Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History...

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Module 3 Patient Assessment

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Transcript of Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History...

Page 1: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment.

Module 3

Patient Assessment

Page 2: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment.

Patient Assessment Scene Size Up

Initial Assessment

Physical Examination

Patient History

On-Going Assessment

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Scene Size Up

Body Substance Isolation

Is the Scene Safe?

Mechanism of Injury/Nature of Illness?

How many patients involved?

Additional Resources Needed?

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Body Substance Isolation

“Body substance isolation (BSI) precautions must be taken on

every call.”

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Rescuer Wears Protective Eyewear

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Rescuer Dons Gloves

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Rescuer Wears Simple Surgical Mask

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Rescuer Wears HEPA Mask

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Is the Scene Safe?

“An assessment of the scene and surroundings will provide

valuable information to the First Responder and will ensure the

well-being of the First Responder.”

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Unstable Situation

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HazMat Situation

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Violent Situation

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Scene Safety

Personal Protection.Protection of the patient.Protection of bystanders.

If the scene is unsafe, make it safe.If the scene is unsafe, make it safe.Otherwise, DO NOT ENTER.Otherwise, DO NOT ENTER.

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Mechanism of Injury

An evaluation of the forces that caused an injury.

May be beneficial in determining the presence of internal injuries.

Determined from the patient, family or bystanders and inspection of the scene.

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Trauma Patient

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Impact # 1

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Impact # 2

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Impact # 3

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Nature of Illness

Medical. Determined from patient, family or bystanders.

Why was EMS called?

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How many patients?

Obtain additional help prior to contact with patients.

FirePolice

Rescue

ALS Utilities

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Initial Assessment

General Impression

Assess Responsiveness

Airway

Breathing

Circulation

Update EMS

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Initial Assessment

“The initial assessment is completed to assist the First

Responder in identifying Immediate Threats to Life.”

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General Impression

Based on the First Responder’s immediate assessment of the environment and the patient’s

chief complaint.

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General Impression

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Assess Responsiveness Stabilize spine if

trauma is suspected!

AlertVerbalPainfulUnresponsive

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Establish responsiveness with patient prone.

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Establish responsiveness with patient supine.

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Assess Airway Status

Open the airway

Inspect the airway

Clear airway, as needed

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Open airway; perform head-tilt/chin-lift maneuver.

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Open airway; perform jaw thrust.

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Suction with rigid tip.

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Insert oropharyngeal airway.

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Assess the patient’s breathing

Look at the effort of breathing.

Look, listen, and feel for presence of ventilations.

Ventilate as needed.

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Assess breathing; look, listen, feel.

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Mouth-to-mask Ventilations

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Assess the Patient’s Circulation

Assess Pulse

Assess for Major Bleeding

Assess Skin

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Pulse

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Check for a carotid pulse.

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Assess circulation by checking brachial pulse (infant).

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Locate bleeding.

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Rescuer controls hemorrhage.

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Skin Temperature

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Update responding EMS

Age and sex

Chief Complaint

Responsiveness

Airway / Breathing

Circulation

ETA?

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Physical Examination

“The First Responder Physical Exam is designed to locate and begin the initial management of

the signs and symptoms of illness or injury.”

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Physical Examination The First Responder should complete a physical exam on all patients following the initial assessment.Patient and injury specific.

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Physical Examination Inspect and palpate for DOTS.

Deformities

Open injuries

Tenderness

Swelling

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Extremities

Pelvis

Abdomen

Chest

Neck

Physical Examination

Head

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Assess the head.

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Assess the neck.

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Assess the chest.

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Assess the abdomen.

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Rescuer palpates pelvis.

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Rescuer palpates pubic symphysis.

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Rescuer palpates lower extremity.

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Rescuer palpates upper extremity.

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S.A.M.P.L.E. History

“For medical patients the S.A.M.P.L.E. history may be

completed prior to the physical exam.

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Rescuer takes history from patient.

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Signs / Symptoms

Allergies

Medications

Pertinent Past History

Last Oral Intake

Events

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Ongoing Assessment

“While awaiting the additional EMS resources, the First

Responder should continue to assess the patient.”

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Repeat Initial Assessment

Repeat Exam as needed

Check Interventions

Calm and Reassure

Hand Off Report

Ongoing Assessment

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Ongoing Assessment

Repeat Every 15 minutesFor A Stable Patient

Repeat Every 15 minutesFor A Stable Patient

Repeat Every 5 minutesFor an unstable Patient

Repeat Every 5 minutesFor an unstable Patient

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Handoff Report

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Hand Off Report •Age and Sex•Chief Complaint•Responsiveness•Airway and breathing status•Circulation status•Physical findings•SAMPLE history•Interventions provided


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