Patient Assessment - Medical Flashcards
1
Takes or verbalizes body substance isolation precautions
2 - Scene Size-Up
- Determines the scene/situation is safe
- Determines the MOI/NOI
- Determines the number of pts
- Requests additional help if necessary
- Considers stabilization of the spine
3 - Primary Survey (Part one)
- Verbalizes general impression of pt
- Determines responsiveness/LOC
- Determines CC/apparent life-threats
4 - Primary Survey (Part two)
Assesses airway and breathing
- Assessment - Assures adequate ventilation - Initiates appropriate oxygen therapy
5 - Primary Survey (Part three)
Assesses circulation
- Assesses/controls major bleeding - Assesses skin (either skin color, temperature, or condition) - Assesses pulse
6 - Primary Survey (Part four)
Identifies priority pts/makes transport decision
7 - History Taking and Secondary Assessment (Part one)
History of present illness
- OPQRST (each one must be written out) - Clarifying questions of associated signs and symptoms as related to OPQRST
8 - History Taking and Secondary Assessment (Part two)
Past medical history
-sAMPLE (each one must be written out)
9 - History Taking and Secondary Assessment (Part three)
Performs secondary assessment (assesses affected body part/system or, if indicated, completes rapid assessment)
- Cardiovascular - Pulmonary - Neurological - Musculoskeletal - Integumentary - GI/GU - Reproductive - Psychological/Social
10 - History Taking and Secondary Assessment (Part four)
Vital Signs
- Pulse - BP - Respiratory rate and quality - AVPU
11 - History Taking and Secondary Assessment (Part five)
- Diagnostics (must include application of ECG monitor for dyspnea and chest pain
- States field impression of pt
- Verbalizes treatment plan for pt and calls for appropriate intervention(s)
- Transport decision re-evaluated
12 - Reassessment
- Repeats primary survey
- Repeats vital signs
- Evaluates responses to treatments
- Repeats secondary assessment regarding patient complaint or injuries
Critical Criteria 1-3
- Failure to initiate or call for transport of the patient within 15 minute time limit
- Failure to take or verbalize body substance isolation precautions
- Failure to determine scene safety before approaching patient
Critical Criteria 4-6
- Failure to voice and ultimately provide appropriate oxygen therapy
- Failure to assess/provide adequate ventilation
- Failure to find or appropriately manage problems associated with airway, breathing, hemorrhage or shock [hypoperfusion]
Critical Criteria 7 & 8
- Failure to differentiate patient’s need for immediate transportation versus continued assessment and treatment at the scene
- Does other detailed history or physical examination before assessing and treating threats to airway, breathing, and circulation
Critical Criteria 9-11
- Failure to determine the patient’s primary problem
- Orders a dangerous or inappropriate intervention
- Failure to provide for spinal protection when indicated
