Reassessment

Reassessment — 4 components

Reassessment is the last step of patient assessment, and it is the step that turns a single snapshot of the patient into a picture of where the patient is heading. It is built from four components, repeated in order:

1. Repeat the primary assessment. Recheck mental status, airway patency, the rate and quality of breathing, the rate and quality of the pulse, and the color and temperature of the skin.
2. Reestablish the patient's priority. A patient who was stable may no longer be, and a patient who was unstable may have improved.
3. Reassess and record the vital signs, and compare them with the baseline set and with every set taken since.
4. Repeat the pertinent parts of the history and physical exam, and check every intervention you have made: oxygen (O2) delivery, bleeding control, the cervical collar (C-collar), and any splints.

Reassessment must never be skipped. The one exception is the patient whose lifesaving interventions leave you no hands free to perform it, and in that case your partner performs the reassessment instead.

Reassessment intervals

How often you reassess depends on how sick the patient is. The table below gives the interval for each category of patient.

Table 16.1Reassessment intervals

A stable patient is reassessed every 15 minutes, and an unstable or potentially unstable patient every 5 minutes. These intervals are a minimum, not a schedule to wait for. If you suspect any change in the patient's condition, repeat at least the primary assessment immediately rather than waiting for the next scheduled interval.

Trending & FIRR

Trending is the tracking of changes in the patient's condition over time. A single set of vital signs tells you where the patient is at one moment; a series of sets tells you which way the patient is moving. A pulse that rises while the blood pressure (BP) falls, for example, points to a deteriorating patient in shock in a way that neither number would on its own. Because of this, trending is more clinically valuable than any single set of vital signs.

The management of a patient after the assessment can be summarized by the four steps of FIRR: field impression, interventions, reassessments and report. The table below sets out what each step contains.

Table 16.2Trending & FIRR

Your field impression is a working impression, not a diagnosis: it names the body system affected and the probable cause. Interventions follow from it, and any medication beyond oxygen requires authorization from medical control, through standing orders or a direct order per local protocol; document the time each intervention is given. Reassessments are carried out at the interval that matches the patient's status, compared against the baseline, and documented with the time of each. The final step is the report, the handoff to the next provider, usually the emergency department (ED) nurse or physician.

The handoff report follows a set order. You give the patient's name, age and gender; then the subjective information, meaning the chief complaint, history of the present illness (HPI), past medical history (PMH), allergies and medications; then the objective information, meaning vital signs, examination findings and scene observations; then the interventions given and their timing; and finally your reassessment findings.