Skills Station: Initial Patient Assessment

The initial patient assessment, also referred to as the primary survey, is a critical component of prehospital care. When assessing a patient, the prehospital care provider must be able to quickly and accurately determine if a patient is "sick" or not. While the steps involved in an initial patient assessment can be presented as separate and distinct tasks, providers should recognize that the tasks can be performed almost simultaneously. This is especially applicable when more than one provider is available to assist. For the purposes of this discussion, the term "sick" refers to a patient who appears to be potentially critically ill or injured based on the initial assessment.

INITIAL IMPRESSION

It is not necessary to physically contact or touch the patient to begin the initial patient assessment. You can begin the assessment with a visual inspection and making key observations. For example, the patient with pink, dry skin who appears to be conscious and talking will have different needs than a patient who has gray skin and is sweating profusely. The second patient is likely to be "sicker" than the first and may require an aggressive assessment and treatment.

ABCs

As the initial patient impression is formed based on the initial visual inspection, the next priority should be assessment of the patient's airway, breathing and circulation, or ABCs. When assessing the patient's airway, try to determine if it is (a) open or patent, (b) at risk for closing, or (c) not open. This differentiation is not always obvious in the prehospital setting. For example, in the case of an allergic reaction, the patient's airway may initially appear to be open, only to begin to occlude due to swelling within seconds of the initial assessment. It must be noted that the patient with an airway that is either closed or at risk of closing requires immediate intervention.

While assessing and evaluating the patient's airway, you can also begin to assess his breathing, taking into consideration his effort to breathe, such as use of accessory muscles or grunting respirations, and noting the rate of breathing. Abnormal breathing patterns like agonal or Kussmaul respirations are potential flags that should alert you that the patient may be critically sick.

Assess the patient's circulation as soon as possible by checking for a pulse and noting its rate and characteristic. Common pulse locations include the carotid, brachial and radial landmarks. The pulse rate may be described as slow, normal or fast; the pulse may be described as weak, thready, normal, strong or bounding; the rhythm may be described as regular or irregular. An abnormal heart rate should be considered a potential red flag until proven otherwise.

Skin

When performing a hands-on assessment, you can obtain valuable information as soon as your hand touches the patient. The patient's skin provides subtle clues about his overall condition, including his circulation. During the initial assessment, any findings other than warm, pink and dry skin should be considered a potential flag. Skin that is cool, cold, moist, clammy, hot, flushed or mottled may indicate that the patient is sick.

AVPU

The patient's neurological status can also be determined during the initial assessment and visual inspection. The neurological status of the patient who is conscious and cooperative is different from one who is unresponsive with snoring respirations. It is always essential that you conduct a brief or mini neurological exam with each patient. This can be accomplished using the AVPU system: A=alert; V=responds to verbal stimuli; P=responds to painful stimuli; and U=unresponsive.

Equipment

Cardiac and pulse oximetry monitors are not mandatory for performing an initial assessment; however, it is essential that you have the ability to recognize when a patient is sick. An example is the layperson who identifies an individual in cardiac arrest and initiates basic life support until additional help arrives. Failing to identify subtle initial assessment findings, such as respiratory arrest in a drug overdose, can potentially delay the appropriate delivery of care. Regardless of your level of training, the ability to perform a rapid and thorough initial assessment is key to providing successful patient care. If equipment is available, it should be used to support your initial patient assessment.

Time

How much time is needed to complete an initial or primary survey and to recognize that the patient is sick? The art and time required to perform an initial assessment can vary. For example, you can count the patient's breathing or heart rate for 30 seconds and multiply by two, or count for 15 seconds and multiple by 4. Both approaches provide an estimate of the patient's breathing or heart rate for a minute and do not require 60 seconds to complete the task. It is also possible to access the patient and perform an initial assessment in only a few seconds. Over time, prehospital care providers develop the ability to perform accurate and rapid initial patient assessments. The ability to do this may prove invaluable when faced with a critically ill or injured patient.

BIBLIOGRAPHY

1. Chapleau W, Burba A, Pons P, Page D. The Paramedic. Boston, MA: McGraw-Hill, 2008.

2. Hubble M, Hubble J. Principles of Advanced Trauma Care. Albany, NY: Delmar Thompson Learning, 2002.

3. National Registry of Emergency Medical Technicians Advanced Level Practical Examination: Patient Assessment--Trauma.

4. New York State Department of Health. Patient Assessment Definitions. 

Paul Murphy, MSHA, MA, has administrative and clinical experience in healthcare organizations.