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Assessing a patient’s mental status is a little more complicated than simple stating, “mental…that one,” like Ron Weasley did in the first Harry Potter movie. Of course, it would be great to be able to make quick and general assessments. Assessing a patient’s mental status is an important step after the general impression is obtained. A mental assessment should only be made once the patient has been stabilized or immobilized, if a spine injury is present.
To accurately assess a patient’s mental status, the emergency medical technician should introduce himself to the patient and explain who he is and that he is there to help. Once this introduction is made the EMT should observe the patient’s reaction and response.
There are four categories that can be used to describe a patient’s mental status. The first category is alertness. Is the patient alert and interacting with the EMT without having to be prompted for information? The second category is verbal. Does the patient respond verbally when spoken to? The third category is painful. If the patient does not respond to either of the two previous categories the EMT should provide a painful stimulus to see how the patient will respond. The fourth category is unresponsive. If the patient does not respond to verbal or painful stimuli then the patient can be considered unresponsive.
The patient’s mental status can change at any time and should be observed regularly. It is important to note any changes that occur. If the patient becomes more or less responsive then the receiving facility should be notified and the patient’s change in mental status should be documented in the prehospital care report. A patient who has a deteriorating metal status may need airway support. An EMT should be prepared to provide aid to treat patients with signs and symptoms of shock, which can commonly occur and affect a patient’s mental status.
The general impression of a patient’s status is made when the emergency technician makes the first immediate assessment of a patient. This general impression can take place in a few seconds and usually helps the emergency crew to prioritize the patient’s care and plan of action. There are several important assessments that form the general impression.
An emergency medical technician should first determine if the patient has a medical condition or if the patient is injured. A patient with a medical condition may be wearing an alert tag that identifies the type of condition. These tags are often worn as bracelets or necklaces. If there is no alert tag available the EMT will have to determine the nature of the patient’s illness. If the patient is conscious, the EMT can ask questions or pick up on clues about the patient’s condition. For example, if the patient is complaining of shortness of breath he may be suffering from respiratory distress. Chest pain may indicate a potential cardiac emergency. The sooner you are able to classify the patient’s illness the easier it will be to treat the problem.
Often the first impression can accurately indicate if the patient is sick or not. This impression is usually made by the way that the patient appears, the position that the position is in or other physical attributes. This impression can help the EMT to determine if certain types of intervention should be performed to help improve the patient’s state.
If the patient is injured it is important to determine how the injury was caused. Was the patient involved in a motor vehicle accident? Did the patient fall or have burns? Determining how the patient became injured can give the EMT information about possible medical problems that could have caused the trauma, such as a heart attack while driving or a seizure causing the patient to fall. Making note of the patient’s age, gender and race can also help to form the general impression.
The last part of making an accurate general impression is to determine if the patient has any injuries that may be life-threatening. Examples of life-threatening injuries include: obstructed airway, inadequate breathing or circulation, major bleeding or any threat to the airway, breathing or circulation. These types of injuries should be corrected immediately.
A patient’s perfusion can be assessed by looking at the inside of the patient’s lips, the color of the patient’s nail beds or the skin that is just inside of the eyelids. These areas of the body are normally pink in all races of people. If any of these areas look pale, blue-gray, red or yellow than there could be a serious medical problem. A patient that appears blue-gray may be cyanotic. Red indicates flushed and yellow could be caused from jaundice.
Assessing infants and children under the age of 6 is only slightly different. To assess an infant or child, there are several areas that can pressure can be applied to, to evaluate the capillary refill. The nail bed, skin, heel or sole of the foot in infants can be pushed until the area appears blanched. Once the color is gone count how long it takes of the color to return to normal. If it takes longer than 2 seconds than there is a problem with profusion which may indicate shock, fever, hypothermia, or an underlying vascular disease.
The best way to assess a patient’s skin temperature is to place the back of your hand against the patient’s skin. If the skin feels warm and dry to the touch then the patient has a normal skin temperature. If the patient’s skin feels hot, cool, cold, or clammy then the skin temperature is considered abnormal. Unless there is an unusual circumstance, it is not necessary to take a thermometer reading of a patient’s temperature in the field. This can be done when the patient is in the hospital. How the patient’s skin feels can indicate a problem. Cool, clammy skin may indicate shock. If the patient has hot and dry skin then the patient may have a heat emergency, like heat stroke.
Evaluating a patient’s skin by observing the color, temperature and condition is one way of helping you to determine if the patient is experiencing a medical problem.
Phencyclidine is a substance that causes hallucinations. It is commonly known as PCP and is considered an extremely dangerous drug that has been attributed to assaults, murders, and suicides. In the late 1950’s PCP was developed to be a dissociative anesthetic capable of keeping a patient awake but unresponsive to pain. The hallucinogenic aspects of this drug caused it to be discontinued from use in humans. It is still used in veterinary medicine.
PCP is metabolized by the liver. If large quantities of the drug are taken the liver will process and metabolize the drug forming a high concentration in the urine. PCP can stay in the system anywhere from half an hour to 4 days depending on the dose.
A person under the influence of PCP will experience three stages of psychological effect. The first stage will cause the person to feel a change of body image. The second stage will cause a person to experience distorted hearing and vision. The third stage occurs when the patient feels alienated, estranged from others and apathetic.
Physically, there are several obvious effects of PCP on the body. A person under the influence of PCP will be flushed and sweat profusely. The patient’s eyes will have rapid eye movements and double vision. The eye lids will also droop. Most people under the influence of PCP will exhibit signs similar to alcohol intoxication such as staggering and generalized numbness of the extremities.
Many people under the influence of PCP also exhibit signs of paranoid behavior and can be self-destructive. There are other physiological changes that can manifest, such as trachycardia, hypertension, respiratory depression, muscle rigidity, increased reflexes, and seizures.
There is no treatment or antidote for PCP. The only treatment that can be done for a person under the influence of PCP is to put the person in a dark room, away from sensory stimulation and unable to self-inflict injury. There are certain drugs that are often administered to help reduce the effects of anxiety and psychosis.
When I first got out of school, I took a job in a county psychiatric hospital. Six months later, I heard of higher-paying job that had opened opened in the ER where I had worked as a student, so I switched jobs. I was told I’d be starting out with orientation for two weeks, working the night shift, and working with an experienced nurse.
My second night on the job, I came in and discovered that it was the night nurse’s day off and I would be working alone! I was very nervous, to say the least, but I was assured by the unity clerk that because this was a small community hospital and it didn’t usually see much trauma, weeknights were generally pretty quiet. Though that should have tipped me off, I instead simply convinced myself I’d survive. At about 2AM, a man burst through the ER doors shouting, “I’ve been stabbed!” He ran past me into the treatment room and threw himself onto a stretcher.
When I finally caught up with him, he had sprawled himself facedown on a stretcher, and I could see that his back was a mass of clotted blood. The unit clerk located the ER physician, and I began to take the patient’s clothes off and take his vital signs. When the ER doctor came in, we sprang into action getting an intravenous line started and cleaning the wounds to assess the seriousness of the situation. Suddenly the man began to have difficulty breathing.
The ER doctor ordered that the on-call thoratic chest surgeon be summoned. This only added to my unease as the surgeon on call that night was a big shot in every sense of the word – a very talented surgeon, but generally unfriendly, intimidating, and a no-nonsense kind of guy.
The surgeon quickly took over and the ER physician stepped out before I could explain I was new on the job and wished he would stay. The surgeon asked me for the thorocotomy tray and directed me to set up the underwater drainage bottles, wich at that time were used instead of suction to produce negative pressure for the chest tubes. This was all new to me. I got out the tray and called the night supervisor to locate the drainage equipment.
When the equipment arrived, the surgeon asked me to set it up. I had no idea what to do! Although I was a wreck inside, I very calmly-at least on the surface and said, “I’ve never set one up before. You’ll have to tell me what to do.” I’ll never forget the surgeon’s eyes as he looked up at me over the half glasses perched on the end of his nose, relaying a look of “you’re kidding right?” He proceeded to walk me through the procedure.
Somehow I held it all together and made it through the experience and the night. Both the patient and I survived, and I learned more that night than I have ever expected I would.
As first responders to emergency situations, Emergency Medical Technicians (EMT) are trained to be able to identify and treat patients who may be in shock. This very life-threatening condition requires quick action by the EMT.
Any treatment that is used for shock must be able to increase cardiac output, blood pressure and oxygenation of tissues. The best way to treat for shock is to treat the cause and also provide supportive measures that can help reduce shock symptoms like:
1. Have the patient lie flat.
2. Support the patient’s legs so that the patient’s feet can be raised.
3. Keep the patient warm by using blankets but be careful not to overheat the patient.
4. Saturate the patient with oxygen. This can be accomplished by using a mask attached to an oxygen canister. Be sure that the patient has an open airway and use an endotracheal tube if necessary. If the patient is unable to breath independently then artificial ventilation may be necessary.
5. Administer intravenous fluids or blood if needed. It is important not to overload the patient’s circulation.
6. A patient who is in shock because of kidney failure will probably need dialysis until the organs are able to function normally.
Whatever the cause may be, shock symptoms should be treated immediately to prevent serious problems or even death.
Shock can be prevented in patients who are known to have severe allergies. Many patients with severe allergies have adrenaline self-injection kits that they can use as soon as they are aware of any early symptoms of shock. Some early signs of shock are difficulty breathing, abdominal cramps, and puffiness.
Patients with bleeding infections or heart attacks should be helped immediately to prevent shock. Shock can be prevented by providing excellent patient care and the early treatment of severe infections and pain relief when out in the field.
Emergency medical technicians (EMTs) are usually one of the first responders at a trauma scene. Most often patients involved in traumatic accidents or situations are in shock. More than just being surprised, shock is a life-threatening condition that often occurs in patients who have suffered from severe trauma, infection, allergy or heart attack. Shock causes the body’s circulation to collapse. When the circulation is slowed the pressure in the arteries begins to fall and eventually the tissues and organs of the body are unable to maintain an adequate oxygen supply.
Some common symptoms of shock that an EMT or paramedic might look for include all or some of the following: -Pale, cold sweaty appearance -Nausea and thirst -Dry mouth -Irregular breathing -Chest pain -Dilated pupils -Loss of consciousness -Reduces urine output -Confusion or agitation -Warm hands and feet -Fast heartbeat -Swelling of the face Shock is commonly caused by a reduction in the volume of blood circulating through the body. Most often this reduction is due to several possible factors like: Internal or external bleeding Dehydration- This can occur if a patient experiences frequent vomiting or diarrhea. Acute pancreatitis, heat exhaustions, diabetic coma and burns can also cause fluid loss and dehydration. Dilated blood vessels- Bacteria can cause septic or toxic shock when the toxins from the bacteria enter the bloodstream. These toxins often cause severe allergic reactions which can cause the peripheral veins to become dilated inevitably reducing circulating blood volume. Damage to the heart muscle- A myocardial infarction can damage the heart making it more difficult for the heart to pump strongly. A weakened heart is unable to circulate blood effective through the body. Loss of heart’s normal rhythm- A heart arrhythmia is a condition that occurs when the heart beats too quickly, too slowly or irregularly. Whenever the heart is not operating in a normal rhythm it becomes less effective at circulating blood. Pulmonary emboloism- A blood clot can occur in a completely different part of the body and directly affect the heart. For example: If a blood clot from the leg finds its way into the lungs tissue it can become lodged and prevent the flow of blood from the right side of the heart to the lungs. Cardiac tamponade- This condition occurs when excess fluid surrounds the heart in the pericardium. The excess fluid causes the heart muscle to become constricted, which prevents normal filling.
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How to Become a Paramedic or EMT: Heart Failure
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Emergency medical technicians are often called to cases where a patient is experiencing heart problems as serious as heart failure. Heart failure is a condition that occurs when a person’s heart stops pumping blood to the different parts of the body efficiently. This can cause tissues and organs to be deficient in oxygen and nutrients. When an EMT is called to treat a patient who is experience heart failure there are several symptoms that should are associated with heart failure.
Tiredness- Patients who experience severe heart failure are the most likely to feel tired, exhausted or worn out.
Breathless- Often patients with heart failure feel breathless. They are typically breathless whenever they must exert themselves. Eventually the feeling of breathlessness will occur even when the patient is resting.
Coughing up- A pink or white stained frothy sputum may be coughed up. The cause of the colored sputum is from congestion in the lungs and fluid retention in the body.
Swelling- A patient with heart failure may experience swelling in the ankles, lower back and thighs. Patients who are bedridden will experience the swelling in the thighs and lower back because the fluid can accumulate in those areas very easily. Patients who are still mobile will likely have swelling in the ankles because of gravity.
Weight loss- Heart failure can cause a patient to lose his or her appetite, feel nausea or vomit frequently. These symptoms are very common with patients in this condition.
Abdominal pain- Some patients experience abdominal pain. Doctors have determined that most often abdominal pain that occurs during heart failure is the result of liver congestion.
Most cases of heart failure are caused by the heart being damaged from several possible conditions such as coronary heart disease, chronic heart muscle disorders, hypertension, acute or chronic myocarditis, valvular disease, narrowing of the aorta, high output demand or impeded heart flow.
As a health-care provider, you will often have patients that are unable to swallow or ingest anything orally. For patients in this situation, another route for administering medications must be used. A nasogastric tube or a gastrostomy tube can be used to administer medications into the patient’s stomach.
A nasogastric tube must be passed through the the nose and into the stomach opening in order for medications to be administered directly into the stomach. This tube can also be used as a feeding tube and to remove any stomach contents when necessary. The gastrostomy tube is used by inserting the tube through the skin and directly into the stomach. This tube is used as the primary feeding tube for administering medications.
The following protocol should be used whenever nasogastric or gastrostomy tubes are used to administer medications to patients.
-Always check the prescriber’s order to ensure that you are performing the correct procedure on the right patient and to double check that you are following all of the necessary instructions.
-Ensure that the tube is in the right position by doing either of these methods:
1. Attach a syringe to the free end of an NG tube. Then, inject 1 or more 20 mL bursts of air into the tube. Then aspirate the gastric contents and check the pH of the contents with litmus test paper. If the paper shows the acidity of the gastric contents to be between 0 and 4 then the tube is correctly positioned in the stomach.
2. Inject 10 mL of air through an NG tube. Use a stethoscope over the stomach to listen for a rush of air. This step is not performed when inserting a gastronomy tube.
-Once the tube is properly positioned, remove the plunger from a syringe and pour the medications to be administered to the patient into the syringe.
-Close the clamp on the nasogastric or gastrostomy tube and attach the syringe.
-Once the syringe is attached open the clamp on the tube and hold the tube up so that the medication in the syringe can flow down the tube and into the patient.
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How To Become a Paramedic: Intradermal Injections
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There are several ways that a medication can be administered to a patient by an EMT or Paramedic. Certain types of medications require specific routes. Medications that are injected intradermally have a localized effect on the injection area. The injected medication does not enter the blood stream. Instead, the injected medication is meant to pool at the injection site and create a wheal (blister).
Health-care providers that perform intradermal medications should follow specific protocol in order to administer the medication correctly. Intradermal injections should be given using a 26-27 gauge needle and a 1 mL syringe that is calibrated in 0.01 mL increments. On average, a typical injection is between 0.01 to 0.1 mL.
To inject medication intradermally the health-care provider should first check the prescriber’s medication order to ensure that the right medication and dosage is being given to the right patient. Once the medication order is verified, the health-care provider should wash hands and put on a new pair of clean gloves. Avoid using latex gloves. The patient should be properly identified before the injection occurs. The injection site should be cleansed with alcohol or betadine in a circular motion depending on the medication that is being injected or the policy of the health-care facility. The nurse should hold the patient’s skin taut and position the belvel up while inserting the needle at a 10-to-15-degree angle. When done correctly, you should be able to see a faint outline of the needle beneath the skin. The medication can now be injected slowly into the site to form a wheal (blister). Once the wheal forms, slowly remove the needle. Do not massage the injection site. Instead, mark the injection site with a pen so that you will be able to find the site again later. Give the patient instructions not to wash the mark off until the health-care provider has assessed the site and determined if a reaction has taken place. The patient should return to have the injection site assessed between 24 and 72 hours after the injection. If the patient is allergic to the medication that was injected than the diameter of the wheal will increase.
