CEM-19_Patient Assessment_EE
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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