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Paramedic Patient Care Assessment

This document outlines the steps for a paramedic's primary and secondary patient assessment. The primary assessment covers initial contact with the patient including protective equipment, level of consciousness, airway status, breathing, circulation, disability, and exposure/environmental control. The secondary assessment involves a more detailed head-to-toe examination including vital signs, medical history, and trauma management. The assessment is used to guide the patient's treatment and appropriate transport decision.

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Jim Courtney
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3K views2 pages

Paramedic Patient Care Assessment

This document outlines the steps for a paramedic's primary and secondary patient assessment. The primary assessment covers initial contact with the patient including protective equipment, level of consciousness, airway status, breathing, circulation, disability, and exposure/environmental control. The secondary assessment involves a more detailed head-to-toe examination including vital signs, medical history, and trauma management. The assessment is used to guide the patient's treatment and appropriate transport decision.

Uploaded by

Jim Courtney
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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PARAMEDIC – PATIENT CARE THEORY I

Name: Start Time: Finish Time:

PRIMARY ASSESSMENT SECONDARY ASSESSMENT

Personal Protective Equipment  Skull lobes (frontal, occipital, left & right parietal) 
EMCA  Face (orbitals, zygoma, nasal, maxilla, mandible, mouth) 
Intro/LOC (AVPU) Ears (behind and inside ears) 
Airway – open & inspect  C-spine (palpate & visualize C-spine) 
Suction as needed  Thorax (Rclv, Lclv, Rscp, Lscp, Ster, Symm, Exp 
Size & insert airway as needed  6 point auscultation 
C-spine – rule in / out in / out Clear breath sounds yes / no
(manage with airway) Equal air entry yes / no
Breathing yes / no Abdomen (RUQ, LUQ, RLQ, LLQ, Flk, Palp and Exp) 
Respiratory distress yes / no Pelvis (Ant, Let, Post) 
Select O2 delivery device  Left Leg (U, K, L, F, Circ, Sen, Mvmt, Str, Symm, ROM) 
BVM – O2 flow rate L/min Right Leg (U, K, L, F, Circ, Sen, Mvmt, Str, Symm, ROM) 
• vol. delivery (5-7ml/Kg) ml Left Arm (U, E, L, H, Circ, Sen, Mvmt, Str, Symm, ROM) 
• absence of gastric  Right Arm (U, E, L, H, Circ, Sen, Mvmt, Str, Symm, ROM) 
distension  Spine (C, T, L, S/C, Palpate and Expose) 
• chest rise/fall 
L/min VITALS / ASSESSMENT FINDINGS
• compliance
– O2 flow rate
JVD/trach dev/subcu emph  Pulse Rate1: Rhythm1: Volume1:
4 point auscultation  Rate2: Rhythm2: Volume2:
Circulation – carotid and radial 
Gross bleed/med alert check  Respirations Rate1: Rhythm1: Volume1:
Cardiac monitor yes / no Rate2: Rhythm2: Volume2:

HISTORY BP 1: / 2: /

Name: Skin Colr1: Temp1: Moisture1:


Age Colr2: Temp2: Moisture2:
Sex M/F
CC: Pupils Size1: Equal1: Reactivity1:
OPQRST  Size2: Equal2: Reactivity2:
AEIOU TIPS 
SAMPLE GCS 1: 2:

Temp 1: 2:
TREATMENT SP O2 1: 2:
Blood Glucose 1: 2:
Oxygen on @
Appropriate transport decision  Trauma Management
Transport @ Immobilization 
Symptom Relief Sager 
Drug: KED 
Good protocol use  Splints 
Contraindications  Dressings 
Defibrillation
Protocol: Verbalization throughout 
Good protocol use 
Contraindications  COMMENTS

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