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Patient Assessment

Patient Assessment. Medical. Scene Size-Up. Scene Size-up/Assessment PPE for BSI Scene Safety Number of Patients Need for more resources – consider the need for Advance Life Support Mechanism of Injury a. Medical b. Trauma.

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Patient Assessment

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  1. Patient Assessment Medical

  2. Scene Size-Up • Scene Size-up/Assessment • PPE for BSI • Scene Safety • Number of Patients • Need for more resources – consider the need for Advance Life Support • Mechanism of Injury a. Medical b. Trauma

  3. Initial Assessmentidentify and treat any life threatening conditions • Consider C-spine stabilization • Partner stabilizes the head • Apply c-collar if enough man power • General impression of the patient • How are they laying? • Skin color? • Respirations? • Blood?

  4. Initial Assessment • Assess patient’s mental status – AVPU • Alert – 3 questions • Verbal • Painful • Unresponsive • Determine chief complaint and life threatening injuries What’s your name? Where are you? What day is it?

  5. ABC’s TREAT AS YOU GO!!!!

  6. Assess Patients AIRWAY Status • Responsive Patient • If they are talking you know they have an airway • Unresponsive Patient • If there is suspicion of a spinal injury use the jaw thrust, otherwise use the head-tilt, chin-lift method

  7. Assess Patient’s BREATHING • Respirations – look, listen and feel • Quality • Feel both sides of the chest for bilateral expansion **initiates appropriate oxygen therapy and assures adequate ventilation**

  8. Assess Patient’s CIRCULATION • Pulse • Quality • Control Major Bleeding – arterial bleeding = EMERGENCY • Hands pat down of body – look at gloved hands • Skin color, relative temperature, and condition • Perfusion • Capillary refill – infants and children ONLY

  9. ABC’s should take 60 – 90 seconds!!!!

  10. Identify priority patients and make transport decision • CUPS status • If patient is a load and go, do not wait on scene for Advanced Life Support. Have them meet you along the way (intercept).

  11. Focus History & Physical Exam • Assess History of Present Illness

  12. 1. Cardiac & Respiratory Patients Onset – what were you doing when this started? Provoked – do you know what triggered the pain? Quality – describe how it feels. Radiates – does the pain go any where else? Severity – scale of 1-10; how much does it hurt? Time – how long ago did the pain start? Interventions – did you do anything that made the pain go away?

  13. 2. Altered Mental Status • Description of episode • Onset • Duration • Associated symptoms • Evidence of trauma • Interventions (by patient) • Seizures • Fever

  14. 3. Allergic Reactions • History of allergies • What were you exposed to? • How were you exposed? • Effects • Progression of signs/symptoms • Interventions (by the patient)

  15. 4. Poisoning/Overdose • Substance • When did you ingest or become exposed? • How much did you ingest? • Over what time period? • Interventions (by the patient) • Estimated weight

  16. 5. Environmental Emergency • Source • Environment • Duration • Loss of consciousness • Effects: general or local

  17. 6. Obstetrics • Are you pregnant? • How far along are you in the pregnancy? • Pain or contractions • Bleeding or discharge • Has your water broken? • Do you feel the need to push? • Last menstrual period

  18. 7. Behavioral • How do you feel? • Determine suicidal tendencies • Is the patient a threat to themselves or others? • Is there an underlying medical problem? • Interventions (by the patient)

  19. Obtain a SAMPLE History • Signs and symptoms • Allergies (to medications) • Medications (presently taking) • Past pertinent medical history • Last oral intake • Events leading up to the present problem

  20. Obtain a Baseline Set of Vitals • Respirations • Quality and quantity • Pulse • Quality and quantity • Blood pressure

  21. Performs a focused physical exam consistent with patients chief complaint. • Treatment and/or Interventions • Consistent with NYS protocols • Transport • Re-evaluate transport decision –hot vs. cold • Verbalize the consideration of completing a detailed physical examination.

  22. Ongoing Assessment(verbalized) • Repeat initial assessment • Stable patient every 15 minutes • Unstable patient every 5 minutes • Repeats vital signs • Repeats focused assessment • Reassesses mental status • Maintain open airway • Reassesses breathing • Reassesses pulse • Monitor skin color and temperature • Re-establish patient priority

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