Lesson 1 -- Initial Assessment

1-1. WHAT ARE "VITAL SIGNS"?

Following the initial assessment and control of any immediate life threats, you will begin a more thorough assessment of your patient. Two essential elements of this assessment will be measuring vital signs and obtaining a medical history. Vital signs are measurable life signs. The term "vital signs" usually refers to the patient's temperature, pulse, breathing, and blood pressure. Because they reflect the patient’s condition, you must take them early and repeat them often. The medical history includes information about the present medical problem and facts about the patient that existed before the patient required emergency medical response. This information can affect the treatment you give. It is called a SAMPLE history because the letters in the word SAMPLE stand for elements of the history.

1-2. INITIAL ASSESSMENT AND SAMPLE HISTORY

A thorough, properly sequenced rapid assessment is essential to identifying a patient’s needs and providing proper emergency care. To assess a patient, the combat medic must gather, evaluate, and record key information including the patient’s vital signs, injuries, and symptoms and the conditions leading to the illness or injury. The combat medic must learn the history of what happened before and since the accident or medical problem occurred and learn the patient's past medical history and overall health status. Assessment is a process which must be taught in steps in order to establish good assessment habits and a systematic approach in order to avoid missing important injuries or illnesses. In the field, many aspects of the patient assessment may be done simultaneously.

Assessment is one of the most complex skills that must be learned to be an effective combat medic. During the assessment, the combat medic must use his eyes, ears, nose, hands, and a few basic medical instruments to obtain essential information about the patient.

1-3. ESTABLISH PATIENT CONTACT

After assessing the scene for safety and determining the need for additional help, the number of patients, the mechanism of injury or nature of illness, and considering the need for cervical spine immobilization, the combat medic must make contact with the patient. The patient is assessed for ABC’s and his level of consciousness; then you can begin questioning your patient for vital information about the current medical problem with which you are concerned. This is the "chief complaint."

The chief complaint is the major signs, symptoms, or events that caused the illness or injury. Symptoms are conditions that the patient feels and tells you about, such as dizziness or particular pain. Symptoms are the subjective information you obtain from you patients. Signs can be seen, heard, felt, smelled, or measured, such as wounds, external bleeding, deformities, breathing rate, and pulse. You must be able to record and report how and when the signs and symptoms began.

Initial assessment is a rapid evaluation of the patient’s general condition to identify any potentially life-threatening injuries or conditions.

1. Repeated vital signs will be compared to the baseline set.
2. Vital signs are key indicators used to evaluate and determine the patient’s overall condition. Because key indicators include quantitative (numeric) measurement, vital signs always include breathing, pulse, and the blood pressure.

1. The first vital sign is breathing. Breathing is discussed in Lesson 4.
2. The second vital sign is the pulse. The pulse is discussed in Lesson 3.
3. The third vital sign is the blood pressure. Blood presser is discussed in Lesson 5.
4. Other key indicators include:

• Skin temperature and condition in adults.
• Capillary refill time (in children).
• Pupillary response.
• Level of consciousness (LOC).

1-4. ASSESSING THE SKIN

The skin is an easily observed indicator of the peripheral circulation and perfusion, blood oxygen levels, and body temperature. The skin color, temperature, and condition are good indicators of the patient's condition and circulatory status. They may also be good initial indicators of heat or cold injuries. This initial indicator should always be confirmed, when time permits, with a core body temperature (see Lesson 2).

Color.

• Many blood vessels lie near the surface of the skin.
• Pigmentation in individuals will not hide changes in the skin’s underlying color.
• In lightly pigmented individuals, skin normally has a pink color.
• In patients with deeply pigmented skin, changes in skin color may only be apparent in certain areas, such as the fingernail beds, the lips, the mucous membranes in the mouth, the underside of the arm and hand, and the conjunctiva of the eye.
• Poor peripheral circulation will cause the skin to appear pale, white, ashen, gray, or waxy and translucent like a white candle. These skin colors can also appear in abnormally cold or frozen skin.
• When the blood is not properly saturated with oxygen, it changes to a bluish color. Skin over the blood vessels appears blue or gray, a condition called cyanosis.
• Red skin will result from carbon monoxide poisoning, significant fever, heatstroke, sunburn, mild thermal burns, or other conditions in which the body is unable to properly dissipate heat.
• Color changes may also result from chronic illness. Liver disease dysfunction may cause jaundice, resulting in a yellow cast to the skin.

Temperature.

• Normally, the skin is warm to the touch.
• The skin feels hot with significant fever, sunburn, or hyperthermia.
• The skin feels cool in early shock, profuse sweating, heat exhaustion, and profound hypothermia and/or frostbite.
• Feel the patient’s forehead with the back of your ungloved hand to determine marked fever.

Moisture.

• The skin is normally dry.
• Wet, moist, or excessively dry and hot skin is considered abnormal.
• In descriptions of the skin, it is usually listed as color, condition, and temperature (CCT).

Capillary Refill.

Capillary refill can be assessed as part of the evaluation of the skin.

1. Capillary refill is used to evaluate the ability of the circulatory system to restore blood to the capillary system (perfusion). Capillary refill is used primarily in the assessment of pediatric patients. Refill time in adults is not considered as accurate due to differences in circulation from medications and various other factors. This can still be used as a simple test of perfusion to the extremities, but many factors must be considered, such as the age of the patient and the environment (cold will decrease capillary refill time).
2. Capillary refill is evaluated at the nail bed in a finger.

• Place your thumb on the patient’s fingernail and gently compress.
• Pressure forces blood from the capillaries.c) Release the pressure and observe the fingernail.
• As the capillaries refill, the nail bed returns to its normal deep pink color.
• Capillary refill should be both prompt and pink.
•  Color in the nail bed should be restored within 2 seconds, about the time it takes to say "capillary refill."

1-5. ASSESSING LEVEL OF CONSCIOUSNESS

Level of consciousness should also be assessed upon initial contact with your patient and continuously monitored for changes throughout your contact with the patient.

a. AVPU. The AVPU scale is a rapid method of assessing LOC. The patient's LOC is reported as A, V, P, or U.

(1) A: Alert and oriented.

(a) Signifies orientation to person, place, time, and event. Ask your patient simple open ended questions that can not be answered with yes or no to determine the LOC. For example, "Where are you right now?" and "What time is it?" Do not ask your patient, "Do you know were you are right now?" since this can be answered with a yes or no.

(b) If the patient is alert, you can reported your results as a patient oriented score from 1 (lowest) to 4 (highest), noting any areas not oriented to. For example, you can state the patient is "A and O X 4" (fully alert and oriented) or "A and O x 2 and does not know time and place."

(2) R: Responds to verbal stimulus. This indicates that your patient only responds when verbally prompted. It is also important to note if the patient makes appropriate or inappropriate responses. If you ask your patient, "What is your name?" and he responds with, "Flaming monkeys," this would be an inappropriate response and shows that although he responds to verbal, he is not appropriately oriented.

(a) Response to normal voice stimuli.

(b) Response to loud voice stimuli.

(3)  P: Responds to pain.

(a) Use if patient does not respond to verbal stimuli.

(b) Gently but firmly pinch patient’s skin.

(c) Note if patient moans or withdraws from the stimulus.

(4)    U: Unresponsive.

(a) If the patient does not respond to painful stimulus on one side, try the other side.

(b) A patient who remains flaccid without moving or making a sound is unresponsive.

b. Glasgow Coma Scale. The Glasgow Coma Scale is an assessment based on numeric scoring of a patient’s responses based on the patient's best response to eye opening, verbal response, and motor response. The patient's score (3 to 15) is determined by adding his highest eye opening, verbal response, and motor response scores.

(1) Eye opening (1 to 4 points).

(a) Spontaneous: E4. Eyes are open and focused; the patient can recognize you and follow eye movements.

(b) To voice: E3. The patient opens his eyes when spoken to or when directed to do so.

(c) To pain: E2. The patient opens his eyes when given some sort of painful stimuli.

(d) None: E1.

(2) Verbal response (1 to 5 points).

(a) Oriented: V5. The patient can talk and answer questions about his location, time, and who he is. In some situations, it is also appropriate to question the patient to see if he is oriented to the event that led him to be in his current condition.

(b) Confused: V4. The patient can talk and speak coherently, but is not entirely oriented to person, place, time, and event.

(c) Inappropriate words: V3. The patient answers with some sort of inappropriate response to the question that was asked or answers with excessive use of profanity that is not associated with anger toward the event.

(d)  Incomprehensible words: V2. Unintelligible words or sounds.

(e) None: V1

(3) Motor response (1 to 6 points).

(a) Obeys command: M6. The patient can follow appropriate commands or requests. It is also important to asses the patient for the ability to follow commands across the central plane of the body. For example, the command, "Please touch your left shoulder with your right arm," helps to ensure the patient can cross the hemispheres of the brain since the left and right sides of the body are controlled by the opposite sides of the brain.

(b)  Localizes pain: M5. Can the patient localize the pain that he is feeling? If you elicit a pain response by pinching of squeezing the right side, watch for the patient to reach across with the opposite arms to check for cross body localization.

(c) Withdraws to pain: M4. This indicates a correct pain response. The body should withdraw away from the pain and not towards it.

(d) Flexion (decorticate posturing): M3. This is an abnormal posturing usually caused by severe brain trauma. The body curls into a protective posture by flexing the arms into the chest.

(e)  Extension (decerebate posturing): M2. In this form of posturing, the body is abnormally extended. The arms and legs may be extended and very rigid or difficult to move.

(f) None: M1.

c.      PEARRL. Use the guide PEARRL when assessing the pupillary response of the patient's eyes.

(1) P: Pupils. Are they both present? What is their general condition?

(2) E: Equal. Are both pupils the same size? Unequal pupils can indicate a head injury causing pressure on the optic nerve. There is a small percent of the population that has unequal pupils normally, so a good patient history is critical.

(3) A: And.

(4) R: Round.

(5) R: Regular in size.

(6) L: React to light. Both eyes should be assessed twice for reaction to light. The first time the light is shined in the right eye, for example, you should watch the right eye for reaction, the second time the left eye should be watched to ensure sympathetic eye movement is present. (both eyes are doing the same thing at the same time).

d Vital Signs.

(1) The first set of vital signs establishes an important initial measurement of the patient’s condition and serves as a key baseline.

(2) Monitor vital signs for any changes from initial findings throughout care.

(3) Reassess and record vital signs at least every 15 minutes in a stable patient and at least every 5 minutes in an unstable patient.

(4)  Reassess and record vital signs after all medical interventions.

1-6. SAMPLE HISTORY

SAMPLE is an acronym used to help determine a patient's history of the current illness. SAMPLE history is very important in that will help you to determine some of the patient's key complaints. In the medical patient, a good history will help determine about 80 percent of the indications of what illness you are dealing with. During the SAMPLE history, it is also important to determine what allergies and medications the patient may have. This is a very important step in the treatment of any patient.

a. Signs and Symptoms. Signs are the things you can see about the patient's condition. Symptoms are what the patient tells you about his condition. Use OPQRST to help determine the patient's history.

(1) O -- Onset of the current condition, What were you doing when this happened? Did it come on suddenly? Did it come on slowly?

(2)  P-- Provokes. What makes this condition better or worse? Did this get better when you rested? Took a medication?

(3) Q -- Quality. What is the quality of the pain? Have the patient describe in his own words what the pain feels like (stabbing, pressure, tearing, crushing, etc.). Try not to lead the patient by asking questions like, "Is it a stabbing pain?"

(4) R -- Radiation. Does the pain radiate? Or is it located in one specific area?

(5) S -- Severity. This is usually assessed by having the patient rate the pain on a scale of 1 to 10 with 10 being the worse. It is necessary to ask the patient about the worst pain they have ever felt to obtain a good basis for their pain threshold and previous pain exposure.

(6)  T -- Time, How long has it been since the pain started?

b. Allergies. Is the patient allergic to medications, food, or other substances?

c. Medication. What medications is the patient currently taking? Make sure to ask about over-the-counter medications, herbal medications, and supplements that the patient may be taking.

d. Pertinent Past History. Does the patient have any pertinent medical history? Anything that the patient may feel is applicable to the current illness or injury?

e. Last Oral Intake. When did the patient last eat or drink?

f. Events Leading to the Injury or Illness. What events lead to this incident? What where you doing just before the event happened or started?