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41 Cards in this Set
- Front
- Back
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5 steps for the Patient Assessment
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Perform the scene size up
perform an initial assessment perform a focused history and physical exam perform a detailed physical exam perform ongoing assessment |
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Scene Size up
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a quick assessment of the scene and the surrounding about the safety of the scene any MOI/or NOI, the number of patients, and need for additional resources
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Three factors affecting MOI
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amount of force applied to the body
Length of time applied areas of the body involved |
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Initial assessment
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Begins only when you come into contact with the PT
Used to identify and initiate treatment of immediate or potential life threats. |
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general impression
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base on your immediate assessment of the environment, the presenting signs and symptoms, the MOI or NOI
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Orientation AOX?
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check PT momory of Person Place, Time, and event
Long term -Name and place intermediate term-Place and time short term- Event |
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Altered mental status
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If PT has altered mental status, you should rapidly complete the initial assessment and give high-flow O2 and initiate transport as soon as possible
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High pri immediate trasport PT if
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A serious MOI
Poor general impression Unresponsive with no gag Resposive but unable to follow diff breathing Pale skin complicated birth uncontrolled bleeding severe pain any where chest pain inability to move any part of body |
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three goals of focused history and physical exam
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1. identify the PT chief complaint
2. Understand the specific circumstances surrounding the chief complaint 3. what problems can be identified through the physical exam |
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DCAP-BTLS
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D Deformities B burns
C contusions T Tenderness A abrasions L Laceratioins p punctures S Swelling |
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Goal of Rapid Trauma Assessment
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Find and treat any immediate life threats
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Subcutaneous emphysema
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Air under the skin
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Rales
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Also know as crackles-sounds that are produced by oxygen passing through moisure in the bronchoalveolar system sounds like rubbing two pieces of hair together
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Rhonchi
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continuous sounds with a lower pitch and a rattling quality and are indicative of fluid in the larger airways in the lungs usually heard during exhalation
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Stridor
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heard during inspiration even without a stethoscope. it is a crowing-type sound caused by the narrowing, swelling , or obstrucion of the upper airway. Often indicates a life-threatening problem especially in children
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wheezing
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a high pitched, whistling noise that is usually more prominent during expiration. It is caused by air being forced through narrowed airways and is often associated with asthma, bronchitis and other
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Pleural friction rub
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a low-pitched, dry, rubbing sound caused by the movement of inflamed pleural surfaces as the slide against one another during breathing.
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Abdomen -aortic pulsations terms to use
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firm, soft, tender, or distended
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SAMPLE
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Signs and symptoms
Allergies Medications Pertinent past history Last oral intake Events leading up to the episode |
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Repiratory rates
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Adults 12-20
children 15-30 infants 25-50 |
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Pulse tates
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adults 60-100
children 70-140 toddlers 90-150 infants 100-160 |
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blood prussure
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Adult men ad 100 to age to 150
women add 90 to age to 150 children age in y x2 +70 |
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OPQST-I
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Onset
Provoking/palliating factors Quality of pain Radiatioin/Refferred pain Severity Time Interventionis |
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Onset
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When the patient's problem began. Ask when the problem started or when the incident occurred and how long ago the PT first noticed the problem
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Provoking/palliating factors
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Provoking factors any thing that seems to bring on the problem or that seems to make the problem worse
Palliating include anything that brings relief. |
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Quality of Pain
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Ask PT to explain what the pain feels like
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Radiation/Referred Pain
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radiation- refers to an area of the body form which the origin of pain or discomfort may traval
Referred- pain that exists in more than one place, without a trail. |
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Severity
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PT perception of how bad the current incident is comparison with others (0-10)
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Time
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when the problem began and whether the PT has experienced the problem on other occasions
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Interventionis
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What did the Pt do to try and fix the problem
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Chest Pain-Evaluate
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The skin color, pulse, and BP. Look for trauma to the chest assess the external jugular veins, and listen to the breath sounds
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shortness of breath-Evaluate
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apply O2. Look at skin color, pulse, BP, rate and depth of respirations. look for airway obstruction and for trauma to the neck and chest. listen carefully to the breath sounds and assess for hypoxemia
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Abdominal Pain- Evaluate
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skin color, pulse and bp. look fo rtrauma to the abdome, and palpate the abdomen to identify tenderness or rigidity
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Bone and Joint Pain
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Skin. movement and sensation adjacent to and below the affected area
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dizziness
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skin, pulse, bp, and adequacy of respirations, monitor the level of consciousness and orientation. head for signs of trauma. assess for signs of dehydration
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CN II, III
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Pupil response
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CN III, IV, VI
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Do PT eyes follow your finger
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CN V
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PT clenchs teeth and palpate the masseter muscles; check sensation to the forehead, , cheek, and chin
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CN VII
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Have PT smile wide and show teeth
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Protocols
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predefined written treatment guidelines that provide genearl guidance to the EMT-I when caring ofr the most commonly encountered medical and trauma emergencies
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Standing orders
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a type of protocol, are written orders that deliniate functions ot be carried out by the EMTI provide a specific list of tasks or functions that the EMT_I should cary out before contacting medical control.
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