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patient assessment

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Question
Answer
PART I   BSI; scene safety; location, TOD, weather, and clues; general impression; age, sex, and weight; ABC's; disability and exposure; chief complaint; status  
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PART I (ABC's)   ALWAYS done first, no matter what else is going on.  
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PART I (airway)   Open or closed? Patent or not patent?  
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PART I (breathing)   General rate; tidal volume; audible lung sounds; work of breathing; more importantly: effective of ineffective?  
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PART I (circulation)   PULSE CHECK: radial vs. carotid, general rate, rhythm, quality. CAPILLARY REFILL: immediate or delayed. SKINS: temperature, color, moisture. MAJOR BLEEDING: arterial, venous.  
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PART I (intact)   What is intact? What is not? What can/do we do?  
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PART I (DE)   DISABILITY: eyes, verbal, motor. EXPOSURE: what do you see? what do we need to see?  
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PART I (c/c)   CHIEF COMPLAINT: cannot move on without it; sometimes obvious, other times not.  
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PART I (status)   DETERMINE PT STATUS: mild, moderate, acute? What is going to help determine this, and why is it important?  
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PART I (assessment/interventions)   ASSESS, INTERVENE, and REASSESS! Give intervention time to work, and then reassess.  
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PART II   OPQRST; BRIM; BRIMCAC; GCS  
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PART II (onset)   Sudden or gradual?  
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PART II (provocation)   What were they doing when it started? What were they doing when symptoms/signs began?  
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PART II (quality)   Have THEM describe it; examples only as a last resort.  
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PART II (region, radiation, reoccurrence, relief)   REGION: locate pain/symptoms. RADIATION: ask THEM where it travels. REOCCURRENCE: Hx of pain/symptom? What was done for it last time? Seen by MD? Dx? RELIEF: taken anything for relief? Has it relieved itself? What was done in the past for relief?  
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PART II (severity)   0-10 pain scale; How we can relate it? Considerations for Pt not being able to give a #  
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PART II (time)   When did it begin? Put a time of day to it vs how long ago it happened.  
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PART II (BRIM)   Breathing; Response; I Eyes; Movement/muscle tone/motor; Chest  
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PART II (BRIMCARB)   Breathing; Response; I Eyes; Movement/muscle tone/motor; Chest; Abdomen; Refill; BP  
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PART II (GCS)   EYES: spontaneous, verbal, pain, none. VERBAL: oriented, confused, inappropriate, incomprehensible, none. MOTOR: obeys commands, localizes pain, withdraws (pain), flexion/decorticate (pain), extension/decerebrate (pain), none.  
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PART III   Vital signs; PROBELLS  
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PART III (vital signs, PROBELLS)   Pulse, Respirations, O2 Saturation, BP, Eyes, Lungs, LOC, Skins. SPECIALIZED VITALS: orthostatic vitals (rough change of 20 points in BP or HR indicates volume problem), 12 lead EKG, temperature, blood sugar. EKG, temp and BS not always required.  
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PART IV   History, Medications, Allergies, SPECIAL QUESTIONS, Pertinent Negatives  
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PART V   TREATMENT: what will they need? TRANSPORT: where do they need to go and how are they getting there? REASSESS: what needs to be reevaluated; pick top 3.  
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Created by: leper
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