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Patient Assessment

Patient Assessment. Chris Morse 10/3/04. The Patient Assessment Flow-Chart. Ongoing Assessment!!!. Assessment Goals. Detect and care for life threatening emergencies Determine other problems Evaluate and facilitate transport decisions

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Patient Assessment

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  1. Patient Assessment Chris Morse 10/3/04

  2. The Patient Assessment Flow-Chart Ongoing Assessment!!!

  3. Assessment Goals • Detect and care for life threatening emergencies • Determine other problems • Evaluate and facilitate transport decisions • Perform a complete assessment and note all significant findings • Cause no further harm!

  4. Scene Size-Up • BSI!! • Scene Safety • Determine # of patients • Request additional assistance • Determine MOI/NOI • C-Spine Immobilization??

  5. Significant Mechanism of Injury Falls from height MVAs High speed collisions Gunshot/stab wounds Pedestrian/MVA Motorcycle accidents Significant Nature of Illness Unresponsive pt. Stroke Resp./Cardiac Arrest Chest Pain Abnormal PR/RR Near-drowning Severe Allergic Reaction A quick word on MOI/NOI(Verticality and Velocity!!)

  6. Initial Assessment • General Impression (think index of suspicion!) • Assess responsiveness • AVPU! • Assess ABC(DE) • Stabilize ABCs • Identify Priority Pts. • Initiate Transport Decision

  7. Unresponsive Patients

  8. Principles of the Patient Exam • Pt. exams are an interactive process conducted by one rescuer to find all possible injuries • Head-to-toe: look, listen, feel, and ask. • For a responsive pt. explain what you are doing and ask about any elicited pain (OPQRST) • Avoid unnecessary movement. • Inspection, comparison, palpation, auscultation, circulation, sensation, motion.

  9. DCAP-BTLS • Deformity • Contusions • Abrasions • Punctures, Penetrations • Burns, Bleeds • Tenderness • Lacerations • Swelling

  10. Significant MOI Rapid Trauma Assessment Baseline Vitals/SAMPLE Rapid Transport No significant MOI Focused Physical Exam based on CC Baseline Vitals/SAMPLE Reevaluate Transport Decisions Responsive Trauma Patient Always reconsider the MOI

  11. Responsive Medical Patients • History of Illness (OPQRST) • SAMPLE History • Focused Physical Exam based on CC • Baseline Vitals • Reevaluate Transport

  12. Detailed Physical Exam (in-da’ hut) • To further investigate problems found in focused physical exam and to possibly determine cause. • The detailed physical exam should NEVER delay transportation! • Head-to-toe steps • Systematic Exam using DCAB-BTLS (assess CSMs) • Vitals! • Inspection, comparison, palpation, auscultation, circulation, sensation, motion.

  13. Ongoing assessment • Repeat the Initial Assessment • Reassess Vitals • Repeat Focused Assessment (in responsive pts.) • Check Interventions

  14. The Patient Assessment Flow-Chart Ongoing Assessment!!!

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