Transcript Patient Assessment

Patient Assessment
Patient Assessment
Scene-Size-up –
Initial Assessment –
Focused history and physical examDetailed Physical ExamOn-Going Assessment-
Patient Assessment
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Patient Assessment
Scene Size-up – Initial Assessment – Focused Hx. & PE –
Detailed Assessment – On-going assessment
Patient 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
Patient Assessment
► 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: Breathing problems
Number of patients: 68 year old female
Considers stabilization of spine
Requests additional help if necessary: ALS
Scene Safety
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
V erbal Response
Assess Breathing
Assess Breathing
Triage
P ainful Response
U nresponsive
Patient Assessment
Initial Assessment
► General Impression:
68 year old white female
Sitting on the couch answering questions in broken
sentences and obeying commands
Obviously A & O x 4
c/c of Shortness of breath
Index of suspicion: PMHx. Of Asthma
Life Threats:
► A B C’s
Patient Assessment
Airway: Patent; answering questions
Breathing: Complains of shortness of breath
Rhythm and quality
Labored
Shallow
O2 @ 15lpm with NRB
► Circulation: Major bleeding???
Pulse
rhythm
and quality
regular
strong
► Transport decision: Stay/play vs Load/go
emergent/non-emergent
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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
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Index of suspicion
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Head to toe physical exam quickly conducted
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O–P–Q–R–S–T
SAMPLE
Rapid Assessment
Base-line Vital Signs
Treat
Rapid Trauma Assessment
Base-line Vital Signs
Assess S A M P L E history
Components Medical
History of present illness
IF UNRESPONSIVE:
Rapid Assessment
Base-line Vital Signs
Assess S A M P L E
Care
Patient Assessment
Focused History and Physical Exam
► Onset?
45 minutes ago
► Provokes?
Nothing makes pain better/worse
► Quality?
Dull
► Radiates?
Non-radiating
► Severity?
4:10
► Time?
>1 hour ago
► Interventions?
Patient Assessment
Allergies: PCN
Medications: NTG, asa, Toprol XL, lasix
► Past pertinent history: “I go to a heart DR.”
► Last oral intake: Breakfast-eggs, toast, coffee
► Event leading to present illness: Cleaning out a closet
► Performs focused physical examination: lung sounds
short of breath; warm/dry/pink;
► Vitals: 142/86
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► Interventions: O2
► Transport decision: More informed decision
► Detailed physical examination necessary? YES
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A M P L E history
► Signs/Symptoms
► Allergies
► Medications
► PMHx.
► Last oral intake
► Events leading to the illness/injury
Vital Signs and Sample
History
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
Patient Assessment
Detailed Physical Exam
Head: Facial cyanosis; cyanosis
Neck: - JVD; - Tracheal deviation
Chest: Symmetrical; LS clear, bilat, all fields
ABD: Soft/non-tender/- distension
LE: - LE or pedal edema
UE- - peripheral edema
VS: 154/90
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► 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
Patient Assessment
On-going Assessment
► Repeats initial assessment: ABC, MS,
Monitor
► Repeats vital signs: 132/68
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► Repeats focused assessment regarding
patient complaint or injuries: O2 helping;
Pain?
Patient Assessment
Scene Size-up – Initial Assessment – Focused Hx. & PE –
Detailed Assessment – On-going assessment