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patient assessment notes

patient assessment notes

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Published by joepagiii

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Published by: joepagiii on Jun 01, 2009
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Initial Assessment Notes:Assess Mental Status:
– the patient’s eyes open spontaneously as you approach, and the patient appears aware of youand responsive to the environment. The patient appears to follow commands, and the eyes visuallytrack people and objects.
Responsive to verbal stimulus
– the patient’s eyes do not open spontaneously. However, the patient’seyes do open to verbal stimuli, and the patient is able to respond in some meaningful way whenspoken to.
Responsive to pain
– the patient does not respond to your questions but moves or cries out inresponse to painful stimulus. There are appropriate and inappropriate methods of applying painfulstimulus based a great deal on personal preference. Be aware that some methods may not give anaccurate result if a spinal cord injury is present.
– the patient does not respond spontaneously or to verbal or painful stimulus. These patients usually have no cough or gag reflex and lack the ability to protect their airway. If you are indoubt about whether a patient is truly unresponsive, assume the worst and treat appropriately.
The most common test evaluates a patient’s ability to remember four things:
– the patient is able to identify his or her name
– the patient is able to identify his or her current location
– the patient is able to tell you the current year, month, and approximate date
– the patient is able to describe what happened (MOI or NOI)Mental status may be difficult to evaluate in children. First determine whether the child is alert. Even infantsshould be alert to your presence and should follow you with their eyes. Ask the parent whether the child is behaving normally, particularly in regards to alertness. Most children older than 2 years should know their name and the names of their parents and siblings. Evaluate mental status in school – age children by askingabout holidays, recent school activities, or teacher’s name.
Assess The Airway:Responsive patients
Patients of any age who are talking and crying have an open airway
Watching and listening to how patients speak, particularly those with respiratory problems, may provide important clues about the adequacy of their airway and the status of their breathing.
Stridor suggest a partially occluded airway caused by swelling
High pitched crowing sounds may indicate a partial airway obstruction form a foreign body
A conscious patient who cannot speak or cry most likely has a complete airway obstruction
If you identify an airway problem, stop the assessment process and obtain a patent airway, this may beas simple as positioning the patient so the air moves in and out easier or a complex as abdominalthrust to remove a foreign body from the airway.
If you patient has signs of respiratory difficulty or is not breathing you should immediately takecorrective actions using appropriate airway management techniques
Unresponsive patient:
With an unresponsive patient or a patient with a decreased level of consciousness, you shouldimmediately assess the patency of the airway.
If it is clear then you can continue your assessment, if the airway is not clear, your next priority is toopen it using the head tilt chin lift or jaw thrust maneuver.
Airway obstruction in an unconscious patient is most commonly due to relaxation of the tonguemuscles, allowing the tongue to fall to the back of the throat
Dentures, blood clots, vomitus, mucus, food, or other foreign objects may also create an obstruction.
Signs of airway obstruction in an unconscious patient include the following:
Obvious trauma, blood, or other obstruction
 Noisy breathing, such as snoring, bubbling, gurgling, crowing, or other abnormal sounds (normal breathing is quiet)
Extremely shallow or absent breathing (airway obstructions may impair breathing)
The body will not have the necessary oxygen needed to survive if the airway is not managed quicklyand efficiently. Remember that airway positioning depends on the age and size of you patient.
Spinal considerations:
Managing a patient’s airway can be complicated by the presence of a spinal injury.
Trauma patients, those who are conscious or unconscious, should be stabilized to protect their spine.
Conscious or unconscious medical patients, however may have fallen and have a potential for a spinalinjury.
It is important for you to consider spinal precautions during scene size up and evaluate the MOI and NOI further when determining the chief complaint
Thousands of deaths per year occur from airway obstruction following acute alcohol intoxication or drug overdose. Generally, these patients vomit while lying on their backs and cannot protect their airway because of a severely decreased level of consciousness. Never leave anyone who has passedout unattended. If the person cannot be continually monitored, place the patient prone or on their side,not supine
Assess breathing:
Look, listen, and feel for the presence of breathing and then assess the adequacy of breathing
A normal respiratory rate varies widely in adults, ranging from 12 to 20 breaths/min
Children breathe at even faster rates
Remember the goal of your initial assessment is to identify and treat airway, breathing, and circulation problems as quickly as possible.
 Normal respirations are not usually shallow or excessively deep
Shallow respirations can be identified by little movement of the chest wall
Deep respirations cause a great deal of chest rise and fall

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