College of Medicine , University of Rijeka

Study : 1st year of Integrated undergraduate and graduate university study Medicine

PATIENT EVALUATION

Student: Veronika Lončar

Professor: Izv. prof. dr. sc. Arijana Krišković, prof

Academic year: 2019/2020

 CONTENTS:

1. INTRODUCTION......................................................................................................3

2. HISTORY OF A FIRST AID....................................................................................4

3. STRUCTURE OF PATIENT EVALUATION........................................................4-5

4. INITIAL EVALUATION..........................................................................................5

5. ABCDE APPROACH................................................................................................5-6

6. CRITICAL CONSCIOUS PATIENT......................................................................6-7

6.1. EVALUATION OF A CHILD...........................................................................................7

6.2. EVALUATION OF AN OLDER PERSON......................................................................7

7. CRITICAL UNCONSCIOUS PATIENT...............................................................7-8

8. AUTOMATED EXTERNAL DEFIBRILLATOR.................................................8-9

9. THREE TYPES OF CLINICAL EVALUATION..................................................9-10

9.1. STROKE PATIENT............................................................................................................9

9.2. PULMONARY PATIENT..................................................................................................10

9.3. HEART FAILURE..............................................................................................................10

10. CONCLUSION.........................................................................................................11

11. SUMMARY...............................................................................................................11-12

REFERENCES...............................................................................................................13

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1. INTRODUCTION

Every year all around the world millions of people are killed or hurt from injuries because
adequate and timely assistance is not provided. For example, just in Europe every year 350 -
700 thousand people die from unexpected heart attack. These are real facts and being
conscious that quick defibrillation can result surviving in 50 to 70 percent of cases means that
recognizing a life threatened condition of the patient and effective process is very important
for quick and good emergency medical help. Knowing the principles of early detection in
many cases can prevent patient from critically worsening, cardiopulmonary arrest and after all
death. Clinical signs and physiological parameters in dangerous conditions are reflections of
respiratory, cardiovascular and neurological disorder. If we evaluate the condition of a sick
people, then we know how to treat them. The definition of evaluation is very simple: ''A
critical appraisal or assessment; a judgment of the value, worth, character, or effectiveness
of something; measurement of progress. A broad view of evaluation in health care includes
three approaches, directed toward structure, process, and outcome.'' (1) Based on that
definition we can see how it is important to do every step systemic and carefully, so the result
can be better. But, we need to be aware that first step is always recognizing in which phase is
our patient, that we can know only if we follow steps of the first aid. Evaluation at first aid is
as important as evaluation in hospitals before surgeries. Understanding the perioperative
evaluation of the potential risk for developing pulmonary, heart or stroke complication allows
the medical team to choose the adequate anesthetic technique and surgical and clinical care
required by each patient, thereby reducing adverse outcomes. So we can say that both, first
aid evaluation and clinical evaluation are important if we want to help our patient.

The main goal of this essay is to provide all the basic concepts related to the evaluation in first
aid, point out all lacks of not knowing it and at the end explain it to the reader, both the one
who approaches with the big and the one who approaches with the small corpus of (pre)
knowledge.

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2. HISTORY OF A FIRST AID

The idea of a first aid was born in 1888 when Robert Wood Johnson started a conversation
with the Denver & Rio Grande Railway’s chief surgeon. The doctor said to Johnson that
railroad construction was very dangerous and that they don't have enough medical supplies to
treat industrial injuries, and also he said that hospitals were too far. From this exchange,
Johnson saw an opportunity to both advance the field of healthcare and build his young
business. And from this modern need, the commercial First Aid Kit was born. In 1859 a man
named Jean-Henry Dunant witnessed The Battle of Solferino. That had big influence on him,
so he decided to write a book about his experience. In this book he said that all countries
should give aid to the sick and wounded. His idea in 1863 was accepted by The International
Committee of the Red Cross and the adoption of the Geneva Convention a year later. In 1870
First aid was formalized and introduced into the military by Prussian military surgeon
Friedrich von Esmarch who was responsible for training soldiers. But in 1878 First aid skills
as we know today are taught to civilians for the first time in the Presbyterian school in
Woolwich. (2)

First aid has a long history, which is good to know if we want to improve it. First aid is by the
definition ‘’A set of initial actions and procedures which is given to the suddenly ill or
injured person until the arrival of the health care workers.’’ First aid provider is a person who
knows recognize and evaluate the need for help, offer care using methods and also recognize
limitations and ask for help if it is needed. (3)

3. STRUCTURE OF PATIENT EVALUATION

The basic components of evaluation are identifying the specification of the subject, they are
precise limitations that we must not ignore because they define the area of evaluation. Next,
developing criteria means that we recognize which parameters we will emphasize, for
example respiratory function, neuromuscular function, emotional status, or any other. Very
important step is data collecting. That step is taken through examination and history taking.
Also in clinical evaluation are often used procedures as laboratory analysis and testing,
radiologic studies, and other diagnostic techniques. Measuring the data against the criteria is
important when the evidence indicates that all of the criteria are being met, so that means

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there is no indication of a problem in the area of evaluation. And last, based on collected
information and results make evaluation for improvement of patient. Of course, it's important
to remember that every patient is special and we have to approach to every situation very
carefully following the steps above. (1)

4. INITIAL EVALUATION

Before we approach to our patient we have to be sure that environment is safe. The contact
with patient doesn’t need to be done before we check everything around us. In that time it is
useful to see how many people need help and sort out which of them can talk or walk and
which of them are not responding to our call or they are acting weird. Also it is helpful for
next steps to determine the nature of the disease according to object which are near them. For
example, if we see worker laying down on the ground and scale above him, we can assume
that he had fallen. All of this steps we take before ABCDE approach and it is called ‘’initial
evaluation’’. If we need help at that moment and see people around us, we can ask them if
they want to help. It is very important that we ask only on person while looking at them and
with hand showing in their way,because there is ‘’mass effect’’. People think that somebody
else will help, but at the end no one really help because everybody is thinking in the same
way. Of course, there are different situations and if we want to help then we have to improvise
a lot. If patient doesn’t breath and you are outside the hospital, call ambulance on specific
number. In Croatia we call 194. Also it is good to call 112 for ambulance, firefighters and
police if we are not sure which of them we need considering the situation in front of us. In
Great Britain emergency number is 999. (4) It is very important to be very specific about
information we give to them, our name and last name, address and of course we explain what
we see and that we know person doesn’t have pulse and can’t breath. If we are starting with
reanimation we should inform also about that.

5. ABCDE APPROACH

After we come near injured who is laying on ground, we shake them and ask loudly ‘’do you
hear me?’’. If they respond that means that they are awake and can breath. If not,then we use
the first step in our ABCDE approach. ABCDE is a structured approach to assessing patients
condition and treatment. The term came from english and it means airway-breathing-
circulation-disability-exposure. We have to check their airway by pulling their head a little bit
up and open mouth. Then using technique watch-hear-feel in the second step we come with

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our ear near patients mouth so we can hear if they breathe. At the same time we watch if their
breast is moving up and down and feel air coming from a mouth for ten seconds. In case that
patient is breathing, it’s important to evaluate the speed, normal is 12 to 20 breath in one
minute. Then the volume, rhythm, chest symmetry and noises. Hard breathing indicate the
presence of secretions in airway, stridor indicates a partial but significant obstruction. It’s
good to check oxygen saturation values on a pulse oximeter, because normal values are 97 to
100 percent. After these actions and according to a report are able to give cardiopulmonary
resuscitation, set oropharyngeal or nasopharyngeal tube or apply oxygen through a nasal
catheter or mask. After we have done second step, next is important to evaluate a circulation
of our patient. Medical staff checks the pulse on artery carotis communis on the neck, but
anyone who knows can check pulse on a radial artery on wrist. Besides that, we have to
determine the time of capillary filling by pressing our finger on patients forehead to see how
fast the blood is coming, normal value is less than two seconds. Also we can notice the colour
of the skin and temperature of the body and conclude a lot based on that. If it is evaluate that
bloodstream is threatened, it is necessary to establish venous path and also connect patient to
electrocardiogram which measures heart rates. In that way we are sure that we are
compensating volume correctly. Then we are ready for our fourth step, disability. Fast
neurological evaluation we can see in which phase of wakefulness is our patient. Alert is for
someone who is conscious, verbal for someone who can tell us some information, pain means
that patient can only feel that we touched him so he for example moves his finger,
unresponsive is someone who can’t talk or move, means that he is fully unconscious. At this
point we are also using our lamp to see reaction to the light and the look of the pupils and also
measure the blood sugar. With patients in phase unresponsive we should definitely think
about condition which can bring to hypoxia, hypercapnia, decreased blood supply to the brain,
hypoglycemia or recently taken medication. And finally last step, exposure and environment.
We need to take off all clothes from patient and review him from legs to head, but don’t
forget to cover him up that he doesn’t catch a cold. After a complete ABCDE approach it is
necessary to repeat it every five minutes for unconscious patients and every fifteen minutes
for conscious patients till the emergency arrive. (3)

6. CRITICAL CONSCIOUS PATIENT

After we determine that our patient is conscious, the main goal in this phase is to notice and
treat the signs and symptoms of the disease by collecting information about past illnesses and
with physical examination. It’s important to ask key questions to our patients. We want to find

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out when the problem has started, what is the cause, is the pain spreading and where, how
strong is pain and how long does it last. After that we want to ask questions which associate
signs and symptoms of disease. To make it easier to remember we use term SAMPLE which
also come from english language. Word S is for symptoms, we ask a patient: ''What is the
problem?''. A is for allergies and question: ''Are you allergic to anything?''. Letter M for
medication, we want to know if patient take any medications. P means past medical history,
for example we ask: '' Do you have any medical conditions (angina, high blood pressure,
diabetes…)?'', also we want to know if patient has been in hospital before. Letter L for last
meal, it is important to know when had a patient last eated. And E for events preceding the
incident, we ask: ''Do you remember what happend and what were you doing?''. Medical
history is often the most valuable factor during evaluation. After we collect information, we
can definitely know what to do next, maybe measure blood pressure, electrocardiography or
whatever our patient need. It is important to continuously supervise their condition. If it’s
possible, it is very useful to take notes, so we can later treat right and that we don’t forget
anything. The most usual problem while evaluating is a poor taken medical history, because
then are some details of symptoms left out. Questions have to be asked in that way that patient
can describe problem with their own words. Only after that we are allowed to ask sub-
questions. Good communication and safe atmosphere is imperative. (3)

6. 1. EVALUATION OF A CHILD

Little children maybe don’t know history of their diseases, so it is better to ask their parents or
people who take care for them about that. It is necessary to transport child in appropriate
health institution. (3)

6. 2. EVALUATION OF A OLDER PERSON

If we have a patient which is a bit older, maybe measuring a pulse on wrist won’t be able
because of vasoconstriction and atherosclerosis. For this kind of measuring it is better to do it
on artery on a neck. Equally, earlier health problems can affect on currently condition of
patient. (3)

7. CRITICAL UNCONSCIOUS PERSON

Patient without conscious is a big challenge for medical team because they cannot talk or ask
questions to them. In that kind of situation we have to rely on physical examination and index
of doubt with who we assume what is the cause of that condition. Person who lost conscious

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is definitely high priority for caring and transporting to hospital if we are not in it. This patient
must be examined all over the body. On head first we see if person is throwing up, on neck if
jugular veins are increased or trachea displaced to the side, on chest we notice if there are the
same breathing noises, then if abdomen is painful, incontinence of urine and stool, limb
motility and bleeding. Except this cases, high priorities are patients who don’t follow orders,
people who breathe hard or those which are in shock, pregnant women, patients with chest
pain and systolic pressure under 100 mmHg and patients with uncontrolled bleeding. After we
have done ABCDE approach, we have two scenes. In first, our patient cannot breathe and
doesn’t have a pulse. In that case we need to do Basic Life Support. It means that we have to
do 30 compressions with palm in the middle of the chest, necessary rhythm is 100 to 120 in
one minute with 5 - 6 centimeter depth and 2 breaths, each one second. Survival reduced by
10 - 12 percent each minute defibrillation delayed. In second scene, our patient can breathe
and have a pulse, but it’s not conscious. Then we have to put him in stable lateral position, for
easier breathing. (3)

8. AUTOMATED EXTERNAL DEFIBRILLATOR

If we see that the victim is unresponsive and not breathing normally, after doing basic life
support we use an automated external defibrillator. An automated external defibrillator (AED)
is a device that delivers an electric shock through the chest to the heart.The shock can stop
arrhythmia which is an irregular heart beat. It can help to have a normal rhythm to resume
following sudden cardiac arresr (SCA) which appears when heart stops beating. It is
necessary that it's treated in a short time or it can occur a death. A screen on computer shows
heart rhythm of a patient and it is connected to electrodes. Electrodes are placed on chests of a
victim. If its needed shave chest hair of patient because it can be dangerous to put electrodes
there, but spend as little time as possible for doing this. One electrode we put to the right of
the sternum, below the clavicle, another we out is in the mid-axillary line, approximately level
with the V6 ECG electrode position or the female breast.The computer sees if defibrillation is
needed and if it is then recorded voice on computer tell us that we need to press the shock
button which stuns the heart and stops all activities. AEDs give a shock in cases of ventricular
fibrillation or pulseless ventricular tachycardia. (5)

Non-medical personnel such as police, fire service personnel, flight attendants, security
guards and other lay rescuers who have been trained can use AEDs. All healthcare
professionals should consider the use of an AED to be an integral component of basic life
support. Early defibrillation should be available throughout all hospitals, outpatient medical
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facilities, and clinics.AEDs also should be placed in public areas such as shopping malls,
sports field, hotels and schools. They should also be in any other public or private place where
large numbers of people gather but are too far from the hospitals. They should be placed near
cafeterias, on walls in main corridors,elevators and etc.

In Croatia we have 621 automated external defibrillators. (6) But just in Zagreb, 120
defibrillators were installed in exactly 27 locations, and in Rijeka there are just 8 of them.
This information shows us that not only we have to small number of this device, but the real
question is how many people know how to use it in case of emergency.

9. THREE TYPES OF CLINICAL EVALUATION

9. 1. STROKE PATIENT

''A stroke happens when blood flow to a part of the brain is interrupted as a result of a
ruptured or blocked blood vessel.'' (6) Brain cells don't get enough blood with oxygen and
die, so they cause a big damage to brain which reflected to some part of the body. The
symptoms of stroke depend on which part of the brain is affected. Also there is different
between an ischemic or hemorrhagic stroke. A hemorrhagic stroke happens when a blood
vessel in the brain breaks so blood can come into brain. And an ischemic stroke happen when
a blood vessel which goes to brain is stopped. To evaluate first we need to determine which of
stroke does a patient have with a CT scan or MRI of the head. Computed tomography (CT) of
the head uses x-ray to made a picture of our body inside and then shows that picture on
screen. MRI of the head shows us structures of blood vessels with magnetic field and radio
frequency pulses and computer. If we want to know what did cause a stroke and how we will
need to treat it in the future we use blood tests or an electrocardiogram for making sure that a
heart didn't cause a stroke. Also we use Doppler ultrasound for checking artery carotis
communis which brings blood to brain, like that we can see how blood flows in these arteries
in neck. Cerebral angiography is kind of mix of these methods before and with it we can see
narrowing of the arteries. Also we can add that after we have evaluate stroke, then in some
cases it is treated with surgery to remove blood from brain or repair a vessel. But usually
patients take medications and receive post-stroke rehabilitation to repair problems with body
that stroke had caused.

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9. 2. PULMONARY PATIENT

It is known that most surgical procedures are done because of pulmonary function changes.
Exactly because of that key components in evaluation of pulmonary patient are his history,
physical examination and chest x-ray. In history usually belongs symptoms of dyspnea, chest
pain, stridor and cough. If one of the symptoms is more expressed than others and is
absolutely correct, then doctors are focused on that problem. Usually is important also to
check family history or past illnesess, drugs, smoking, exercise intolarence. While taking a
history from patient we can't ignore some obvious signs, for example inability to finish the
sentence without a break for breathing. Like we see physical examination plays an important
role. That means that it's important to check symptoms of increased sputum secretion,
emphysema, respiratory insufficiency, obstruction findings (wheezing, prolonged expiration),
hypertension,arrythmia or tachycardia. Checking arterial blood gases is next, hypercarbia
(PaCO2 > 45 mmHg) is believed to be high surgical risk and hypoxemia is not a predictor of
complication alone. Also x-rays are usually essential before surgery for patients older than 60
with cardiac or pulmonary problems. (7)

9. 3. HEART FAILURE

''Heart failure (HF) is a common clinical syndrome caused by a variety of cardiac diseases.''
(8) Like in previous cases, evaluation of heart failure includes history and physical
examination, but besides that it includes chest radiography, electrocardiography, and
laboratory assessment to identify causes. Symptoms are abdominal swelling, exercise
intolerance, recent weight gain and some alternative causes can be anorexia, weight loss
(sarcoidosis), chest pain (coronary artery disease) , palpitations (tachyarrhythmia), recent
fevers, viral infection (endocarditis, myocarditis, infection), syncope (bradycardia, heart
block). Chest pain is very important as a symptom of heart disease but is sometimes difficult
to evaluate. Location is usually in the front of the chest (retrosternal) but can also be in the
upper abdomen and then it spreads to the neck, jaw,left arm or left shoulder. With physical
examination we can notice that in case of heart failure extremities can be cool, skin pallor,
breathing can be labored and heart can have irregular rate or rhythm (arrhythmia).

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10. CONCLUSION

Evaluation is oriented to patient and goals set forth in the care plan and how care for the
patient might be improved. The purpose of the evaluation is not to find mistakes. It is focused
on progress or lack of progress toward achievement of specified goals. It is done for the
purpose of improvement, by identifying areas and criterias that need to be improved. Some
problems that could be found during evaluation are identifying false areas or collecting false
datas, so it doesn't match with parameters on which we are focused. Evaluation is an
continuos and gradual activity. Giving appropriate first aid immediately can help to reduce a
person’s recovery time and make the difference between the patient having a temporary or
long term disability. In some cases, when it’s done right, the recovery time becomes faster. A
careful and detailed assessment is essential in order to assess the likely cause and severity of
symptoms. It serves to direct reassessment of patient status, the reordering of priorities and
new goal-setting. The most important thing is not to forget to ask for a help if it's needed.
Also, using all available resources, from history of patient to tests. But more important is not
making unrealistic goal-setting, beacuse results may be incompatible with it. If all steps have
done right, patient have ability for faster recovery and also longer and more quality future life.

11. SUMMARY

Idea of first aid started hundred a years ago and since then it has changed and improved.
Evaluation in first aid today has an extraordinary importance. Of course, every case is special,
so we have to make a difference between conscious and unconscious person which can be a
child or an older patient. Basic steps include identifying the specification, developing criteria
and data collecting. Before approaching to a patient we have to be sure that our environment
is safe and if it's needed to ask for a help, because it is first important to protect yourself. For a
treatment of an unconscious patient today we use ABCDE approach, which has five important
steps including checking airway-breathing-circulation-disability-exposure. And for conscious
patients we use ''SAMPLE'' with whom we collect information about symptoms, allergies,
medications, past medical history, last meal and events before accident. In the clinic history,
physical examination and of course tests take an important place. An automated external
defibrillator is necessery to use if patient can't breathe and doesn't have a pulse. It is an good
example of device which can be used by anyone and can be everywhere, but the main
problem is a lack of this devices in Croatia and not knowing how to use it. This techniques
definately make easier to remember what first aider have to do in case of emergency. They are

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important because every step have to be done completely and correctly if we want that our
patients recovery lasts shorter and that he lives longer.

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REFERENCES

(1) https://medical-dictionary.thefreedictionary.com/evaluation

(2) http://ourstory.jnj.com/birth-first-aid-kit

(3) https://www.redcross.org/take-a-class/first-aid/performing-first-aid/first-aid-steps

(4) https://chandlersfordtoday.co.uk/emergency/

(5) https://www.youtube.com/watch?v=tPwc5Sy_w4A

(6) https://www.radiologyinfo.org/en/info.cfm?pg=stroke

(7) https://www.merckmanuals.com/professional/pulmonary-disorders/approach-to-the-
pulmonary-patient/evaluation-of-the-pulmonary-patient

(8) https://www.aafp.org/afp/2012/0615/p1161.html

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