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14 Cards in this Set
- Front
- Back
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TE Patient assessment medical |
To identify all possible signs and symptoms relating to the injury or illness |
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Indications Patient assessment medical |
All patients |
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Contraindications Patient assessment medical |
Lack of patient consent Patient or scene presences an immediate physical threat to rescuers |
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SE Patient assessment medical |
Possible delay in care or transport time |
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Demonstrate scene size up |
Park the vehicle in a safe and convenient location Take standardized precautions Evaluate scene safety for personnel patient and bystanders Consider possible etiology of problem: MOI NOI Establish the number of patients Evaluate the need for additional resources personal equipment and special equipment |
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Demonstrate primary assessment 5 before ABCs |
Form a general impression of the patient upon approach (establish priorities) Control gross hemorrhage always stop and treat life threatening conditions when found If patient is conscious perform introductions, gain consent, and obtain chief complaint If patient is unconscious or spinal injury is suspected maintain immobilization of C-spine Establish level of consciousness AVPU alert * 4 Person Place time and event |
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Demonstrate Patient assessment medical after 5 primary do ABC |
Airway is the breathing open? Will the airway stay open? Is anything in danger of the airway? a.) ensure patient has a patent airway b.) consider an airway adjunct and or the possible need for suction Breathing is the patient breathing? Is the patient having trouble breathing? Are the rate and depth adequate? Does anything in danger of the patient’s breathing? a.) RATE absent fast slow normal b.) DEPTH shallow deep normal c.) QUALITY normal labor d.) Initiate appropriate oxygen therapy Circulation does the patient have a pulse and where is it located? If carotid is present blood pressure is at least 60 mmHg systolic a.) RATE Absent slow fast normal b.) Rhythm Regular irregular c.) QUALITY normal weak thready strong bounding d.) SKIN Color temperature condition e.) BLEEDING check Four and control any life-threatening bleeding not already addressed |
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Based on primary assessment determine patient’s priorities rapid transport unstable/load and go or on scene assessment stable/stay play |
Significant MOI/NOI or if patient fails primary assessment conduct a rapid assessment head to toe 60 to 90 seconds Medical patient conduct a focus assessment and modified secondary assessment |
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Identify affected body system and perform a focus assessment exam Determine pertinent positives or negatives with associated signs/symptoms |
Cardiac onset, provocation quality, radiation, severity, time, interventions Respiratory rate, quality, posture/appearance, accessory muscle, use lung sounds Stroke onset, describe episode, duration, neuro exam (facial droop arm drift speech) Altered mental onset, describe episode, duration, symptoms seizure, fever, trauma, intervention Syncope LOC,duration,position HX, incompetence, HX of blood and vomiting or stools, orthostatic vs trauma GI/GU location of pain, bleeding/discharge, last menses, blood in vomiting/stools, orthostatic vs trauma Poisoning/OD Substances, when, amount, how was patient exposed, time, Patient estimated weight, interventions Allergic reaction HX of allergies, exposed to what, how was patient expose, effects progressions, interventions 0B/GYN Pregnant, due date, last menses, para/gravida, pain/contractions, bleeding/discharge, urine changes Psychological/social Disorder/psychiatric hx, Previous attempts, Ideation (thinking about hurting themselves) environmental (stress loss of work divorce death of a family member) State field impression of patient and verbalize treatment plan for patient and core for appropriate interventions |
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Rapid assessment if primary assessment was failed expose and complete a 60 to 90 seconds scan of the body to identify life-threatening injuries |
Head and neck Inspect and palpate for life-threatening injuries to the head face and neck Inspect eyes/peoples for pearl inspect for Jugular vein dissension JVD tracheal deviation, tugging Inspect For the family or tenderness to the neck inspect for subcutaneous emphysema properly size and apply a c-collar Chest Inspects and palpates for life-threatening injuries Auscultate for equal and present breath sounds in four locations Inspect for sucking chest wound build trust and or palpated objects Abdominal Inspects and palpates for life-threatening injuries Palpates for tenderness, rigidly, distention Pelvis Inspects and palpates for life-threatening injuries check for deformity or stability (if C/O pain, crepitus, or obvious deformity do not palpate again) Verbalize assessment of the genitalia/perineum as needed Lower extremities Inspect and palpate for life-threatening injuries Inspects, palpates, assess, pulse motor sensation PMS in each leg Upper extremities Inspects and palpitates for life-threatening injuries and specs, how paints, assesses pulse motor sensation PMS in each arm Back Done during transfer to backboard And specs and palpates for life-threatening injuries head thorax pelvis and back of legs |
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Baseline vitals signs |
Baseline vital signs assessed/record a complete set of vital signs 1 Respirations, 2 pulse 3 Blood pressure, 4 lung sounds, 5 skin condition, color, temperature, 6 Capillary refill (particularly children’s <6 yrs old) 7 pupils 8 pulse oximetry 9 glucose |
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History taking |
Investigate the patients Chiefs complaint Medical history Questions family members caretakers or by standards for further information Obtain a sample history SAMPLE Obtain QPQRSTI for patients experiencing pain OPQRSTI |
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Patient assessment Of body |
Head/scalp Check for position check for the DCAP BLS TIC (Frontal temporal parietal occipital area’s) Face check your zygomatic arch maxilla mandible TMJ. Periorbital ecchymosis Eyes check pupils for Pearla (pupils equal, brown, reactive to light and accommodating) Check for hyphema foreign bodies Ears Check for blood CSF or other fluids and battle signs Nose Check for a blood CSF or other fluids and crepitus Mouth check for blood CSF form bodies teeth dentures fluid tissue damage odor discoloration Neck check for JVD tracheal deviation stairstepping and medical alert tags Suprasternal/clavicular Check for subcutaneous emphysema check for NTG or other medication patches pacemakers and crepitus Chest Palpate stern on for crepitus symmetry and paradoxical motion Auscultate for present and equal breath sounds check six fields Abdomen Palpate quadrants for softness rigidity distention tenderness and guarding gently palpate for pulsating masses Pelvis Palpate the integrity of the pelvic girdle and pubis symphysis (do not repeat if crepitus instability or deformity were noticed in the rapid scan) Legs Check for position and length, splint fractures palpate femoral and dorsalis pedis pulse motor ROM and sensation Arms check for position and leg splint fractures Palpate brachial and radial pulses motor ROM sensation, grip strength Check for medical alert tags Shunts track marks Posterior Assess head, thorax, pelvis and back of legs if not already done Ensure patient is packaged properly and ready for transport |
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Patient assessment medical Reassessment 7 |
1 Repeat primary assessment mental status, ABC’s 2 Repeat vital signs unstable every 5 minutes stable every 15 minutes 3 Reassess chief complaint 4 Check interventions 5 Identify and treat changes in the patient’s condition 6 Record any changes in the patient’s condition 7 Document any medication dose action route time DART and patient’s responses (+/-) |
