Mosby's EMT Textbook - Revised Reprint, 2011 Update, 2nd Edition 14

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CHAPTER 14 Ongoing Assessment KEY TERMS Ongoing assessment

The final aspect of the evaluation of a patient. Ideally, it should be conducted while en route to the hospital.
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IN THE FIELD
EMTs Jake and Nathalie were dispatched to a street where a man had fallen an unknown height from a ladder. On arrival at the scene, they found no hazards and determined the scene was safe. Their initial assessment revealed a 23-year-old man who was alert and oriented, had a patent airway, was breathing in an unlabored manner (at 14 breaths per minute), and had a strong regular pulse with a rate of 88. The focused history and physical examination for this trauma patient revealed injuries to his right arm and right leg. Jake and Nathalie splinted the extremities prior to transport, and the patient was fully immobilized because of the mechanism of injury. The detailed physical examination was performed once the patient was in the ambulance and transport had begun. As Jake and Nathalie transported the patient to the hospital, Nathalie performed an ongoing assessment. The transport time would be approximately 45 minutes. Because the patient remained stable during this time, Nathalie performed three assessments, one every 15 minutes. Throughout the transport, she continually spoke to the patient, monitoring his mental status. From the way the patient interacted, she knew the airway was clear. She monitored the patient's respiratory rate and quality. Every 15 minutes, she checked the patient's pulse for rate and quality and obtained a blood pressure measurement. She noted the patient's skin color, temperature, and condition and kept Jake informed regarding the patient's status. Nathalie contacted the receiving emergency department to notify them of the patient's status. She also checked the flow of oxygen to the patient and all other interventions she and Jake had performed. Approximately 5 minutes prior to arriving at the receiving facility, Nathalie reevaluated the patient for each of the components of the ongoing assessment. Once you have responded to a call, evaluated the scene, assessed and cared for the patient, and begun transport to the appropriate facility, the patient must be continuously evaluated. This reassessment occurs during the ongoing assessment. The purpose of the ongoing assessment is to reevaluate the patient's condition and to check each intervention for adequacy. Frequent evaluations allow you to notice subtle changes in the patient's condition. Reevaluating patients also allows you to observe trends in their condition that you should document and relay to the receiving facility. Trends in a patient's mental status, blood pressure, or other vital signs can provide valuable information to the other healthcare professionals who will assume care of the patient.
Mosby's EMT Textbook - Revised Reprint, 2011 Update, 2nd Edition
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PRINTED BY: Ahed Al Najjar <najjarahed@gmail.com>. Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted.
COMPONENTS OF THE ONGOING ASSESSMENT

Once you have responded to a call and are en route to the appropriate facility, continuous evaluation of the patient must take place. The ongoing assessment repeats the initial assessment and the focused assessment and includes an assessment of all interventions performed. Box 14-1 summarizes the elements of the ongoing assessment. For stable patients, the ongoing assessment should be repeated and the results recorded every 15 minutes. For unstable patients, the assessment should be repeated and the results recorded at least every 5 minutes.
BOX 14-1 Components of the Ongoing Assessment

Repeat the initial assessment. Check mental status. Check airway patency. Assess breathing rate and quality. Assess pulse rate and quality. Assess skin color, temperature, condition, and perfusion. Reestablish patient priority. Record vital signs. Repeat the focused assessment. Evaluate all interventions.
Stable patients are those medical or trauma patients who have simple, specific injuries. For example, for a stable patient who injured an ankle playing softball, repeat and record the assessment every 15 minutes. A patient with a history of nausea and vomiting and no other associated injuries or illnesses may also be considered to be stable. Unstable patients are those medical patients in severe distress or trauma patients who have sustained a significant mechanism of injury, even if they appear to be stable. An example would be a patient standing beside her car with significant damage to it; however, she appears to be stable. The patient's status can change quickly, so you must always be prepared. Patients generally receive the ongoing assessment in the back of the ambulance en route to the receiving facility. If the EMS unit is a non-transporting unit or is awaiting additional personnel, the ongoing assessments should be performed on scene. Ongoing assessments are generally performed after the detailed
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physical examination. Although not every patient receives a detailed physical examination (as discussed in the previous chapter), all patients receive ongoing assessments.
REPEAT THE INITIAL ASSESSMENT

The ongoing assessment begins by repeating the components of the initial assessment. First, reassess the mental status of the patient. You should constantly be interacting with the patient throughout the transport. This interaction allows you to observe the mental status of the patient and note any changes for either better or worse. Always ensure that the patient has an open and patent airway and that there is nothing in the mouth that might obstruct the airway (Fig. 14-1). Again, if you are interacting with a responsive patient en route to the hospital, you can continuously monitor the mental status and the patency of the airway at the same time by talking to the patient. The third component is to monitor the breathing for rate and quality. With experience you can do this while
Fig. 14-1 Inspect the mouth for injury or the presence of foreign bodies.
a responsive patient is resting comfortably on the stretcher during transport to the facility. Evaluate the pulse for rate and quality. If a radial pulse is palpable, use it for the ongoing assessment. However, for those patients with barely palpable radial pulses, evaluate the carotid pulse. Children's pulses
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are assessed the same as an adult patient's. Although a radial pulse can be obtained on an infant, the preferred method is assessing the brachial artery. Next, evaluate the patient's skin color, temperature, and condition. The skin may be evaluated as you obtain the patient's radial pulse. Note and document any deviations from normal or changes from your previous assessment (Fig. 14-2). Checking skin color allows you to assess perfusion as in the initial assessment. With children younger than 6 years of age, assess perfusion by checking capillary refill as in the initial assessment. Although there is no need for a separate step to reassess for major bleeding as you did in the initial assessment because it is unlikely that the patient will suddenly start bleeding, you should confirm that major bleeding that was assessed and controlled earlier is still being controlled. Do this assessment as part of checking the effectiveness of all interventions, as described in a later section in this chapter. Finally, reestablish the patient's priority for transport. Ideally, all patients will remain stable or improve during transport. In reality, sometimes the patient's condition takes a turn for the worse. Therefore, reestablish the patient's priority. For example, a patient having mild chest discomfort is provided oxygen, evaluated, and transported. During transport, this patient's pain may increase or the patient may go into cardiac arrest, becoming a higher priority patient. The transport then changes from a comfortable, unhurried ride to a quick, but cautious, ride with lights and siren to expedite the transport.
Fig. 14-2 Assess skin temperature and condition as part of your ongoing assessment of vital signs.
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REVIEW QUESTIONS
COMPONENTS OF THE ONGOING ASSESSMENT/REPEAT THE INITIAL ASSESSMENT 1. Which patients require an ongoing assessment? 1. All medical and trauma patients receive ongoing assessments during care by EMT-Basics. 2. What is the goal of the ongoing assessment? 2. To have continuous information about the patient's status and care that has been rendered. 3. What are the components of the initial assessment that are repeated in the ongoing assessment? 3. Reassess the mental status; airway; breathing; pulse; skin color, temperature, and condition; and reestablish the patient priority.
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REPEAT VITAL SIGNS AND FOCUSED ASSESSMENT

The ongoing assessment also requires EMTs to reassess and record the patient's vital signs. The vital signs described in Chapter 5 are all evaluated as part of this process, at least every 15 minutes for stable patients and at least every 5 minutes for unstable patients. These vital signs are documented in the prehospital care report and relayed to the staff at the receiving facility. The ongoing assessment also repeats the focused assessment of the patient's specific complaint or injury. For a patient with a specific injury and no major mechanism of injury, reevaluate that injury site specifically. For a medical patient with a respiratory problem, focus the assessment on the patient's respiratory status. The focused assessment is described in detail in Chapters 11 and 12. Sometimes patient situations may require you and your partner to focus on the life-threatening conditions. All of your medical effort will be required to maintain the patient's airway, breathing, and circulation. During these types of situations, you may not be given the opportunity to move to the ongoing assessment. This is appropriate. During these unfortunate situations, your ongoing assessment occurs in the care you are providing.
CHECK INTERVENTIONS
Evaluate interventions that have been performed as part of the patient care process. Ensure the adequacy of oxygen delivery or artificial ventilation. For patients receiving oxygen, ensure that the oxygen flow rate is set at 15 L/min and the oxygen is adequately flowing, the oxygen mask is a nonrebreather, the reservoir bag is remaining inflated, and enough oxygen remains in the cylinder for the duration of the trip (Fig. 14-3). If the patient would not tolerate a mask and has a nasal cannula in place, make sure the prongs are placed
Mosby's EMT Textbook - Revised Reprint, 2011 Update, 2nd Edition Page 5 of 8
correctly in the patient's nose, the rate is set up to 6 L/min, and that the oxygen is flowing adequately as described previously. If the patient is being artificially ventilated, make sure the ventilations are adequate by watching the chest rise and fall and monitoring the patient's vital signs. Other interventions to assess include ensuring that bleeding is still being controlled, splints are still effectively immobilizing injured extremities (remember to check pulse, sensation, and motor function), and straps on a long backboard are secure but not tight enough to injure the patient. All interventions you perform should be reevaluated during the ongoing assessment. Any intervention that is no longer meeting the needs of the patient must be corrected immediately.
Fig. 14-3 Ensure that the nonrebreather bag remains inflated and the oxygen flow to the patient is adequate.
REVIEW QUESTIONS
CHECK INTERVENTIONS/REPEAT VITAL SIGNS AND FOCUSED ASSESSMENT 1. How often should the vital signs be reassessed for stable patients? 1. At least every 15 minutes.
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2. How often should vital signs be reassessed for unstable patients? 2. At least every 5 minutes. 3. List three interventions that EMTs should evaluate. 3. Oxygen delivery effective, dressings secure, splinting secure 4. What should be done if an intervention has not proven to be effective; for example, if blood has soaked through a bandage? 4. If any intervention has not been effective, it should be corrected immediately. For example, if the splint that you applied to the patient's forearm has become too loose and is no longer immobilizing the arm, secure the splint again until the arm is properly immobilized. Approximately 5 minutes from the receiving facility, repeat the ongoing assessment a final time to document the patient's condition at the time of arrival at the receiving facility. Relay all information to the staff about trends in the patient's condition.
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CHAPTER SUMMARY COMPONENTS OF THE ONGOING ASSESSMENT

All patients receive an ongoing assessment, which repeats the components of the initial assessment and focused assessment. Stable patients need to be evaluated at least every 15 minutes during transport. Unstable patients should have the ongoing assessment performed at least every 5 minutes.
REPEAT THE INITIAL ASSESSMENT

Reassess the mental status, check the airway, and monitor the breathing rate and quality. Evaluate the rate and quality of the pulse and check the skin color, temperature, and condition. Make sure bleeding is still controlled. Reevaluate the patient's priority status.
REPEAT VITAL SIGNS AND FOCUSED ASSESSMENT

Check the vital signs every 5 minutes for unstable patients and every 15 minutes for stable patients. Repeat the focused assessment of the patient's specific complaint or injury.
CHECK INTERVENTIONS
The ongoing assessment is an opportunity to check interventions that were performed before and during transport. Document and communicate this information to the receiving facility. Prior to arrival at the
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appropriate receiving facility, perform all the components of the ongoing assessment one last time to complete the prehospital care report, and provide this information to the receiving facility.
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United States Department of Transportation National Highway Traffic Safety Administration EMT-Basic Objectives
Check your knowledge. The National Registry of EMTs and many state EMS agencies use the objectives below to develop EMT-Basic certification examinations. Can you meet them?
Cognitive
1. Discuss the reasons for repeating the initial assessment as part of the ongoing assessment. 2. Describe the components of the ongoing assessment. 3. Describe trending of assessment components.
Affective
1. Explain the value of performing an ongoing assessment. 2. Recognize and respect the feelings that patients might experience during assessment. 3. Explain the value of trending assessment components to other healthcare professionals who assume care of the patient.
Psychomotor
1. Demonstrate the skills involved in performing the ongoing assessment.
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CHAPTER 14 Ongoing Assessment KEY TERMS Ongoing assessment