LIMMC12_0131142445.qxd 4/1/04 5:03 AM Page 211 RKAUL-4:Desktop Folder:irm:lim10ch12: 12 C H A P T E R Ongoing Assessment al. et er m m Li n. o diti E h Covers Lesson 3-6 and portions of Lesson 3-9 of the 1994 U.S. Department of nt e T Transportation’s EMT-Basic National Standard Curriculum e, ar C y c n e Total Teaching erg m DOT OBJECTIVES Time:1 hour E c. n Page numbers in parentheses refer to pages in the textbook. on, I The total teaching time being ati Knowledge and Attitude recommended is only a guide- uc d 1. Discuss the reasons for repeating the initial assessment as part of the lines. Instructors should take n E ongoing assessment. (p. 289) into consideration such factors arso as: the pace at which students e 2. Describe the components of the ongoing assessment. (pp. 289–298) P learn, the size of the class, and y 3. Describe trending of assessment components. (pp. 286, 289, 291) breaks. The actual time devoted 5 b 0 4. Explain the value of performing an ongoing assessment. (p. 286, 288) 0 to teaching objectives is the re- 2 5. Recognize and respect the feelings that patients might experience © sponsibility of the instructor. during assessment. (p. 288) 6. Explain the value of trending assessment components to other health professionals who assume care of the patient. (p. 291) Resources Needed • Scored Chapter 11 quizzes Skills • 4 nonstudent volunteers to 1. Demonstrate the skills involved in performing the ongoing assessment. serve as patients • 4 EMTs to serve as teaching assistants • 2 medical jump kits with BSI REVIEW equipment, stethoscopes, BP cuffs, airway management In the last lesson, “Assessment of the Medical Patient,” students learned equipment, and penlights how to assess the most common type of patient they will encounter, the •2 trauma jump kits with BSI responsive medical patient. With such patients, the physical exam is usu- equipment, assorted cervical collars, stethoscopes, BP ally of lesser importance than it is with trauma patients. Instead, the focus cuffs, airway management is on careful and thorough collecting of information about a patient’s ill- equipment, and penlights ness and medical history. However, the overall goal of the assessment is •4 portable oxygen cylinders •4 portable suction units 211 LIMMC12_0131142445.qxd 4/3/04 12:36 AM Page 212 Rkaul-2 Rkaul 2:Desktop Folder:Tempwork:PQ814-LIMMER IM: the same as with a trauma patient—to provide adequate assessment and emergency care at the scene without delaying transport to the hospital. Distribute the scored quizzes from the last class. Review each of the questions on the quiz and clarify or address any concerns students may have about the answers. INTRODUCTION TO CHAPTER 12 Chapter 12, “Ongoing Assessment,” covers the sixth lesson and part of the ninth lesson in Module 3 of the DOT curriculum. Point out to stu- dents that assessment continues until the patient is turned over to med- ical personnel at the hospital. A patient’s condition can change at almost any time. There may be a change for the better: an unresponsive patient regains consciousness. Or there may be change for the worse: an alert, al. oriented patient becomes confused. As a result, all members of the EMS et team must reevaluate the patient frequently, using the procedures of the er m ongoing assessment. m Li n. Evaluation Distribute copies of the Chapter 12 Objectives Checklist and ask students to o diti Handout 12-1 look it over while you briefly paraphrase the objectives in your own words. E Chapter 12 Objectives Checklist h nt e T e, ar LECTURE C y c gen Point to Emphasize The following suggested lecture outline is based on the 1994 Department er An ongoing assessment loses m of Transportation’s EMT-Basic National Standard Curriculum. In some E some of its value if good base- nc. line vital signs were not obtained places, topics in that outline have been rearranged or expanded upon to n, I initially. enhance student understanding. The page numbers in parentheses in the o ati outline refer to pages in the textbook. The parenthetical references in c u dark, heavy type are to figures, tables, and scans in the textbook. Ed ✧ on PowerPoint (cid:1) ars Presentation THE ONGOING ASSESSMENT e y P Chapter 12, Slides 2–4 I. Components of Ongoing Assessment (p. 289) b 5 ✧ (Scan 12-1, pp. 288–289) 0 0 © 2 PowerPoint II. Repeat Initial Assessment (p. 289) Presentation For a stable patient, repeat and record every 15 minutes; for an Chapter 12, Slides 5–6 unstable patient, repeat and record at a minimum every 5 minutes. A. Reassess mental status. (p. 289) B. Maintain open airway. (p. 289) Point to Emphasize C. Monitor breathing for rate and quality. (p. 289) Some severely injured patients D. Reassess pulse for rate and quality. (p. 289) may need to be monitored every E. Reestablish patient priorities. (p. 289) 2 or 3 minutes. III. Reassess and Record Vital Signs (p. 290) ✧ A. Use pulse oximeter per local protocol. (p. 290) PowerPoint IV. Repeat Focused Assessment Regarding Patient Complaint or Presentation Injuries (p. 290) Chapter 12, Slides 7–11 V. Check Interventions (p. 290) A. Assure adequacy of oxygen delivery/artificial ventilation. (p. 290) B. Assure management of bleeding. (p. 290) ✧ C. Assure adequacy of other interventions. (p. 290) PowerPoint VI. Observe Trends (pp. 290–291) Presentation VII. Ongoing Assessment for Stable and Unstable Patients Chapter 12, Slides 12–13 (p. 291)(Fig. 12-1, p. 291) 212 Module 3 • Patient Assessment LIMMC12_0131142445.qxd 3/19/04 2:27 PM Page 213 RKAUL-15 RKUAL-15:Desktop Folder:TEMPWORK:z_backup:03/19:Limmer-IM: REVIEW QUESTIONS Check on how well students can apply what they have learned by dis- cussing the Review questions on page 294. Q1: Name the four steps of the ongoing assessment and list what assess- ment you will make during each step. A1: 1) Repeat the initial assessment—Reassess mental status. Maintain Point to Emphasize open airway. Monitor breathing for rate and quality. Reassess Ongoing assessment means that as long as the patient is under pulse for rate and quality. Monitor skin color and temperature. the care of the EMT, some part Reestablish patient priorities. of the assessment process con- 2) Repeat and record the vital signs. tinues performed. 3) Repeat the focused history and physical exam—chief complaints and injuries. 4) Check interventions—Assure adequacy of oxygen delivery and ar- tificial ventilation. Assure management of bleeding. Q2: Explain the value of recording, or documenting, your assessment Critical Thinking al. A2: Bfiny ddinogcsu,m anendt ienxgp lfaiinnd tihneg sm, ethaen iEnMg To-fB t hcea nte rnmo tter eanndyin cgh.anges in the Review and discuss students’ re- er et sponses to questions on p. 294 m patient’s condition, adjust treatment, or begin new treatment. m of the student text. Li Trending is evaluating and recording changes in a patient’s condi- n. o tion, such as slowing respirations or rising pulse rate, that may show diti improvement or deterioration, and that can be shown by document- h E ing repeated assessments. ent T e, Application ar C y Q: What do you need to do if your ongoing assessment turns up one of c n e these findings? erg a. Gurgling respirations m E b. Bag on nonrebreather mask collapses completely when the c. n patient inhales n, I o c. Snoring respirations ati c u d A: E n a. Suction patient. Teaching Tip arso b. Increase oxygen. Have students do an assessment e P c. Open airway. but have a “mock” patient hold by something back through the 05 0 detailed assessment and see if © 2 STREET SCENES student discovers or identifies the problem during the ongoing assessment. Ask a student to volunteer to read aloud to the class the case study on pages 294–295 of the textbook. Discuss answers to questions at appropri- ate points within the scenario. Workbook Q1: How does the patient’s mental status affect the way you maintain Chapter 12Activities the patient’s airway? A1: Patients who are less than alert (responding to verbal or painful stimuli) may have difficulty maintaining their airways. These Active Learning patients may position themselves in such a manner as to occlude Manual their airways through a partial blockage by the tongue—a condition Chapter 12 that can be resolved by repositioning. Also, with less-than-alert pa- tients, EMT-Bs need to be prepared for suctioning. They may also Companion need to move these patients into a position that will facilitate Website drainage. (Note to Instructor: Point out that when a patient is unre- Send students to sponsive, he or she must be monitored constantly. EMT-Bs should be http://www.prenhall.com/limmer. prepared to reposition the patient as needed, to insert an OPA [if no Chapter 12 • Ongoing Assessment 213 LIMMC12_0131142445.qxd 3/10/04 12:21 AM Page 214 Abhinav-1 PDF-MAC3:Desktop Folder:LIMMER-TODAY: gag reflex is present], and to apply suctioning. Patients with an al- tered mental status require constant assessment of the airway and Student CD immediate availability of the necessary equipment to correct any Chapter 12 problems that may develop.) Q2: What questions should you ask the patient and her husband? Point of Interest A2: Explain that at this point the EMT-Bs should have completed a SAMPLE When a child decompensates as the result of hypoperfusion survey. Questions might include the following: Has the patient had a (shock) it is usually very rapid. similar condition in the past? Is the patient taking any blood pressure medication? If so, what is the medication? Is the patient compliant in taking it? In specifically questioning the husband, the EMT-Bs might Reading Reference ask: “When was the last time you saw your wife?” “Was she manifest- Nixon, R., “How Does Your ing any of the current signs or symptoms at that point, such as trouble Garden Grow? Herbal Remedies walking, slurred speech, or obvious facial drooping?” In specifically EMS May Encounter,”Emergency questioning the patient, the EMT-Bs might ask: “Are you having any Medical Services,August 2002, trouble breathing?” “Are you in any pain?” (Note to Instructor: You VOl. 31, No. 8. might introduce the topic of a stroke at this point and/or refer students to examine the signs and symptoms listed in Chapter 19, “Diabetic Emergencies and Altered Mental Status,” of the textbook.) al. et Q3: How should you perform an ongoing assessment on this patient? er m A3: Student answers should reflect the steps listed in the textbook. For ex- m Li ample, the EMT-Bs should monitor the patient’s airway, breathing, on. and any changes in her level of consciousness. They should periodi- diti cally reassess the patient’s speech and observe facial drooping. The E h EMT-Bs should reassess the patient’s pupils and vital signs approxi- nt eT mately every 10 minutes. They should also periodically reevaluate are, changes in movement, strength, and sensation in all extremities. C y c n e g er m RUNNING A CALL E c. n n, I Teaching Tip Give students a chance to apply what they have learned to a real-life situa- o ati Run a practice scenario from tion. Begin by setting up four practice scenarios in empty classrooms or pri- c du start to finish. Don’t let students vate areas. The scenarios should be the following: (1) responsive trauma pa- E n stop when they “load the patient tient, (2) unresponsive trauma patient, (3) responsive medical patient, and o ars and go.” Build into the scenario (4) unresponsive medical patient. There should be complete medical jump e P a transport time long enough to y kits at both medical sites, and complete trauma jump kits at both trauma b ensure that students perform at 5 sites. All sites should have oxygen cylinders and suction units. Arrange to 00 least one ongoing assessment. 2 have four EMTs serve as teaching assistants at the scenario sites. Also arrange © for four volunteers to play the roles of patients. Brief the “patients” on their roles, which should be based on the cases of Mr. Schmidt, Mrs. Malone, Clara Diller, and Brian Sawyer described in Chapters 8–12 of the textbook. Then divide students into teams of two. (If you have an odd number of students, it is acceptable to have one team of three students.) Explain that four practice scenarios have been set up. Tell students that each team will go through all four scenarios. Call pairs of students at random and direct them to the location of each scenario. Before teams head to their respective sites, direct them to re- spond appropriately to on-scene conditions. Remind team members to utilize all the information and skills that they have learned to date about patient assessment and treatment. Also advise them that there will be an EMT at each station to observe their performance and to provide feed- back. Because you will have more than four teams of students, not all students will begin this activity at the same time. Advise those teams waiting for their turn to practice performing patient assessments on other members of the class. 214 Module 3 • Patient Assessment LIMMC12_0131142445.qxd 3/20/04 12:11 AM Page 215 Rkaul-2 Rkaul 2:Desktop Folder:Tempwork:PQ814-LIMMER IM: Periodically visit each station to monitor progress. Provide assistance to the EMTs if necessary. Make sure each team visits all four stations. Help students who are waiting to begin this activity with their patient assess- ment skills. When each pair has completed each scenario, make sure that they return to the main classroom. Reading/Reference Textbook, pp. 286–295 ASSIGNMENTS Have students read Chapter 13, “Communications,” before the next class. Workbook Also ask them to complete Chapter 13 of the Workbook and Brady’s Chapter 13 Activities Active Learning Manual. Active Learning Manual EVALUATION Chapter 13 Chapter Quiz Distribute copies of the Chapter Quiz provided in Evaluation al. Handout 12-2 to evaluate student understanding of this chapter. Remind Handout 12-2 er et Chapter 12 Quiz m students not to use their notes or textbooks while taking the quiz. m Li ★ n. o TestGen You may wish to create a custom-tailored test using Prentice TestGen diti E Hall TestGen for Emergency Care, 10th Edition to evaluate student Chapter 12 Test h nt understanding of this chapter. eT e, ar C Online Test Preparation (for students and instructors) Additional test Online Test cy n Preparation e preparation is available through Brady’s new online product, EMT Send your students to merg Achieve: Basic Test Preparation at http://www.prenhall.com/EMTAchieve. http://www.prenhall. Ec. Instructors can also monitor student mastery online. com/EMTAchieve. n n, I o ati c u d E n REINFORCEMENT o (See pp.xi–xiii forfurther information.) Reinforcement ars Handouts 12-3 to Pe Handouts If classroom discussion or performance on the quiz indicates 12-6 by 5 that some students have not fully mastered the chapter content, you may Reinforcement Activities 00 2 wish to assign some or all of the Reinforcement Handouts for this © chapter. Brady Skills Brady Skills Series EMT-B Video/CD Have your students watch Series the skills come to life on either VHS or CD-ROM. • Patient Assessment, Part 2 (Ongoing Assessment) ✧ PowerPoint Presentation (for instructors) The PowerPoint material PowerPoint developed for this chapter offers useful reinforcement of chapter content. Presentation Chapter 12, PowerPoint Student CD (for students) A wide variety of material on this CD-ROM will reinforce and also expand student knowledge and skills. Student CD Chapter 12 Chapter 12 • Ongoing Assessment 215 LIMMC12_0131142445.qxd 3/10/04 5:03 AM Page 216 Abhinav-1 PDF-MAC3:Desktop Folder:LIMMER-TODAY: Companion Website (for students) Additional review quizzes and Companion links to EMS resources will contribute to further reinforcement of the Website http://www.prenhall.com/limmer chapter. EC 360 A new 60-hour distance learning program for didactic portions EC 360 of the course, is offered on one of three platforms: CourseCompass, Chapter 12 Blackboard, or Web CT. Includes the IRM, PowerPoints, TestGen, and Companion Website for instruction. Ask your local sales representative for more information. Medical Emergency Medical Emergency Response Simulator (MERS) (for students) Response Simulator The following MERS scenarios offer important skill reinforcement for this Chapter 12 Scenarios chapter. Brady Pocket Reference for the Level of Complexity Case Number al. EMT-B et • Assessment Skills (Ongoing er Assessment) Intermediate All cases at these two levels m m Advanced Li n. o diti E h nt e T e, ar C y c n e g er m E c. n n, I o ati c u d E n o ars e P y b 5 0 0 2 © 216 Module 3 • Patient Assessment LIMMC12_0131142445.qxd 3/30/04 12:28 AM Page 217 RKAUL-15 RKUAL-15:Desktop Folder: HANDOUT 12-1: Charting Learning Goals Student’s Name O OBJECTIVES CHECKLIST B J E C Knowledge and Attitude Date Mastered T I V 1. Discuss the reasons for repeating the initial assessment as part of the E ongoing assessment. S 2. Describe the components of the ongoing assessment. 3. Describe trending of assessment components. 4. Explain the value of performing an ongoing assessment. 5. Recognize and respect the feelings that patients might experience during assessment. al. et 6. Explain the value of trending assessment components to other health mer m professionals who assume care of the patient. Li n. o diti E h nt Skills Date Mastered eT e, ar 1. Demonstrate the skills involved in performing the ongoing assessment. C y c n e g er m E c. n n, I o ati c u d E n o ars e P y b 5 0 0 2 © Chapter 12 • Ongoing Assessment 217 LIMMC12_0131142445.qxd 3/30/04 12:28 AM Page 218 RKAUL-15 RKUAL-15:Desktop Folder: HANDOUT 12-2: Evaluating Content Mastery Student’s Name N CHAPTER 12 QUIZ O I T A U Write the letter of the best answer in the space provided. L A ______ 1. To check the level of responsiveness in a 7-month-old infant who appears V E drowsy, the EMT-B should: A. perform a sternal rub. C. tap the bottom of the feet. B. pinch the back of the neck. D. pat the baby on the head. ______ 2. Throughout the assessment of the conscious adult patient, the EMT-B should remember to do all of the following except: A. explain procedures as they are carried out. B. talk in a reassuring tone. C. never speak directly to the patient. D. consider the patient’s feelings. al. er et ______ 3. When assessing a conscious child, the EMT-B should remember to: m A. maintain eye contact with the patient. m Li B. speak only to the parents. on. C. use medical terms to explain care. diti D. never let the child handle equipment. E h nt ______ 4. The only thing that should prevent an EMT-B from performing the e T e, ongoing assessment of a patient is: Car A. police orders. C. delayed transport. y c B. life-saving interventions. D. initial vital signs that are normal. n e g er ______ 5. When assessing the circulation of a young child or infant, the EMT-B m Ec. should remember to check: n, In A. capillary refill. C. chest movement. o B. nuchal rigidity. D. Babinski’s reflex. ati c du ______ 6. Ongoing assessment is a means of determining: E n A. mechanism of injury. C. consent. o ars B. trending. D. liability. e P y ______ 7. During the ongoing assessment, attempt to look at a patient as if you had b 05 never seen him before when checking: 0 2 © A. blood pressure. C. pupils. B. pulse. D. interventions. ______ 8. The EMT-B’s findings during the ongoing assessment are particularly important for the: A. dispatcher. C. hospital staff. B. insurance report. D. QI review. ______ 9. Just how often to conduct the ongoing assessment is determined by the: A. location of the injury. B. initial assessment. C. patient’s condition. D. number of interventions performed. ______ 10. The recommended interval for conducting the ongoing assessment for stable patients is: A. every 5 minutes. C. determined by medical control. B. once during transport. D. every 15 minutes. 218 Module 3 • Patient Assessment LIMMC12_0131142445.qxd 3/30/04 12:28 AM Page 219 RKAUL-15 RKUAL-15:Desktop Folder: HANDOUT 12-3: Reinforcing Content Mastery Student’s Name R E I IN THE FIELD N F O R Read the following real-life situation. Then answer the questions that follow. C E Another busy day at the ambulance service is in full swing. You and your crew have just returned to M the station when the tone sounds again. You are dispatched to a home where a 65-year-old female pa- E tient was found to be unresponsive. N T The site of the call is a quiet suburban street. A man greets you at the curb. He tells you that he had been working in the garden and just came in for lunch. He called his wife, and when he got no an- swer, looked for her and found her lying on the sofa. He states that his wife has been “feeling poorly” for the past week. The patient is still lying on the sofa in the den when you enter the house. She does not respond to your voice, but pulls away from mild painful stimulation. You note snoring and gurgling respirations. The patient’s husband informs you that his wife has a history of allergies and shortness of breath. You notice that the patient is breathing at a rate of 40 breaths per minute, with shallow respirations. et al. er While you are assessing the airway, your partner is assessing the patient’s blood pressure. He informs m m you that the blood pressure is within normal limits. The patient’s heart rate is 104 beats per minute. Li n. o 1. Is this patient breathing adequately? diti E h nt e T e, ar C y c n e g er m E 2. What initial interventions will you perform? c. n n, I o ati c u d E n o ars e P y b 3. How will you manage this patient? 05 0 2 © 4. How would you check interventions during the ongoing assessment? Chapter 12 • Ongoing Assessment 219 LIMMC12_0131142445.qxd 3/30/04 12:28 AM Page 220 RKAUL-15 RKUAL-15:Desktop Folder: HANDOUT 12-4: Reinforcing Content Mastery Student’s Name T N E CHAPTER 12 REVIEW M E C R Write the word or words that best complete each sentence in the space provided. O F 1. It is important to observe and reobserve your patient, not only to determine his condition when N you first see him, but to note . I E R 2. During the , you will repeat key elements of assessment procedures you have already performed. 3. When reassessing oxygen delivery to a patient, you should check the , the , the tubing, and the mask. 4. During the ongoing assessment, al. must be watched for continually and managed immediately et er when discovered. m m Li 5. When assessing circulation in a young child, if you press on a nail bed and then release the n. o diti pressure, the pink color should return in less than E h . nt e T e, 6. During the ongoing assessment, you will reassess and record the vital signs, comparing the ar C y results with the . c n e g 7. It is especially important to each vital sign as soon as you er m Ec. obtain it. n n, I 8. is present when a part of the o cati chest moves in a direction opposite to the motion of the rest of the chest. u d E n 9. Trending refers to o ears in a patient’s condition. P y 5 b 10. The ongoing assessment should be performed every 5 minutes for a(n) 0 0 2 © patient. 220 Module 3 • Patient Assessment