Beyond the Basics: Patient Assessment

The ability to perform an accurate patient assessment is one of the most important skills in EMS.

CEU Review Form Patient Assessment (PDF)Valid until September 5, 2006

The ability to perform an accurate patient assessment is one of the most important skills in EMS. The information gained during the assessment is used to make decisions regarding emergency interventions, such as the need for immediate airway management and ventilation; to formulate a differential field diagnosis; and to provide continued and advanced prehospital care. Since this information is used in clinical decision-making, it is important that the assessment findings are interpreted correctly and efficiently. Some findings elicited from a patient may provide confusing or misinterpreted results. Following is a variety of clinical insights intended to clarify and reinforce the assessment skills already being practiced by EMTs and paramedics.

Painful Stimuli
     Following the scene size-up, determining the patient's neurologic status is the next step in assessment. These assessment findings are extremely important, as they provide a baseline of information regarding arousal and cognitive function that will be used throughout the entire time you are managing the patient. Thus, interpreting the assessment findings accurately is essential.

     If the patient does not spontaneously open his eyes, or fails to open his eyes to verbal stimuli of shouts and calling his name, a painful stimulus is applied to elicit a response. The intent of applying a painful stimulus is to test the integrity of cerebral function, which is determined by the patient's response. A more purposeful response is interpreted as a higher level of cerebral function. A nonpurposeful or no response would be an ominous sign and indicate poor cerebral function.

     There are two different types of painful stimuli: central and peripheral. Central stimuli are applied to the core of the body; whereas, pain applied to the extremities is considered peripheral stimuli. In 1974, neurology professors Graham Teasdale and Bryan J. Jennett suggested using fingernail pressure as a form of peripheral painful stimuli to determine if a response is present. A central painful stimulus is then applied to assess for localizing, or the patient's ability to attempt to remove the stimulus. More current literature suggests caution when applying and interpreting the results of peripheral stimuli. When pain is applied to the fingernail bed, lower legs or elsewhere in the periphery, it might elicit a spinal reflex response. That is, the pain impulse travels via a sensory nerve tract to the spinal cord, where it is immediately turned around by a spinal reflex and sent out via a motor nerve tract to the muscle of that extremity, causing the patient to move. The movement may be withdrawal, where the patient pulls the finger or distal extremity away from the painful stimulus, which is interpreted as localizing the pain. Since the impulse was never transmitted to the brain and interpreted by the cerebrum, what appears to be purposeful movement is not a positive indication of cerebral function, but only an indication of intact peripheral nerve tracts. Thus, be skeptical of withdrawal or localizing effects when painful stimulus is applied to the extremities.

     To avoid misinterpretation, assessment for localizing should be performed using a central painful stimulus. Localizing to pain is an important assessment finding, since it identifies the level of cerebral function. It is also a necessary component of the Glasgow Coma Scale scoring for best motor response. When pain is applied to the central portion of the body, the sensory stimulus is sent to the cerebrum, suggesting interpretation within the higher centers of the brain. If the brain is intact, it wants to remove the pain, which it attempts to do by sending a motor response to eliminate or remove the painful stimulus. The assessment finding is an extremity that moves upward toward the pain in an attempt to remove it. True localizing is distinguished from withdrawing to pain by the amount and direction of movement involved. True localizing is defined as the patient bringing his arm up to the level of his chin or to the site of pain. Withdrawing from pain, or withdrawal, is where the patient typically flexes his arms toward the pain; however, he does not make a "purposeful" attempt to remove the pain or move his arms beyond chin level.

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