14.1 Patient assessment and history taking
4 min read•august 7, 2024
Patient assessment and history taking are crucial skills in first aid. They help identify life-threatening conditions and guide treatment decisions. The primary survey uses the , while the secondary survey involves a head-to-toe examination.
Vital signs provide key information about a patient's condition. The gathers essential details about the patient's health and the incident. Understanding the mechanism of injury helps predict potential injuries and tailor the assessment process.
Patient Assessment
Primary and Secondary Surveys
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- Primary survey quickly identifies life-threatening conditions using the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure)
- Involves checking for responsiveness, assessing airway patency, evaluating breathing quality and rate, checking pulse and signs of bleeding, determining level of consciousness, and exposing the patient for a thorough examination
- Secondary survey is a head-to-toe assessment performed after the primary survey to identify additional injuries or conditions
- Includes a systematic examination of the patient's body, starting from the head and working down to the toes, looking for signs of injury, deformity, or abnormalities (bruising, swelling, tenderness)
Vital Signs and Body Systems Assessment
- Vital signs provide crucial information about the patient's physiological status and include temperature, pulse rate, respiratory rate, blood pressure, and oxygen saturation
- Temperature can indicate infection, hypothermia, or hyperthermia (normal range: 97.7°F to 99.5°F or 36.5°C to 37.5°C)
- Pulse rate reflects the heart's functioning and can be measured at various pulse points (radial, carotid, femoral) (normal adult range: 60-100 beats per minute)
- Respiratory rate and quality indicate the effectiveness of the patient's breathing (normal adult range: 12-20 breaths per minute)
- Blood pressure measures the force of blood against the arterial walls during systole and diastole (normal adult range: 120/80 mmHg)
- Oxygen saturation measures the percentage of hemoglobin saturated with oxygen and can be assessed using a pulse oximeter (normal range: 95-100%)
- Body systems assessment involves evaluating the functioning of major organ systems, such as the cardiovascular, respiratory, neurological, and gastrointestinal systems
- Assessing the cardiovascular system includes checking for signs of shock, evaluating capillary refill time, and monitoring heart sounds
- Respiratory system assessment involves observing chest wall movement, auscultating lung sounds, and checking for signs of (cyanosis, nasal flaring, retractions)
History Taking
SAMPLE History and Chief Complaint
- SAMPLE is an acronym used to gather essential patient information: Signs/Symptoms, Allergies, Medications, Past , Last oral intake, Events leading to the incident
- Obtaining a SAMPLE history helps provide context for the patient's condition and guides treatment decisions
- Signs and symptoms are the patient's subjective complaints and objective findings (pain, nausea, visible injuries)
- Allergies to medications, foods, or environmental factors should be identified to avoid adverse reactions during treatment
- Medications, both prescription and over-the-counter, can impact the patient's condition and treatment options
- Past medical history, including chronic illnesses, surgeries, and hospitalizations, provides insight into the patient's overall health status
- Last oral intake helps determine the risk of aspiration during resuscitation and guides the decision to administer oral medications
- Events leading to the incident, such as the mechanism of injury or onset of symptoms, help establish the cause and severity of the patient's condition
- is the primary reason the patient is seeking medical attention and should be documented in the patient's own words (shortness of breath, chest pain, abdominal pain)
Mechanism of Injury
- Mechanism of injury describes the forces and events that caused the patient's injury or illness
- Understanding the mechanism of injury helps predict potential injuries and guides the assessment and treatment process
- Examples of mechanisms of injury include blunt trauma (motor vehicle accidents, falls), penetrating trauma (stab wounds, gunshot wounds), and medical emergencies (stroke, myocardial infarction)
- Gathering information about the height of a fall, the speed of a vehicle, or the type of weapon involved can provide valuable insights into the severity of the injury
Neurological Assessment
Glasgow Coma Scale and Pain Assessment
- The (GCS) is a standardized tool used to assess a patient's level of consciousness and neurological functioning
- GCS evaluates three components: eye-opening response (4 points), verbal response (5 points), and motor response (6 points)
- The total GCS score ranges from 3 (deep coma) to 15 (fully conscious) and helps guide treatment decisions and monitor patient progress
- is a crucial component of patient care, as pain can be a sign of underlying injury or illness
- Pain can be assessed using various scales, such as the numeric rating scale (0-10) or the visual analog scale (line with "no pain" and "worst pain" endpoints)
- Patients should be asked to describe the location, intensity, quality, and duration of their pain, as well as any aggravating or alleviating factors
Neurological Assessment Techniques
- Neurological assessment involves evaluating the patient's cognitive function, motor strength, sensory perception, and reflexes
- Cognitive function can be assessed by asking the patient to state their name, location, and current date/time (orientation) and testing short-term memory
- Motor strength is evaluated by having the patient resist force applied to various muscle groups and comparing strength bilaterally
- Sensory perception is assessed by testing the patient's ability to feel light touch, pain, and temperature in different dermatomes
- Reflexes, such as the patellar and biceps reflexes, are tested using a reflex hammer to evaluate the integrity of the nervous system
- Pupillary response to light is assessed by shining a light into each eye and observing the constriction and dilation of the pupils (normal response is equal and reactive)
- Abnormal neurological findings, such as weakness, numbness, or altered mental status, can indicate underlying conditions (stroke, traumatic brain injury, spinal cord injury) and require prompt intervention
Key Terms to Review (21)
ABC Assessment: The ABC Assessment is a systematic approach used in emergency situations to evaluate a patient's vital functions, specifically focusing on Airway, Breathing, and Circulation. This assessment is crucial for identifying life-threatening conditions and initiating appropriate interventions quickly. The ABC sequence helps prioritize actions that can save lives, particularly during cardiac emergencies, severe allergic reactions, or when gathering important patient history.
ABCDE Approach: The ABCDE approach is a systematic method used in first aid and emergency medicine to prioritize patient assessment and management. It stands for Airway, Breathing, Circulation, Disability, and Exposure, guiding responders through the crucial steps to stabilize a patient effectively and efficiently while identifying life-threatening conditions.
Active Listening: Active listening is a communication technique that involves fully concentrating, understanding, responding, and remembering what the speaker is saying. It goes beyond just hearing words; it requires engagement and feedback, ensuring the speaker feels heard and valued. This skill is crucial in various high-pressure situations, as it helps build trust, clarifies information, and supports effective decision-making.
Chief complaint: The chief complaint is the primary symptom or issue that prompts a patient to seek medical attention. It serves as the focal point in patient assessment and history taking, guiding healthcare providers in their evaluation and treatment plan. Understanding the chief complaint is crucial as it not only reveals the patient's immediate concerns but also helps prioritize further questioning and examination based on the reported issue.
Critical Intervention: Critical intervention refers to the immediate and often life-saving actions taken by healthcare professionals during patient assessment to address potentially life-threatening conditions. These interventions are crucial during the initial stages of care as they help stabilize a patient's condition, ensuring their safety while further evaluations or treatments are planned. Understanding when and how to perform these interventions can greatly influence patient outcomes, particularly in emergency situations.
Emergency care priority: Emergency care priority refers to the systematic approach used by healthcare providers to assess and address the needs of patients in urgent situations, ensuring that those who are most critically injured or ill receive immediate attention. This process is essential for effectively managing resources and providing timely interventions to save lives or prevent further harm. Establishing priorities during patient assessment helps determine the most urgent needs based on the severity of the condition and can significantly impact patient outcomes.
Glasgow Coma Scale: The Glasgow Coma Scale (GCS) is a clinical scale used to assess a person's level of consciousness after a brain injury by evaluating three aspects: eye opening, verbal response, and motor response. This scale helps emergency responders prioritize care and determine the severity of head injuries, which is crucial for patient assessment and history taking.
Medical history: Medical history refers to the comprehensive record of a patient's past health experiences, including previous illnesses, surgeries, medications, allergies, and family medical conditions. Understanding a patient's medical history is crucial for effective patient assessment and informed decision-making regarding diagnosis and treatment plans.
Objective data: Objective data refers to measurable and observable information collected during a patient assessment that is free from personal feelings or opinions. This type of data includes physical findings, vital signs, laboratory results, and any other quantifiable evidence that can be verified by others. It is crucial for accurate documentation and effective handover procedures, as it ensures that healthcare providers have a clear and factual basis for decision-making.
Pain assessment: Pain assessment is the systematic process of evaluating a patient's pain to understand its intensity, quality, and impact on daily life. This evaluation is crucial in guiding treatment decisions and ensuring effective pain management, as it allows healthcare providers to identify specific pain characteristics and monitor changes over time.
Patient rapport: Patient rapport refers to the trusting and respectful relationship established between a healthcare provider and a patient. This connection is essential for effective communication, encouraging patients to share their concerns and symptoms openly, which can lead to better assessment and care outcomes.
Primary Assessment: Primary assessment is the initial evaluation of a patient to identify life-threatening conditions and ensure their immediate safety. It is a critical process that involves checking the patient's responsiveness, airway, breathing, circulation, and any significant injuries or medical needs. This assessment is essential for establishing priorities in emergency care and informs the necessary actions to stabilize the patient effectively.
Respiratory distress: Respiratory distress refers to a condition where an individual has difficulty breathing, often accompanied by a feeling of shortness of breath. It can indicate an underlying health issue that requires immediate attention, as it affects the body’s ability to get enough oxygen. Recognizing respiratory distress is crucial, as it can influence vital signs like heart rate and blood pressure, and understanding the patient's history can help in identifying the cause and determining the appropriate treatment.
Sample History: Sample history refers to a systematic method of gathering essential information about a patient’s current condition and past medical history during the assessment process. It is crucial for understanding the patient's background, identifying potential causes of their symptoms, and determining appropriate treatment options. Collecting a sample history involves asking specific questions about the patient's medical history, medications, allergies, and any relevant family history that may impact their health status.
Secondary assessment: The secondary assessment is a detailed examination of a patient after the primary survey is completed, focusing on identifying any additional injuries or medical conditions. This process is crucial as it allows for a comprehensive understanding of the patient's overall health, guiding appropriate treatment and interventions. It involves gathering vital signs, conducting a head-to-toe physical examination, and asking relevant questions about the patient's medical history and symptoms.
Shock signs: Shock signs are physiological indicators that a person may be experiencing shock, a critical condition where there is inadequate blood flow and oxygen delivery to the body's tissues. Recognizing these signs is crucial in patient assessment and history taking, as they can indicate the severity of an injury or illness and the need for immediate medical intervention. Understanding these signs helps responders prioritize care and make informed decisions during emergencies.
Sphygmomanometer: A sphygmomanometer is a medical instrument used to measure blood pressure, consisting of an inflatable cuff and a pressure gauge. It plays a critical role in assessing a patient’s cardiovascular health, allowing healthcare providers to determine if the blood pressure is within a normal range or indicative of hypertension or other conditions. Accurate blood pressure readings can influence treatment decisions and help track a patient's health over time.
Stethoscope: A stethoscope is a medical instrument used to listen to the internal sounds of a patient’s body, primarily the heart and lungs. It amplifies these sounds, allowing healthcare providers to assess vital functions and diagnose various conditions effectively. The stethoscope is an essential tool for monitoring health status and is commonly used in clinical settings during examinations and patient assessments.
Subjective data: Subjective data refers to the information that comes directly from a patient, reflecting their personal feelings, perceptions, and experiences. This type of data is crucial for understanding a patient's condition from their perspective, as it provides insights into symptoms that may not be observable through physical examination. Gathering subjective data allows for better patient assessment and is an essential component of effective documentation and handover procedures.
Triage Protocol: A triage protocol is a systematic approach used in emergency situations to prioritize patients based on the severity of their condition and the urgency of their need for medical treatment. This process helps ensure that limited medical resources are allocated effectively, allowing healthcare providers to focus on those who require immediate care while also considering the overall capacity and needs of the healthcare system.
Vital signs assessment: Vital signs assessment is the process of measuring key physiological parameters that provide essential information about a patient's health status. These signs typically include heart rate, respiratory rate, blood pressure, and temperature, which help in evaluating the body's basic functions and detecting any abnormalities. By systematically assessing these indicators, healthcare providers can make informed decisions about patient care and identify potential medical emergencies.