Patient Initial Assessment – Vital Signs – Skin Temperature – Blood Pressure

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

List the five general procedures a medical first responded should complete when arriving at the scene.

List the six phases of the patient assessment plan.

List the six steps of the initial assessment.

Demonstrate a complete physical examination as defined in this lesson.

Patient Assessment Photos

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

1. Scene Size-up

Conduct a scene size-up as described in Lesson 4, then continue with the process described in the following paragraphs.

1.1 Arrival on the Scene

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

  1. Ensure your own personal safety (includes the use of body surface isolation and securing the scene).
  2. Ensure patient safety.
  3. Establish a general impression of the scene (determine mechanism of injury) and begin your initial assessment of the patient (if responsive, identify yourself).
  4. Identify and treat life-threatening injuries.
  5. Stabilise and continue to monitor the patient.

1.2 Identify Yourself

  1. State your name and organization.
  2. Identify yourself as a Medical First Responded.
  3. Ask the patient if you may help him/her (obtain consent).

1.3 Immediate Sources of Information

  1. The scene itself (observe, plan, react)
  2. Patient (if responsive)
  3. Relatives or bystanders
  4. The mechanism of injury (forces that caused the injury – kinematics)
  5. Any remarkable deformity or obvious injury
  6. Any signs or characteristics of certain types of injury or illness

 

2. Initial Assessment

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

Steps of the Initial Assessment:

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

  1. Form a general impression.
  2. Determine if the situation is trauma or medical.
  3. 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 immediately 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: Alert, Verbal, Painful, Unresponsive 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 – AA0x3).
V =Verbal: A patient who responds only when spoken to. We say he/she 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 patient’s

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 airway is open and patient is breathing adequately.

4) Verify breathing – look, listen and feel for air exchange (3-5 seconds). Respiration’s must be adequate. Adequate breathing is characterized by three factors:

  1. Full rise and fall of chest
  2. Easy breathing
  3. Normal respiratory rate

Inadequate breathing is characterized by:
Insufficient rise and fall of 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)

Apply oxygen as needed. Select appropriate delivery system and appropriate accessories.

Oxygen is used for both medical and trauma patients.

5) Assess circulation.

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

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

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

6) Patient status update. Inform responding EMS units of your findings

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

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.
  • The physical exam is a thorough survey of the patient’s entire body. It is meant to reveal any signs of illness or injury.
  • The physical exam proceeds in a logical order, usually from head to toe, but may vary from patient to patient.

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:

  1. Inspection (looking): A method of examination that involved looking for signs of injury or illness. Simply make an overall observation of your patient, then an observation of the body.
  2. 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.
  3. 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.

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 medic alert necklace.
  • 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 ribs 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 ileum, ischium and pubic bone.
  • Pelvic or hip fracture could result in blood loss of liters or more.
  • Internal organs, blood vessels and nerves pass through pelvic area.
  • Spinal injury possible.
  • Genital region: Priapism in males.
  • Deformities not always obvious. Palpate iliac crest (pelvic wings) and pubic bones.
  • Open injuries may occur, but are uncommon. Penetrating injuries 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 Carotid  pulse.
  • Check for motion  wiggle
  • Check for sensation – gently squeeze one extremity then another. Ask the patient somthing ?
  • When do you remove 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 Carotid pulse.
  • Check for motion – wiggle
  • Check for sensation – gently squeeze one extremity then another. Again, ask the patient ?
  • 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 entire length of 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 practise 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 B/P

More important than just measuring vital signs are measuring changes over time. It is important to establish baseline vital signs. For example, if pulse on 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 Respiration’s per minute

Infant25-50 rpm
Child15-30 rpm

To count respirations, count the number of times a 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 contractions ofthe heart. 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 Respiration per minute

Infant

25-50 rpm

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 characterized by:

  • Paleness
  • Redness:
  • Blueness:
  • Yellowness:
  • Black and blue mottling:
  • In people with darker skin, you can also check for colour changes in these areas:

Skin Condition

Reported as dry, moist or wet with respect to 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 colour 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 changed 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)
AdultChild
Systolic100+age80+(2*age)
Diastolicup to 150 mmHg

Methods for Taking Blood Pressure

Auscultation: The auscultatory technique (also recognized as the Riva Rocci Korotkoff or manual method for blood pressure measurement) is the LISTENING of Korotkoff sounds in the brachial artery.
Palpation: Inflate the cuff rapidly to 70 mmHg, and increase by 10 mm Hg increments while palpating the radial pulse. Note the level of pressure at which the pulse goes away and consequently reappears during deflation might be systolic blood pressure.

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 scene.

  • Secure the scene
  • Patient history
  • Gather information

Remember differences between a medical and a trauma patient. In trauma, perform 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.

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: Medications, food, environment. May determine possible causes of patient’s condition.
(M) Medications: Identify all medications the patient is currently taking or has recently taken. These may identify a medical condition.
(P) Pertinent history: Obtain historical information pertinent to the emergency care you are providing.
(L) Last oral intake: Ask your patient when the last time was he or she ate or drank anything. Pertinent to a patient who is unresponsive or confused. Important if the patient needs immediate surgery.
(E) Events: Activities prior to the incident.

5. Ongoing Assessment

A patient may be in 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 patient’s modesty. Do not leave patient unattended.

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:
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?
    • Medical or mechanism of injury
 
    • Observe for hazards
   
General impression (Trauma or Medical) BP-DOC S.A M P.L E. Repeat Initial Assessment Patient age and sex
Where is it going? • What are the possibilities? Responsiveness Head Signs and symptoms .................... ... Repeat Physical Exam Chief complaint
How do I control il?
    • What resources are needed?
   
Airway Neck Allergies Reassesses treatment and interventions Level of responsiveness
Breathing Chest Medications Calm and reassure the patient Airway status
Circulation Abdomen Past history Breathing status
Patient status update Pelvis Last oral In take Physical exam findings
Extremities E vents S.A.M P.L.E. history
Back Treatment
Vital signs
    • Respiration
 
    • Pulse
 
    • Skin
 
    • Pupils
 
    • Blood pressure
   

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