Primary & Secondary Assessment

Information Covered:

  1. Primary Survey/Primary Assessment
    1. Initial General Impression – Based on the Patient’s Age-Appropriate Appearance
      1. Appears stable
      2. Appears stable but potentially unstable
      3. Appears unstable
    2. Level of Consciousness
      1. While approaching the patient or immediately upon patient contact attempt to establish level of consciousness
        1. Speak to the patient and determine the level of response
        2. EMT should identify himself or herself
        3. EMT should explain that he or she is there to help
      2. Patient response
        1. Alert
          1. the patient appears to be awake
          2. the patient acknowledges the presence of the EMT
        2. Responds to verbal stimuli
          1. the patient opens his/her eyes in respond to the EMT’s voice
          2. the patient responds appropriately to a simple command
        3. Responds to painful stimuli
          1. the patient neither acknowledges the presence of the EMT nor responds to loud voice
          2. patient responds only when the EMT applies some form of irritating stimulus
            1. when an irritating stimulus is encountered, the human body will either attempt to move away from the stimulus or will attempt to move the stimulus away from the body
            2. acceptable stimuli
              1. pinch the patient’s ear
              2. trapezius squeeze
              3. others
        4. Unresponsive – the patient does not respond to any stimulus
    3. Airway Status
      1. Unresponsive patient
        1. Medical patients
          1. open and maintain the airway with head-tilt, chin-lift technique
          2. see the current American Heart Association guidelines for the steps in performing this procedure for victims of all ages
        2. Trauma patients
          1. open and maintain the airway with modified jaw thrust technique while maintaining manual cervical stabilization
          2. see the current American Heart Association guidelines for the steps in performing this procedure for victims of all ages
      2. Responsive patient
        1. If the patient speaks, the airway is functional but may still be at risk -- foreign body or substances in the mouth may impair the airway and must be removed
          1. finger sweep (solid objects)
          2. suction (liquids)
        2. If the upper airway becomes narrowed, inspiration may produce a high-pitched whistling sound known as stridor
          1. foreign body
          2. swelling
          3. trauma
        3. Airway  patency must be continually reassessed
    4. Breathing Status
      1. Patient responsive
        1. Breathing is adequate (rate and quality)
        2. Breathing is too fast (>24 breaths per minute)
        3. Breathing is too slow (<8 breaths per minute)
        4. Breathing absent (choking)
      2. Patient unresponsive
        1. Breathing is adequate (rate and quality)
        2. Breathing is inadequate
        3. Breathing is absent
    5. Circulatory Status
      1. Radial pulse present (rate and quality)
        1. Normal rate
        2. Fast
        3. Slow
        4. Irregular rate
      2. Radial pulse absent
      3. Assess if major bleeding is present
      4. Perfusion status
        1. Skin color
        2. Skin temperature
        3. Skin moisture
        4. Capillary refill (as appropriate)
    6. Identifying Life Threats
      1. Assess patient and determine if the patient has a life-threatening condition
        1. Unstable – if a life threatening condition is found, treat immediately
        2. Stable – assess nature of illness or mechanism of injury
    7. Assessment of Vital Functions
  2. Integration of Treatment/Procedures Needed to Preserve Life
  3. Evaluating Priority of Patient Care and Transport
    1. Primary Assessment: Stable
    2. Primary Assessment: Potentially Unstable

Primary Assessment: Unstable

  1. Techniques of Physical Examination
    1. General Approach
      1. Examine the patient systematically
      2. Place special emphasis on areas suggested by the present illness and chief complaint
      3. Keep in mind that most patients view a physical exam with apprehension and anxiety—they feel vulnerable and exposed
      4. Maintain professionalism throughout the physical exam while displaying compassion towards your patient
    2. Respiratory System
      1. Expose the chest as appropriate for the environment
      2. Chest shape and symmetry
      3. Respiratory effort
        1. Accessory muscle use
        2. Retractions
      4. Auscultation
        1. Technique – medical versus trauma
        2. Presence of breath sounds
        3. Absence of breath sounds
    3. Cardiovascular System
      1. Pulse
        1. Rate
        2. Rhythm
        3. Predictable
        4. Adjust timing for irregularity
        5. Strength
        6. Location
          1. common locations
          2. pelationto perfusion
      2. Perfusion
        1. Blood pressure
          1. equipment size
          2. placement of cuff
          3. position of patient
          4. position of arm
          5. methods of measurement
            1. auscultation
            2. palpation
          6. relation to perfusion
    4. Neurological System
      1. Mental status
        1. Appearance and behavior
          1. assess for level of consciousness (AVPU)
            1. alert
            2. response to verbal stimuli
              1. drowsiness
              2. stupor
                1. state of lethargy
                2. person seems unaware of surroundings
            3. response to painful stimuli
            4. unresponsive
              1. coma
                1. state of profound unconsciousness
                2. absence of spontaneous eye movements
                3. no response to verbal or painful stimuli
                4. patient cannot be aroused by any stimuli
          2. observe posture and motor behavior
          3. facial expression
            1. anxiety
            2. depression
            3. anger
            4. fear
            5. sadness
            6. pain
        2. Speech and language
          1. rate
          2. appropriateness
            1. slurred
            2. garbled
            3. aphasia
        3. Mood
          1. nature
          2. intensity
          3. suicidal ideation
        4. Thought and perceptions
          1. assess thought processes
            1. logic
            2. organization
          2. assess thought content
            1. unusual thoughts
            2. unpleasant thoughts
          3. assess perceptions
            1. unusual
            2. hearing things
            3. seeing things
        5. Memory and attention
          1. person
          2. place
          3. time
          4. purpose
    5. Musculoskeletal System
      1. Pelvic region
        1. Symmetry
        2. Tenderness
      2. Lower extremities
        1. Overview
          1. symmetry
          2. surface findings
        2. General physical findings
          1. range of motion
          2. sensory
          3. motor function
          4. circulatory function
        3. Peripheral vascular system
          1. tenderness
          2. temperature of lower legs
          3. distal pulses
      3. Upper extremities
        1. Overview
          1. symmetry
          2. strength
          3. surface findings
        2. General physical findings
          1. range of motion
          2. sensory
          3. motor function
          4. arm drift
      4. Back
        1. Overview
          1. symmetry
          2. contour
          3. surface findings
        2. General physical findings
          1. flank tenderness
          2. spinal column tenderness
    6. All Anatomical Regions
      1. Head
        1. Scalp
        2. Skull
        3. Face
          1. symmetry of expression
          2. appropriate facial expression
        4. Eyes
          1. pupil size, shape, and response
            1. normal – equal and reactive to light
            2. abnormal
              1. constricted
              2. dilated
              3. unequal
          2. conjunctiva color and hydration
        5. Ears – fluids
        6. Nose
          1. symmetry
          2. fluid in nares
        7. Mouth and pharynx
          1. odor
          2. hydration
          3. condition of teeth
      2. Neck
        1. Physical findings
        2. Symmetry
        3. Masses
        4. Arterial pulses
      3. Chest
        1. Overview
          1. expose appropriately
          2. chest shape and symmetry
          3. respiratory effort
          4. surface findings – inspection
        2. Auscultation
          1. technique – medical versus trauma
          2. lung sounds
            1. absence of breath sounds
        3. Anterior chest
          1. auscultation findings – lungs
          2. intercostal muscle use
          3. retraction
        4. Posterior chest
          1. auscultation
          2. spinal column
      4. Abdomen
        1. Overview
          1. position patient for examination
          2. shape and size
          3. palpation method
            1. four quadrants
            2. palpate affected area last
        2. Physical findings
          1. symmetry
          2. masses
          3. organ margins
          4. contour
          5. softness
          6. tenderness
          7. findings associated with pregnancy – physical changes of contour and shape
  1. How and When to Reassess
  2. Identify and Treat Changes in the Patient’s Condition in a Timely Manner
    1. Monitor the patient’s condition
    2. Monitor the effectiveness of interventions
    3. Identify trends in the patients vital signs
  3. Reassessments Should Be Performed at Regular Intervals
    1. Unstable Patients – Every Five Minutes, or as Often as Practical Depending on the Patient’s Condition
    2. Stable Patients – At Least Every 15 Minutes or as Deemed Appropriate by the Patient’s Condition
  4. A Reassessment Includes:
    1. Primary Assessment
    2. Vital Signs
    3. Chief Complaint
    4. Interventions
  5. Compare to the Baseline Status of That Component
    1. Level of Consciousness – Is the Patient Maintaining the Same Level of Responsiveness or Becoming More/Less Alert?
    2. Airway – Recheck the Airway for Patency
    3. Breathing – Reassess the Adequacy of Breathing by Monitoring Both Breathing Rate and Tidal Volume
    4. Circulation – Reassess the Adequacy of Circulation by Checking Both Central and Peripheral Pulses
  6. Vital Signs
    1. Repeat Vital Signs as Necessary
    2. Attention Should Be Paid to:
      1. Respirations
      2. Pulse
      3. Blood pressure
      4. Pupils
  7. Chief Complaint
    1. Constantly Reassess the Patient’s Chief Complaint or Major Injury
    2. Determine If Their Pain/Discomfort Is Remaining the Same, Getting Worse, or Getting Better
    3. Be Sure to Ask If There Are Any New or Previously Undisclosed Complaints
  8. Interventions – Reassess the Effectiveness of Each Intervention Performed and Consider the Need for New Interventions or Modifications to Care Already Being Provided

Age-Related Considerations for Pediatric and Geriatric Assessment and Management

Content Creator: James Stone
CAPCE Course Number: 20-EMTP-F3-8302
NJ Course Number: 141110
Total CE Hours: 1.5
Level: Basic
EMT-CE uses the NEMSES guidelines as the foundation for every course outline.