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Patient Assessment

EMS Patient Assessment

QuestionAnswer
Goal of the Primary Assessment To form a General Impression (Chief Complaint) quickly Find out ALL that is wrong for this patient. Don't remain focused only on the Chief Complaint
Chief Complaint What is the patient complaining about? Using the patient's own words is an appropriate practice if they can describe their symptoms. Examples: Chest pain, dizzy, etc Chief Complaint is NOT the cause of the injury.
The order of Patient Assessments 1) Scene Size Up - what might kill in 90 secs 2) Primary Assessment - don't miss anything 3) Secondary Assessment - focus in on findings
Scene Size Up A quick overview of the incident AND its surroundings BSI L I S A Resources # patients Make sure to look around and take in the wider view of the incident Quick - should take no more than 30 seconds
L I S A Considerations during Scene Size-up Life Threats - things that can kill in the next 90 secs. If needed jump into this first Impression - chief complaint - what got us here (MOI, NOI) Spinal (head) - potential for spine or head injury AVPU
MOI Mechanism of Injury What caused the trauma? Examples: fell hit head, hurt shoulder, car ejection, gun shot, etc
NOI Nature of Illness Medical/health conditions, patient is sick or ill Examples: chest pains, asthma attack, fever
Primary Assessment (Goal and Steps) To form a General Impression. Doing ok or not ok? Level of urgency. Life Threats. Identify and treat immediate life threats May take 2-3 minutes B A B C D E Don't miss anything!
B A B C D E 1) Bleeding - major bleeds 2) Airway - open/clear O S O 3) Breathing - inspect regularity O I P A S 4) Circulation - confirm, strength, regularity (no rate) V C R S 5) Disability / Decision (transport now or wait) 6) Expose - to skin
Blood Sweep A pat down looking for blood Start at head Pat all areas - check hands often Don't focus on minor bleeding Potential for bleed out trumps all.
O S O The airway part of patient assessment 1) Open airway - open if needed 2) Suction - remove materials 3) OPA/NPA (oral / nasal conduits) - insert
O I P A S The Breathing part of Primary Assessment "Oh I Passed" Oxygen - supplemental if saturate is low Inspect - visual - depth, regularity, bilateral? Palpate - touch - pain Auscultate - listen - gurgling Seal - sucking chest wounds
Palpate touch or feel
Auscultate Listen listening to the heart and lung sounds of patients EMS focuses mostly on is it normal or abnormal? If abnormal try to classify (gurgle, hissing, crackling, irregular, etc)
V C R S Circulatory Check Voids - check for bleeding Carotid Pulse - for the unconscious OR Radial - for the conscious Skin - check skin color
A V P U Used to rapidly grade a patient's gross level of consciousness A = awake, alert, and oriented V = alert to voice, but not oriented, inappropriate responses P = alert to painful stimuli only, pinch U = unresponsive to voice or painful stimuli
C U P S Ratings used to help prioritize the patient for transport: · C = critical · U = unstable · P = potentially unstable · S = stable
General Impression Summary of Primary Assessment Age, sex, skin color, chief complaint, LOC, MOI/NOI, findings from BABC
LOC Level of Consciousness A V P U
S A M P L E History Assessment: Symptoms / Signs Allergies - Meds, food, insects Medications - Rx, OTC, recreational Past Medical History Last Meal Events leading up to this event
O P Q R S T Pain Assessment: Onset of event - when started Provocation / Palliation - worse/better Quality of Pain - describe it Radiation / Region Severity - rate it Time - how long has it hurt?
Sign vs Symptom Sign - something about the patient you can see, hear, smell, feel. Symptom - something the patient tells you
DCAP – BTLS Physical Exam - after a trauma injury Deformities Contusions Abrasions Penetrations/Pneumothorax Burn Tenderness Lacerations Swelling
Provocation vs Palliation Provocation - what makes the pain worse? Palliation - what make the pain better?
Epistaxis Bleeding from the nose
Paradoxical Movement When something should move one way but is moving a different way. Chest wall with multiple fractures may raise and fall in the reverse direction as would be expected.
PERRL Indicator of potential brain conditions through a quick eye exam. Pupils Equal size Round Reactive (to) Light Note: Both should change with light in one Note: On sunny days cover the eyes for 10-15 second then uncover
Pupillary Light Reflex Normally the pupils will dilate under dark conditions and constrict with light. Light shone into one eye should cause both pupils to constrict.
Pulse Oximeter Device to measure blood oxygen saturation (Sa02) <94% start O2 Warning: Can't tell the difference between O2 and CO2
Rates for Patient Reassessment Unstable re-evaluate every 5 mins Stable -re-evaluate every 10 mins
P A T Ratings for B A B C [D E] Present Adequate Threatened Example: Breathing is Adequate
Secondary Assessment - Purpose To obtain more information about the specific problem after the quick Primary Assessment. Focus in on the Chief Complaint and any findings ABCD
Primary Assessment - Purpose A quick assessment stopping to treat critical issues and to confirm the MOI/NOI. Check all key areas. Don't miss anything.
Provocation Things that make the symptom worse
Palliation Thing that ease pain
Assessment - Skin Color - Observational Terms Pink Pale Cyanotic Red/Flushed Jaundiced Blotchiness
Assessment - Skin Color - what to check C T C Color - Pink, Pale, Cyanotic, Red, Jaundiced, Blotchy Temperature - hot, warm, cool, cold Condition - dry, clammy, moist
Methods to check for unresponsiveness If patient is not responding to voice or tapping Sternal Rub - knuckles on sternum Trapezius Squeeze - Vulcan neck pinch Supraorbital Pressure - thumb on eyebrow Nailbed Press - roll your pen over their finger nail
Created by: danfar
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