Chapter 10 (Patient Assesment) Flashcards
What are the 5 main parts of Patient Assessment?
- Scene Size Up
- Primary Assessment
- History Taking
- Secondary Assessment
- Reassessment
Scene Size-Up
Ensure scene safety, take standard precautions, determine mechanisim of injury/nature of illness, determine number of patients, consider additional/specialized resources (stabalization of spine, EMS assistance).
Primary Assessment
Form a general impression, assess LOC (AVPU + AA x 4), assess the airway: identify and treat life threats, assess breathing: identify and treat life threats, assess circulation: identify and treat life threats, perform primary assessment, determine priority of patient care (chief complaint) and transport.
History Taking
- Investigate the chief complaint (history of present illness) = OPQRST.
- Obtain SAMPLE history (past medical history).
Secondary Assessment
Systematically assess the patient. (Assess in detail body system affected + Detailed Vital Sign Obtaining = BP, Pulse, respiratory rate and quality)
Interventions can also occur during this step (Psychomoter = ye).
Reassessment
Repeat Primary Assessment
Reassess Vital Signs
Reassess the Chief Complaint
Recheck Interventions
Identify and treat changes in patient condition
Reasesss the patient (Unstable = 5min) (Stable = 15 min)
Clarifying Questions:
Neurological: PPTE
Pulmonary: Breath Sounds
Reproductive: Preggy?
Palpate the abdomen
AVPU (Patient Responsiveness Testing)
Awake and Alert: Eyes open and tracking, aware of EMTs, responsive to the environment, and follows commands.
Responsive to VERBAL Stimuli: Responds when talked to. Does so unintelligibly (moaning).
Responsive to PAIN: Responds to sternum pinch.
Unresponsive: Answers to nothing above. No cough or gag reflex - airway is unprotected.
Orientation Test (4)
Person?
Place?
Time?
Event?
If deviation occurs = altered mental status.
Unresponsive Patient Found (Primary Assessment)
Immediately check for patency of the airway. If obvious obstruction noted in airway, noisy breathing, or shallow/absent breathing is present… then suction airway as needed.
Rapid Exam
Primary Assessment (time = 1minute). Look for DCAP-BTLS while examining patient. Start from head and work down to the pelvis (axial skeleton). Listen to breath of patient on both sides of chest. Check extremities.
Deformity
Mishapen body part. (Bent ass arm)
Contusion
Bruising. (Blood collected).
Abrasion
Rubbing or scraping damage.
Punctures
Holes in the skin into the soft tissue.
Symptom
Patient problems that can not be observed by others.
Sign
Patient problem that can be observed objectively by others.
SAMPLE history.
(History)
Signs and Symptoms:
Allergies:
Medications: Normal medications, supplements, herbal remedies, recreational drugs?
Pertinent past medical history: Surgical or trauma occurences? Family history (bipolar)?
Last Oral Intake: When did you last eat or drink?
Events before injury: What happened?
Ascultation
Process of listening to sounds the body makes using a stethoscope.
Pulse Oximetry
Evaluates effectiveness of oxygenation. Device moniters the saturation of hemoglobin in the capillary beds. (94-99%). Depends on proper perfusion. If perfusion not there (loss of blood, vasoconstriction = shock or hypothermia + others), then reading could be wrong.
OPQRST
Onset: What were you doing when the symptoms began?
Provocation: Does anything make the symptoms better or worse?
Quality: What does the symptom feel like? (Sharp, dull, crushing, tearing?)
Region/radiation: Where does the symptom feel like it’s coming from? Do it be moving?
Severity: Scale of 1-10, what is your pain?
Timing: How long have you had the symptom? When did it start?
What conditions identify a patient as a high-priority patient?
Unresponsive, difficulty breathing, uncontrolled bleeding, altered LOC, severe chest pain, pale skin or other signs of poor perfusion, complicated childbirth, and severe pain in any area of the body. (Life threatening).
Immediate transport should be the focus.
A crackling sound produced by air bubbles under the skin is called:
Subcutaneous emphysema.
The Golden Hour
Period inbetween the time of injury and definitive care (hospital setting). Ability to compensate for shock depletes with time! Vamanos!
Paradoxical Motion
When only one section of the chest rises on inspiration while another area of the chest falls.
Rhonchi
Congested breath sounds = mucus or fluid in the lungs. Should sound low pitched and noisy during expiration - kinda like a fart.
“Junk in the Lungs” = Pneumonia
Wheezing
High pitched whistle tone = lower airway obstruction/narrowing.
BRONCHOCONSTRICTION
A: Asthma
A: Anaphalaxyis
C: COPD
Snoring
Upper airway obstruction.
Stridor
Brassy crowing sound heard when breathing in = obstruction in neck or upper part of chest.
- Croup
- Epiglottitis
- Inhalation burn
- Anaphalaxyis
- Obstruction
Cackles
Rice cripsies under milk = fluid in the lungs.
Hand Over Verbal Report
SBAT
Situation/scene: Concise statement of problem. (Trauma alert, hypotensive 28 y/o female, injuries)
Background: Relevant! (Struck by car…35mph…20mins ago)
Assessment: Findings and current thoughts (LOC, Vitals {BP, Pulse, Respiration Quality}, body scan evidence, medical history)
Treatment: Interventions (Applied oxygen, stabalized pelvis and leg)
CHART Reporting
C: Chief Complaint or Concern. (Complaint = headache, concern = signs of stroke)
H: History: Details of the scene of incident + Patient medical history
A: Assessments: LOC, Vital signs, physical assessment
R: (RX) = Treatments and results of treatments
T: Transport details of patient. Ex: how moved onto stretcher?
