Transcript Patient Assessment - emseducation.info

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Patient Assessment
VS
Communication
Documentation
The older folks
The younger folks
Block III written and practical
Scene-Size-up –
Initial Assessment –
Focused history and physical examDetailed Physical ExamOn-Going Assessment-
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Scene Size-up – Initial Assessment – Focused Hx. & PE – Detailed
Assessment – On-going assessment
Scene Size-up
Initial evaluation of the scene
• Continues throughout the scene
Part I SCENE SIZE-UP
Defined:
Begins with dispatch
Initial evaluation of the scene
Goals:
Ensure scene safety
To determine if patient is medical or trauma
Determine total number of patients
• Scene Size-up
Begins with Dispatch
demographics: residence - Pull to curbside in front of
house
Always remember, scene safety is a component of Scene
Size-up
Nature of illness:
Number of patients: Considers stabilization of spine
Requests additional help if necessary: ALS
Personal protection
• Always perform your own size-up
• Observe as you approach and before getting out of the truck
Nature of Illness
• Information can be obtained from
The patient
Family members or bystanders
Scene
• Mechanism of injury
• Number of patients
• Call for additional help if needed
ALS
Collision Scene
• Look and listen
• Check for power outages
• Observe traffic flow
• Check for smoke
As you approach:
• Look for clues to escape hazourdous materials
• Look for patients on or near the road
• Look for smoke not seen at a distance
• Look for broken utility poles and downed lines
• Be on the look-out for bystanders
• Watch for signals of police officers or other agency
personnel
Danger Zone
• No apparent hazard-at least 50ft in all directons
• Fuel spill-at least 100 ft. in all directions
uphill and downwind
avoid gutter, gullies, ditches
do not use flares
• Vehicle fire-at least 100 ft. in all directions
• Downed wires-area in which contact can be made
• Hazardous Materials
Emergency Response Guide Book
Chemtrec
Crimes Scenes and Acts of Violence
Signals of violence:
• Fighting or loud voices
• Visible weapons
• Signs of alcohol or other drug use
• Unusual silence
• Knowledge of prior violence
Nature of call
• Illness
• Injury
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Part II INITIAL ASSESSMENT
Defined:
Discovering and treating life-threatening conditions
Goals:
Determine if the patient is ill or injured
Triage
Components:
General Impression
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Illness or injury
Mechanism of injury/Nature of illness
Age, sex, race
Identify life-threatening problems
Mental Status
A lert
Assess Breathing
Assess Breathing
Triage
V erbal Response
P ainful Response
U nresponsive
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Part III Focused History and Physical Exam
Defined:
To identify additional serious or potentially life-threatening injuries or conditions
Components, Trauma
Reconsider Mechanism of injury
• Index of suspicion
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Rapid Trauma Assessment
• Head to toe physical exam quickly conducted
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Base-line Vital Signs
Assess S A M P L E history
Components Medical
History of present illness
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O–P–Q–R–S–T
SAMPLE
Rapid Assessment
Base-line Vital Signs
Treat
IF UNRESPONSIVE:
Rapid Assessment
Base-line Vital Signs
Assess S A M P L E
Care
Focused History and Physical Exam
• Onset?
• Provokes?
• Quality?
• Radiates?
• Severity?
• Time?
• Interventions?
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A M P L E history
Signs/Symptoms
Allergies
Medications
PMHx.
Last oral intake
Events leading to the illness/injury
General Impression
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Illness or injury
Mechanism of injury/Nature of illness
Age, sex, race
Identify life-threatening problems
Vital Signs
• Pulse
Apical
• Respirations
• Skin color, temp, condition
• Pupils
• Blood Pressure
Auscultation
Palpation
• Mental Status
Communicating with your patient
• Position yourself close to the patient
• Identify and yourself and reassure
• Speak in a normal voice
• Learn your patient’s name
• Learn your patient’s age
• Part IV Detailed Physical Exam
• Defined
• Head to toe physical exam that is performed slower
and in a more thorough manner that the rapid
assessment
• Components
• Head to Toe exam
• Reassess vital signs
• Continue care
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Part V On-Going Assessment
Defined:
To detect any changes in the patient’s condition
To detect any missed injuries or conditions
To adjust care as needed
Goal:
The initial assessment is repeated
Vital signs are repeated and recorded
Focused assessment repeated for additional complaints
Components:
Repeat Initial Assessment
Repeat focused assessment
Check interventions
Note trends in patient condition
On-going Assessment
• Repeats initial assessment
• Repeats vital signs:
• Repeats focused assessment regarding patient complaint or
injuries:
Scene Size-up – Initial Assessment – Focused Hx. & PE – Detailed
Assessment – On-going assessment
Responsive
• Four parts
History of present illness
Focused physical exam
OPQRST
SAMPLE
Baseline VS
• Prior history
• DCAPBTLS
Unresponsive
• Patient history from family, bystanders etc.
• Rapid assessment
Abd: distension, firmness, rigidity
Pelvis: Incontinence of urine, feces
• ID bracelets
• Baseline VS
• Consider need for ALS
• History of present illness and SAMPLE
History of present illness and SAMPLE
• Patient’s name
• What happened
what did family/bystander see
• Did patient complain of anything prior
• Know illness
• Medications