OBJECTIVE

AFTER THIS SESSION YOU WILL BE ABLE TO:

1. Patent Assessment Plan
2. Scene size-up
3. Initial assessment
4. Physical examination
5. Patient History
6. Ongoing assessment
7. Hands off report.
 1 . Scene Size-up
(i) (ii) (iii)
Arrival on the Identify Sources of
Scene Yourself Information:
• Scene safety
• Name of responder • The scene itself
• Ensure your personal
safety and organization (observe, plan, react
• Proper cleaning • Identify yourself as • Patient (if responsive)
• Disinfection
• P.P.E.
First Aider / MFR • Relatives or bystanders
• casualty safety • Ask the patient if • Any remarkable
• Initial assessment you may help
• Establish General
deformity or obvious
Impression him/her (obtain injury
• Identify and threat life
threatening injury • Mechanism of injury
• Stabilize and continue
monitoring
 2 . Initial Assessment
A process used to identify and treat conditions that
pose an immediate threat
2 . Initial Assessment
The steps of the initial assessment are as
follows, in order to importance:-
1. Determine if the situation is trauma or
medical
2. Examine front and back
3. Apply a cervical collar if needed
4. For trauma cases with suspected cervical
spine injury, before continuing,
immediately immobilize the cervical
region to prevent paralysis.
2 . Initial Assessment
A.V.P.U.
 A . Alert-A patient who is alert responsive and oriented (e.g Aware of
surroundings, approximate time and dates, his/her name, place and
date etc.

 V. verbal- A patient who responds only when spoken to, we say he/she
responsive to verbal stimulus

 P. painful-The patient responds only to painful stimulus

 U. unresponsive-The patient does not respond to any stimulus, does

not open eyes, respond verbally or even flinch when pain is applied.
 2 . Initial Assessment
Patient status update
1. Inform EMS units
2. If more recourses will be needed, request
them
3. If patient has life threatening condition, lets
responding units
4. If patient is stable with minor injuries, advise
responding units
 3 . Physical Examination
1. The physical exam is designed to help you identify
and treat life threatening conditions.
2. The physical exam is a through survey of the
patient entire body, it is meant to reveal any signs
of illness or injury OT

3. The physical exam proceeds in a logical order,

usually from head to toe, but may vary from
patient to patient.
 3 . Physical Examination
Patient assessment is a skill and must be practiced. The assessment process
involves the use of your senses.
There are three methods are used during your patient assessment:
Inspection (Looking)-A method of examination that involved looking for signs of injury
or illness. Make an overall observation of your patient, then an observation of the
body.
OT
Auscultation (Listening)- A method of examination that involved Listening for signs of
injury or illness. The most important listening you will do is for air entering and
leaving the lungs to determine respiratory status.
Palpation (Feeling)- A method of examination that involved feeling for signs of injury
or illness. Palpating or feeling with your fingertips is usually done
 3 . Physical Examination
CONDUCTING EXAM
When conducting an exam, look for the following signs of
injury, you can mnemonic “DOTS” to remember them
D.O.T.S.
OT

D. Deformities

O. Open Injuries

T. Tenderness

S. Swelling
 3 . Physical Examination
Head to Toe
Examination of the head-

Scalp and skull: Check for deformities, open injury, tenderness and swelling.
OT in or around openings
Ears and nose: Look for blood or CSF

Pupils: Abnormal findings include no reactivity to light, pupils that remain

constricted, or unequal pupils.
Mouth: Check for deformities, open injury, tenderness and swelling. Check for
possible airway obstructions such as foreign objects, loose teeth etc.

Face: Bone and muscles, Check for deformities, open injury, tenderness and swelling.
 3 . Physical Examination
Head to Toe

Examination of the Neck-

1. Always go front to back.
OT
2. Check for deformities, open injuries, tenderness and swelling.

3. Check trachea for mid-line position

4. Palpate Vertebrae.

5. Open Injuries(bandage immediately)

 3 . Physical Examination
Head to Toe

Examination of the Chest-

Any injury may involve the vital organs or major blood vessels-
OT
1. Check for deformities, open injuries, tenderness and swelling.

2. Feel ribs for deformities all the way to spine

3. Palpate the sternum.

4. Open Injuries(bandage immediately)

 3 . Physical Examination
Head to Toe

Examination of the Abdomen-

Abdominal organs may be injured without external signs-
OT
1. Check for rigidity (hardness) or distention.

2. Cuts, Penetrating wounds, Potential bleeding and infection.

3. Swelling or discoloration.
 3 . Physical Examination
Head to Toe

Examination of the Back-

1. Check chest wall for deformities that may indicate broken ribs.
OT
2. Check for deformities, open injuries, tenderness and swelling along
entire length of spine that may indicate spinal cord injury..
 3 . Physical Examination
Head to Toe

Examination of the Pelvis-

1. Composed of the left and right ileum, ischium and pubic bone.
OT
2. Pelvic or hip fracture could result in blood loss.

3. Internal organs , blood vessels and nerves paas through pelvic area.

4. Spinal injury possible.

 3 . Physical Examination
Head to Toe

Examination of the Lower Extremities-

Common sites of injury-do

OT not rush your examination.

1. Check for deformities, open injuries, tenderness and swelling.

2. Check Femoral pulse.

3. Check sensation.
 3 . Physical Examination
Head to Toe

Examination of the upper Extremities-

Common sites of injury-do

OT not rush your examination.

1. Check for deformities, open injuries, tenderness and swelling.

2. Check Radial, brachial pulse.

3. Check sensation.
 3 . Physical Examination
Head to Toe

Measuring vital signs:

A patient vital sign includes:
OT
1. Respiration

2. Pulse

3. Skin

4. Pupils

5. Blood Pressure
 3 . Physical Examination
Head to Toe
Age definition:
Infant: Under 1 year
Child: One to 8 years
Adult: 9 and older OT
Respiration:
Infant- 25-50 RPM
Child- 15-30 RPM
Adult- 12-20 RPM
Pulse:
Infant- 120-150 PPM
Child- 80-150 PPM
Adult- 60-80 PPM
 3 . Physical Examination
Head to Toe

Capillary refill:
Press on the nailbed and observe how long it takes for the normal time to
return after OT

Pupils:
1. Both pupils should be same size
2. To assess shine a pen light in to the eyes
3. No reaction to light, pupils remain constricted (possible drug overdose) or unequal pupils
(head injury or stroke)
 4 . Patient History
S. A.M. P. L. E.
Remember difference between a medical and a trauma patient, In
trauma, perform physical exam first. For a medical patient
take a history first
1. sign and symptoms-Sign are condition you can observe (See,
Feel or hear), Symptom are OT conditions that only patient can
feel or describe such as stomach pain etc.
2. Allergies- Medications, food may determine
3. Medications-identify all medications the patient currently taking
recently
4. Patients past history-obtain historical information
5. Last oral intake- ask your patient when last time he or shee ate or
drink anything
6. Events- Activities prior to the incidents.
5 . On Going Assessment

• Reassess Level of Responsiveness

• Reassess and Correct Any Airway Problem
• Reassess Breathing for Rate & Quality
• Reassess Pulse for Rate & Quality
• Reassess Skin Temp. Color & Conditions
 6 . Hand-off Report
When you arrive with your patient at a medical facility,
be prepared to give appropriate information about
your patient. This is the hand-off report.

Hand-off report includes

 Name, Age & sex
 Chief complaint
 Level of Responsiveness-AVPU
 Airway & Breathing Status-RPM
 Circulation Status-PPM
 Physical Exam findings
 SAMPLE History
 Treatment given