Patient Assessment(s) Flashcards
Body Substance Isolation
[ 1 ]
STEP 1: Ensure the donning of proper PPE
— Gloves (always) — Mask (N95 / HEPA) — Goggles / Face Shield — Gown / Apron(s)
Scene Size-up
[ 5 ]
STEP 2: Sensorial perception of the scene
1) Safety — Is the scene safe? 2) Patients — How many victims / patients? 3) Additional Help — Do we need backup? 4) Mechanism of Injury / Nature of Illness? 5) Equipment — What do we need to bring?
Primary Assessment
[ 3 / GLC ]
STEP 3: Initial findings of the patient
G) General Impression: • “Gut Feeling”, and first visuals on scene L) Level of Consciousness (LOC): • AVPU (Alert, Verbal, Pain, Unresponsive) • Alert & Oriented (A/Ox3) Medical: • Alert & Oriented (A/Ox4) Trauma: C) Chief Complain / Life Threats: • Are there any threats? • What are their primary concern(s)
Airway
[ ABC’s ]
STEP 4 (a): Assess for the patient’s airway
Airway:
1) Open and assess the airway 2) Insert adjuncts as indicated
Transportation Decision
[ TRANSPORT ]
STEP 6:
• You man transport the patient at any time after attempting a complete Primary Assessment
— Code(s)
— Destination (Hospital, Trauma Center, etc.)
— Helicopter
History Taking
[ OPQRST - ASPN ]
STEP 8 (a):
• OPQRST:
— Onset (acute/fast or chronic/slow)
— Provocation (what caused the condition)
— Quality of Pain (sharp, numb, hot, stingy)
— Radiation (is the pain anywhere else)
— Severity of Pain (scale from 1 - 10)
— Time (when did condition begin)
• ASPN:
— Associated Symptoms
— Pertinent Negatives
History Taking
[ SAMPLE ]
STEP 8 (b):
• SAMPLE:
— Signs/Symptoms
— Allergies (pertinent allergies)
— Medications (known prescriptions)
— Pertinent Past History
— Last Oral Intake (medication, food, etc.)
— Events (leading up into condition)
• Interventions:
— Consult with Medical Control
— State field impression of the patient
• Manage Secondary Injuries / Complaints
CSM
Circulation, Sensory, and Motor responses.
Also referred to as PMS; Pulse, Motor, and Sensation(s).
LOC
Level of Consciousness.
A term used to describe a person’s awareness and understanding of what is happening in his or her surroundings.
DCAP-BTLS
[ 2nd Assessment ]
STEP 7 (b):
— Deformities & Discolorations
— Contusions (bruises)
— Abrasions
— Punctures / Penetrations
— Burns
— Tenderness
— Lacerations
— Swelling
Secondary Assessment
[ 2nd Assessment ]
STEP 7 (a):
• Collect patient’s Vital Signs
— Blood Pressure / BP: 120/60
— Pulse: 60-100 beats/min
— Respirations: 12-20 breaths/min
— SPO2: 94-99% O2
• Conduct a Physical Assessment:
— Focused Assessment
— Full Body Scan
— DCAP-BTLS
NOTE:
Focused Assessment:
— An assessment of the chief complaint of the patient.
Full Body Scan:
— A systematic head-to-toe examination used to identify hidden injuries identify causes that may not have been found during the Primary Survey
Reassess the Patient
[ Reassessment ]
STEP 9:
• Repeat Primary Survey:
— General Impression
— Level of Consciousness (LOC)
— Chief Complaint / Life Threats
— Maintain Open Airway / Breathing
— Reassess Pulse / Skin Vitals
— External bleeding (new blood)
— Re-evaluate patient’s priority Level
• Reassess Vital Signs:
— Blood Pressure / BP: 120/60
— Pulse: 60-100 beats/min
— Respirations: 12-20 breaths/min
• Repeat Focused Assessment:
— For Non-critical Patients
• Observe Trends:
— Changes over time
— At least 3 assessments must be made
• Check Interventions:
— O2 Delivery
— Artificial Ventilation
— Other (splints, bandages, treatments)
Patient Reporting
[ Verbal Report ]
STEP 10:
• Patient Report (En Route):
— ID Yourself (i.e. Med 24)
— Age / Sex
— Chief Complaint
— Findings at the scene
— Physical findings
— Care given to patient
— Code of Transport
— ETA
• Patient Report (At Hospital):
— Patient’s Name
— Age / Sex
— Chief Complaint
— History of patient / situation
— Treatments given
— Response to treatments
— Vital Signs
— Medical information
NOTE: Always ask if they need any other information prior to leaving.
Breathing
[ ABC’s ]
STEP 4 (b): Assess for breathing
1) Are they breathing? Y / N 2) Quality of breathing 3) Assist patient with ventilations
Breathing:
— Expose the chest (as needed) — Assess the breathing (rate and depth) — Jugular Vein Distention (JVD) — Subcutaneous Emphysema (Sub-Q/E) — Open wounds / Chest wall integrity — Flailing chest (broken ribs in 2 places) — Accessory muscle use — Pulse Oximetry (SpO2) — Lung sounds — Assure adequate ventilation — Manage any airway injuries
MNEMONIC:
“Expose the Chest, Assess the Breaths” “JVD, Sub-Q/E” “Open Wounds, Chest Wall too” “Flailing chest, Accessories next (muscles)” “Pulse Ox out, with Lung Sounds” “Adequately Ventilate” “Manage Injured Airways”
Circulation
[ ABC’s ]
STEP 4 (c): Assess for adequate circulation
Circulation:
— Assess and control bleeding — Pulse (estimated) — Perfusion (skin vitals / capillary refill) — Shock treatment / Positioning
MNEMONIC:
“Make the Bleeding Stop” “Then We Treat for Shock” “Get a Patient’s Pulse” “Skin Vitals”
Shock Treatment:
1) Provide High Flow O2 to patient 2) Position patient for shock: 3) Keep patient warm 4) Rapid Transportation