Secondary Assessment Study Guide for the EMT Test

Further Evaluation

In addition to the above assessments, it is important to get an overall view of the patient, including their current living situation and their past medical history. Information from these evaluations can give you insight into the patient’s present condition and also prepare you to treat them safely and in a manner most beneficial to their well-being and recovery.

Interview

The patient interview is the process of gathering information from the patient (and sometimes bystanders, family members, or caretakers) to better understand the patient’s complaint, history, and overall condition. The patient interview is a critical part of the secondary assessment and helps to guide decision-making and treatment.

Medical History

Obtaining a history is an important part of your patient assessment. The history of the current event and the patient’s past medical history can be crucial to determining the proper course of care. The history determines what event triggered the call for help and is often gathered concurrently with the primary assessment.

If the patient cannot give a history, you can obtain information from a family member who is at the scene. Ask questions regarding the patient’s current condition, such as when symptoms started. You can also ask if similar symptoms have occurred in the past. Find out what, if any, medications the patient is taking and if other medical conditions exist. Obtaining a history is sometimes combined with your primary assessment.

Here are some concepts to know:

• OPQRST—tool used by EMT’s during the patient interview to assess pain or a specific symptom:

O—onset (what was the patient doing when it started) P—provocation/palliation (does anything make it better or worse) Q—quality (what does it feel like) R—radiation (does the pain move anywhere) S—severity (how bad is it on a scale from 1–10) T—time (when did it start, does it come and go)

• pertinent negatives—important symptoms, signs, or findings that are not present but help rule out certain conditions (the patient denies chest pain, denies shortness of breath, denies nausea/vomiting).

• SAMPLE history—assessment tool used during patient assessment to obtain important information pertaining to the patients medical history:

  • S—signs and symptoms
  • A—allergies (food, medications, environmental)
  • M—medications
  • P—past medical history (chronic illness like diabetes, asthma, COPD)
  • L—last oral intake (last time and what they ate or drank)
  • E—events leading up to (what were they doing when it started)

• synthesizing—process of bringing together all the information you have gathered

• chief complaint—the main reason the patient called 911; the primary problem they are experiencing

History for Cardiac Patients

At this point in the process, it is assumed that life-threatening factors are being monitored and controlled. During the scene size-up, some of the patient history may have been obtained. It is important to stay calm and speak to the patient and witnesses in a clear, concise, and calm tone. Clarify and fill in important medical and medication history at this juncture. Obtain and pinpoint details of associated and currently occurring signs and symptoms, as well as pertinent comorbid conditions and a history of similar events.

Here are some concepts to know:

• common symptoms of respiratory versus cardiac symptoms—Adventitious lung sounds, chest discomfort that is reproducible on inspiration/expiration, shortness of breath, and coughing are most common in respiratory cases. Chest pain that is not reproducible, hypertension, sweating, and nausea are more common symptoms associated with a cardiac condition.

• key questions for the alert patient during a cardiac emergency—

  • Are you having chest pain?
  • When did it start?
  • Where is it located?
  • Does it travel anywhere?
  • Is it constant or does it come and go?
  • Have you had this pain before?
  • Does anything make it better or worse?
  • Do you have any cardiac history?
  • Have you taken any aspirin?

Reassessment

This is performed at regular intervals during patient care; it may sometimes occur before the secondary assessment is complete to see if the primary assessment findings have changed. The main purpose is to check for improvement or deterioration of the patient.

Here are some concepts to know:

• reassessment intervals of a stable patient—Vital signs should be reassessed every 15 minutes for stable patients.

• reassessment intervals of an unstable patient—Vital signs should be reassessed every 5 minutes for unstable patients.

Cardiac and Respiratory Reassessment

If not already in progress, this is the time to prepare for transportation and communication with the emergency room team. The reassessment, which is basically the same as the primary assessment, focuses on the patient’s current status, with attention to any status changes in the primary complaint/concern. Focus on improvements or lack thereof with adjustments to treatment regimes as appropriate. Ensure that documentation is complete and accurate, with interventions and times included.

Here is a concept to know:

• determination of the frequency of vital signs—the frequency of which vital signs are assessed is determined by the patients stability

  • Unstable patients are typically unresponsive, in respiratory distress, or experiencing a severe medical emergency (heart attack, stroke, traumatic event, etc.).

  • Stable patients are typically conscious/alert, in no immediate distress, and are complaining of a minor or less severe medical emergency.

Cardiac monitoring is done in the field with the use of an ECG machine. Check your jurisdiction for EMT scope of practice in placing electrodes and leads for cardiac monitoring. Prior to placing the electrodes and leads, the skin will need to be assessed and prepped for adherence patency. The placement requires accuracy to ensure an ECG strip free of extraneous interference.

Here are concepts to know:

• automaticity—the ability of cardiac muscle cells to generate electrical impulses without outside stimulation, allowing the heart to initiate its own contractions

• artifact—any distortion, interference, or false reading on a monitor or medical device

• position placement of electrodes and 12-lead ECG

Four electrodes (stickers) are placed on the limbs, typically on the wrists and ankles.

The precordial or chest leads used for the 12-lead are placed in specific positions across the chest. There are 6 chest leads:

1. V1 is placed at the 4th intercostal space to the right of the sternum.
2. V2 is placed at the 4th intercostal space to the left of the sternum.
3. V3 is placed midway between V2 and V4.
4. V4 is placed at the 5th intercostal space, at the midclavicular line.
5. V5 is placed at the left anterior axillary line at the same level as V4.
6. V6 is placed at the same horizontal level as V4, along the midaxillary line.

A heart rhythm appears as a series of waves on an ECG:

• P wave—represents atrial contraction (depolarization)
• QRS Complex—represents ventricular contraction (depolarization)
• T wave—represents ventricular relaxation (repolarization)

Neurological Monitoring

Since neurological status can quickly change, reassessment should be ongoing during transport. Remember that this can include vital signs and possibly a stroke assessment. The patient’s orientation as well as any neurological deficits (facial droop, extremity weakness, slurred speech, etc.) should be continually reassessed for improvement or worsening.

Gastrointestinal Monitoring

Continue with reassessment because patients with gastrointestinal emergencies can quickly develop other serious conditions, including shock. The EMT should observe for any changes in abdominal shape or tenderness, listen for bowel sounds, note any nausea or vomiting, and watch for indicators of internal bleeding (rigidity, guarding, discoloration).

Diabetic Monitoring

It is important to frequently reassess a patient with diabetes during transport to determine if there is a change in status, such as an ALOC. Diabetic monitoring should also involve evaluating the patient’s blood glucose level and watching for signs of hypoglycemia or hyperglycemia. Any noted changes in patient condition including shakiness, confusion, fruity breath, or skin condition may require intervention or affect transport.

Hematological Monitoring

Frequently reassess the patient to determine if there is a change in alertness or oxygen level. Hematological monitoring focuses on assessing a patients blood-related status by identifying signs of issues, such as bleeding, clotting problems, or poor oxygen delivery. EMTs should be sure to monitor skin color and temperature, bruising, bleeding, capillary refill, and note symptoms including weakness, dizziness, or shock.

Psychiatric Patient Monitoring

Reassessment should include monitoring the patient for a change in status, such as increased agitation.

Gynecological Patient Monitoring

Reassess frequently, including taking a blood pressure measurement, since blood loss may be a concern. EMTs should reevaluate the chief complaint, monitor vital signs, take note of any pain or abnormal discharge, assess and treat for signs of shock, and gather SAMPLE and OPQRST.

Pregnant Patient Monitoring

Reassess the patient frequently and be alert for changes in vital signs. This type of monitoring involves closely assessing both the mother and fetus in order to recognize early signs of complications and ensure safe care. EMTs should monitor vital signs, evaluate abdominal pain or contractions, take note of any of any vaginal bleeding or discharge, and assess for fetal movement or crowning.