Transcript CEM-19_Patient Assessment_EE

“When in
danger, when
in doubt,
run in circles,
scream and
shout.”
Survey the Scene
--mechanism of
injury
--nature of illness
Survey the Scene
--identify hazards
--take universal
precautions
Survey the Scene
--locate all patients
--arrange for
needed resources
Level of
Consciousness
AVPU
AVPU
Alert
Verbal
Pain
Unresponsive
Primary Survey:
to identify and
correct all life
threatening
problems
AIRWAY
Patent??
Use head-tilt/chin-lift or
modified jaw thrust
protect airway
continual reassessment
BREATHING





Look, listen, and feel
slow or rapid?
deep or shallow?
Symmetrical chest rise?
Quiet or noisy?
CIRCULATION
Feel carotid and radial
pulses
Fast or slow?
Thready or bounding?
Regular or irregular?
CIRCULATION
notice skin color
CRT: capillary refill time
(should be <2 seconds)
major bleeding
DISABILITY
AVPU
CAOx3??
--conscious, alert, and
oriented to name,
place, and time?
EXPOSE
 Remove clothing as
needed to look for life
threatening problems
 also note scars, medic
alert bracelets,
pacemakers, etc
VITAL SIGNS
 Secondary Survey
 Heart Rate, Blood Pressure, Respiratory
Rate
 Temperature, Skin, Pupils
VITAL SIGNS
Heart Rate
Adult 60-100
Child 80-120
Infant 100-140
VITAL SIGNS
Blood Pressure
Adult:
100-140 systolic/
60-90 diastolic
VITAL SIGNS
+ radial = SBP > 80.
+ femoral = SBP >
70.
+ carotid = SBP >
60.
VITAL SIGNS
Respiratory Rate
Adult: 12-20
Child: 16-30
Infant: 30-50
VITAL SIGNS
Temperature:
Oral: 97.6 - 99.6
Rectal: 98.6 - 100.6
Auxiliary: 96.6 - 98.6
VITAL SIGNS
Skin:
cool/warm/hot...
dry/moist/diaphoreti
c
pale/ashen/flushed
VITAL SIGNS
Pupils:
equal? Reactive?
“PEARL”
dilated/constricted?
Head-to-Toe
Survey
Methods of
Assessment
Inspection
Palpation
Auscultation
Percussion
Head
Palpate skull for
bleeding, fractures.
Inspect eyes, mouth,
nose, ears. Look for
CSF, Raccoon Eyes, or
Battle Signs.
Raccoon’s Eyes:
periorbital bruising
Battle Signs: mastoid
bruising
These two signs are
indicative of a basilar
skull fracture.
Neck
Check position of
trachea.
Assess jugular veins
(JVD).
May palpate C-Spine.
Chest
Inspect for bruising,
trauma, scars,
pacemaker.
Palpate for symmetrical
chest rise.
Auscultate breath
Abdomen (ABD)
Inspect for bruising,
trauma, scars,
distention.
Palpate for rigidity,
masses.
Auscultate bowel
Pelvis
Inspect for bruising,
trauma, scars,
deformity.
Palpate for stability.
Lower Extremities
Inspect for bruising,
trauma, scars,
deformity.
Check each for
circulation, sensation,
movement (CSM).
Upper Extremities
Inspect for bruising,
trauma, scars,
deformity.
Check each arm for
circulation, sensation,
movement (CSM).
Posterior
Inspect and palpate
posterior thorax and
lumbar region for
bruising, trauma, scars,
deformity.
Patient
Interview
SAMPLE
OPQRST
Scene/Situation
What’s going on?
What happened?
Allergies
Are you allergic to
any medications??
Medications
Are you taking any
medications daily??
Have you taken
anything today?
Past Medical
History
Do you have any
medical problems?
Last….
 Meal eaten
 menstrual
period
 bowel
movement
 Time you
used drugs
 time you took
your insulin
 time you took
your meds…..
Events leading up
to problem…
What were you
doing when this
started?
OPQRST
Questions to ask
regarding pain or
a specific symptom
Onset
What were you doing
when this started?
Provoke
What makes it
better or worse?
Quality
Is the pain burning,
stinging, stabbing,
cramping, aching,
sharp, dull...?
Radiation
Does the pain go to
your jaw, shoulder,
arm, neck, back….??
Severity
On a scale of 1 to 10,
ten being the worst
pain you’ve ever had,
what is the pain now?
Time
How long ago did
this start?
Documentation:
If you didn’t write
it, you didn’t do it.
CHART
 Chief complaint
 history
 assessment
 RX (treatment)
 Transport
SOAP
Subjective
Objective
Assessment
Plan