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PATIENT ASSESSMENT Flashcards

1
Q

Therapeutic Effects

A

To identify all possible signs and symptoms related to the injury or illness

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2
Q

Indications

A

All patients

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3
Q

Contraindications 1

A

Lack of patient consent

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4
Q

Contraindications 2

A

Patient or scene presents an immediate life threat to the rescuer

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5
Q

Side Effects

A

Possible delay in care or transport time

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6
Q

Scene Size Up

A
  1. Park Vehicle in safe and convenient location
  2. Standard Precautions
  3. Evaluate scene safety for personnel, patients, bystanders
  4. Consider possible etiology or problem MOI or NOI
  5. Establish number of patients
  6. Evaluate the need for additional resources, personnel, special equipment, ALS
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7
Q

Primary Assessment 1-5

A
  1. Form a general impression upon approach, establish priorities
  2. Control Gross hemorrhaging, Always treat life threats when found
  3. Conscious, perform ICC
  4. Unconscious, or if suspected spinal injury mantain manual imobilization of c-spine
  5. AVPU, Mental status
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8
Q

AIRWAY

A

Is the airway open, will it stay open, does anything endanger the airway

  1. Ensure patient has a patient airway
  2. Consider airway adjunct or suction
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9
Q

BREATHING

A

Is the patient breathing, is the patient having trouble breathing are the rate and depth adequate, does anything endanger breathing

  1. Rate ( absent , fast, slow, normal)
  2. Depth (normal, deep, shallow)
  3. Quality (labored, normal)
  4. Consider oxygen therapy.
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10
Q

CIRCULATION

A

Does the patient have a pulse and where is it location?
Conscious, radial
Unconscious, carotid = 60mmhg

  1. Rate ( absent, fast, slow, normal)
  2. Rhythm (regular, irregular)
  3. Quality ( normal, weak thready, strong bounding)
  4. Skin color temp condition
  5. Any more bleeding?
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11
Q

Primary Assessment 9

A

Is this trauma or medical in nature?

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12
Q

Primary Assessment 10

A

Stay and play or Load and Go

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13
Q

Physical- Rapid or Focused 1

A

If sig MOI or NOI - perform rapid 60-90 scan ( expose and perform head to toe scan looking for life threats)

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14
Q

Physical- Rapid or Focused 2

A

If minor MOI or NOI - perform focused scan ( expose and perform a scan of area based on CC

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15
Q

Physical- Rapid or Focused 3

A

If questionable perform Rapid scan

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16
Q

RAPID ASSESSMENT 1

A

HEENM - head, ears, eyes, nose, mouth

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17
Q

RAPID ASSESSMENT 2

A

Neck- JVD, tracheal deviation, stair stepping, crepitus, deformity of the vertebrae,

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18
Q

RAPID ASSESSMENT 3

A

-inspects and palpates for life threats
-lung sounds, rapid -2 places
-lung sounds, focused 4 places
FLOPS- flail segment, Lung sounds, paradoxical movement , suction chest wounds, symmetry

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19
Q

RAPID ASSESSMENT 4

A

ABDOMEN
-life threats
DRT PGS- deformity, rigidity, tenderness, pulsating masses, guarding, softness

PELVIS

  • life threats
  • check for deformity or stability (if complains of pain, crepitus, or obvious deformity- DO NOT PALPATE AGAIN
  • VERBALIZE PPP
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20
Q

RAPID ASSESSMENT 5

A

Extremities- life threats, PMS

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21
Q

RAPID ASSESSMENT 6

A

Back - DCAP BLS TIC,, head, thorax, pelvis, and back of legs

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22
Q

UPDATE TRANSPORT DECISION

A
  • STABLE , baseline vitals and history
  • UNSTABLE MEDICAL, quick vitals, history, give meds as needed, transport
  • UNSTABLE TRAUMA, backboard, c-collar, transport, vitals, history en route
23
Q

VITALS

A
  1. TEMP
  2. PUPILS
  3. Lung Sounds
  4. Respirations
  5. BP
  6. PULSE
  7. PULSE OX
  8. BLG
  9. CAP REFILL
24
Q

History 1

25
Q

History 2

26
Q

HIstory 3

A

Med history from friends, family, bystandards, caretaker

27
Q

History Med Patients 1

A

GI, GU - LBLBOT- location of pain, bleeding/discharge, last menses, blood in vomit or stool, orthostatic VS, Trauma

28
Q

History Med Patients 2

A

Altered Mental -ODDSSFTI- Onset, describe episode, duration, symptoms, seizure, fever, trauma, interventions

29
Q

History Med Patients 3

A

Psychological/Social- DPIE- disorder psych HX, previous attempts, ideation, environmental stressors

30
Q

History Med Patients 4

A

OB/GYN- PPP BULD- pregnant, due date, last menses, para/gravida, pain/contractions, bleeding/discharge, urine changes

31
Q

History Med Patients 5

A

Cardiac - OPQRSTI

32
Q

History Med Patients 6

A

Allergies - HEHE PI- HX of allergies, exposed to what, how was pt. exposed, effects, progression, interventions

33
Q

History Med Patients 7

A

Respiratory - RQPALS rate, quality, posture/appearance, accesory muscle use, lung sounds

34
Q

History Med Patients 8

A

Poisoning/ O.D, SWAHTWI- substance, when, amt, how was pt exposed, time period, pt estimated weight, interventions

35
Q

History Med Patients 9

A

Stroke - ODD FAST- Onset, describe episode, duration, neuro exam (FAST)

36
Q

History Med Patients 10

A

Syncope- LPHHOT- LOC duration, position, Hx incontinence, Hx of blood vomit in stool, Orthostatic VS, trauma

37
Q

Secondary Physical

A
  • STABLE ,Focused on CC
  • UNSTABLE MEDICAL, Detailed full body
  • UNSTABLE TRAUMA, Detailed full body
38
Q

Secondary Physical 1

A

HEAD SCALP

  • position
  • dcapblstic, frontal, temporal, parietal, occipital areas)
39
Q

Secondary Physical 2

A

FACE

-zygomatic arch, maxilla, mandible, TMJ, periorbital ecchymosis

40
Q

Secondary Physical 3

A

EYES

  • PEARRLA
  • hyphema, foreign bodies
41
Q

Secondary Physical 4

A

EARS

-blood, CSF, fluids, battle signs

42
Q

Secondary Physical 5

A

NOSE

-blood, CSF, fluids, crepitus

43
Q

Secondary Physical 6

A

MOUTH

-blood, CSF, foreign bodies, teeth dentures, fluid, tissue damage, odors, discoloration

44
Q

Secondary Physical 7

A

NECK

-JVD, Trachial deviation, stairstepping, crepitus, deformity of vertebrae, MED alert TAG

45
Q

Secondary Physical 8

A

SUPRASTERNAL/ CLAVICULAR

  • SUBQ Emphesema
  • Medication patches, pacemaker crepitus
46
Q

Secondary Physical 9

A

CHEST

FLOPS- flail seg, lung sounds (6 locations), paradoxical movement, sucking chest symmetry

47
Q

Secondary Physical 10

A

ABDOMEN

-DRT PGS, distention, rigidity, tenderness, pulsating masses, guarding, softness

48
Q

Secondary Physical 11

A

PELVIS-

  • palpate integrity of the pelvic girdle and pubis symphysis (do not repeat if crepitus, instability or deformity were noted in the rapid scan)
  • PPP
49
Q

Secondary Physical 12

A

LEGS

  • check for position length splint fractures.
  • femoral, dorsalis pedis pulse, pms, and RANGE OF MOTION
50
Q

Secondary Physical 13

A

ARMS

  • check for position and length, splint fractures
  • brachial, radial pulse, PMS, RANGE OF MOTION, grip strength
  • medical alert tags, shunts, track marks
51
Q

Secondary Physical 14

A

POSTERIOR

-DCAPBLSTIC

52
Q

Secondary Physical 15

A

Ensure patient is packaged properly and ready for transport

53
Q

REASSESSMENT

A

LACVISM

  • LOC AVPU
  • ABC’s
  • Cheif Complaint
  • Vital signs (5min or 15 min)
  • Interventions
  • Shock
  • Monitor patient record changes in condition.
  • DART

PATIENT ASSESSMENT (1 decks)

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