local environment.

Capillary Refill

Used for infants and children under 6 years old. Not always accurate in adults. Press on the nail bed and observe how long it takes for the normal pink color to return after releasing. Always re-check at the same place. Capillary refill may be delayed in patients with cold extremities. This method is used on adults in triage situations.

Pupils

Normal responses: Pupils constrict with exposure to light and dilate with less light. Both pupils should be the same size unless a prior injury or condition has altered this. To assess, shine a penlight into the eyes. If outdoors, cover the eyes and assess for dilation.

Abnormal Findings No reaction to light, pupils remain constricted (possible drug overdose), or unequal pupils (head injury or stroke).

Blood Pressure

This is the amount of pressure the blood exerts against the artery walls. It can tell you if the organs are getting the blood they need. Use a blood pressure cuff (sphygmomanometer) to measure blood pressure.

The result of a contraction of the heart, forcing blood through the arteries, is systolic pressure. Relaxation between contractions is called diastolic pressure. Both normally rise and fall together.

Blood pressure varies with age, gender, and medical history of the patient. Blood pressure values are usually 10 mmHg lower in females than in males.

Normal Blood Pressure Values (mmHg)

Age Group	Systolic	Diastolic
Adult	100 + age	up to 150 mmHg
Child (up to 12 years old)	80 + (2 × age)	up to 150 mmHg

Methods for Taking Blood Pressure

• Auscultation: Listening to the Korotkoff sounds with a stethoscope while deflating the blood pressure cuff to determine systolic and diastolic pressures.
• Palpation: Feeling for the return of a pulse in an artery (e.g., radial or brachial) while deflating the blood pressure cuff to estimate systolic pressure (diastolic cannot be determined using this method).

Blood Pressure Factors

Several factors can influence blood pressure. Some increase blood pressure, while others will decrease it:

• Conditions or substances that constrict blood vessels can increase blood pressure, such as cold environment, stress, pain, smoking, caffeine, and decongestants.
• Heart failure, trauma, and/or shock will decrease blood pressure.

Other factors can affect a reading, such as not hearing accurately, placing the stethoscope improperly, the arm not at heart level, using the wrong size cuff, or deflating the cuff too fast.

4. Patient History

Re-evaluate what you observed when you arrived on the scene:

• Secure the scene
• Patient history
• Gather information

Remember the differences between a medical and a trauma patient. In trauma, perform the physical exam first. For a medical patient, take a history first.

To conduct a patient interview or history, you can use the mnemonic “S.A.M.P.L.E.”:

• S = Signs and symptoms
• A = Allergies
• M = Medication
• P = Pertinent history
• L = Last oral intake
• E = Events

(S) Signs and Symptoms

Signs are conditions you can observe (see, feel, or hear), such as a broken wrist or unequal pupils. Symptoms are conditions that only the patient can feel or describe, such as stomach pain, tenderness, or dizziness.

Begin by asking open-ended questions such as:

Avoid leading or closed-ended questions that have “yes” or “no” answers, for example:

Do not diagnose. Treatment is based on assessment findings.

(A) Allergies

Identify medications, food, or environmental factors that may determine possible causes of the patient’s condition.

(M) Medications

Identify all medications the patient is currently taking or has recently taken. These may help identify a medical condition.

(P) Pertinent History

Obtain historical information relevant to the emergency care you are providing.

(L) Last Oral Intake

Ask your patient when the last time was they ate or drank anything. This is especially relevant for unresponsive or confused patients and is important if the patient requires immediate surgery.

(E) Events

Identify activities or events leading up to the incident.

5. Ongoing Assessment

A patient may be in a stable or unstable condition. The assessment process must be ongoing until your patient is turned over to the next level of care. Complete the following every 5 minutes for unstable patients and every 15 minutes for stable patients:

1. Reassess
2. Reassess
3. Reassess
4. Reassess
5. Reassess
6. Repeat
7. Reassess
8. Continue to calm and reassure the patient.

Maintain professionalism and concern for the patient’s modesty. Do not leave the patient unattended.

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6. Hand-off Report

When you are relieved of your patient by a higher-level care provider, be prepared to give appropriate information about your patient. This is the hand-off report, also known as patient transfer information.

The hand-off report includes the following eight areas of information:

• Patient’s age and gender: Provide basic demographic details.
• Chief complaint: State the primary reason for the call or patient’s condition.
• Mechanism of injury or nature of illness: Describe how the injury occurred or the type of illness.
• Relevant medical history: Include any pertinent medical, surgical, or medication history.
• Vital signs: Share the patient’s most recent vital signs and any trends observed.
• Treatment provided: Detail any interventions or treatments administered.
• Patient response to treatment: Note how the patient responded to the care provided.
• Any additional observations or concerns: Mention anything unusual or requiring further attention

The report is designed to be an up-to-the-minute account of the patient’s condition, treatment, and other information. Sometimes, this will also appear in your written report.

PATIENT ASSESSMENT PLAN

SCENE SIZE-UP	INITIAL ASSESSMENT	PHYSICAL EXAMINATION	PATIENT HISTORY	ONGOING ASSESSMENT	PATIENT HAND-OFF
What is the current situation?	General impression (Trauma or Medical)	BP-DOC	S.A.M.P.L.E.	Repeat Initial Assessment	Patient age and sex
	– Medical or mechanism of injury
	– Observe for hazards
Where is it going?	Responsiveness	Head	Signs and symptoms	Repeat Physical Exam	Chief complaint
– What are the possibilities?
How do I control it?	Airway	Neck	Allergies	Reassess treatment and interventions	Level of responsiveness
– What resources are needed?	Breathing	Chest	Medications	Calm and reassure the patient	Airway status
Circulation	Abdomen		Past history		Breathing status
Patient status update	Pelvis	Last oral intake	Physical exam findings
	Extremities	Events		S.A.M.P.L.E. history
	Back	Vital signs:			Treatment
		– Respiration
		– Pulse
		– Skin
		– Pupils
		– Blood pressure

 

Conclusion:

In summary, mastering patient assessment is a vital skill for medical first responders, encompassing six critical phases: scene size-up, initial assessment, physical examination, patient history, ongoing assessment, and patient hand-off.

Each step, from securing the scene to providing a comprehensive report, ensures effective and efficient patient care. Statistics reveal that thorough assessments can improve patient survival rates by up to 30% in emergencies.

Key elements like identifying life-threatening conditions, monitoring vital signs, and communicating findings to EMS teams are fundamental. By practicing these procedures regularly, responders can significantly enhance outcomes and deliver life-saving interventions with confidence and precision.