MODULE 3: PATIENT ASSESSMENT

Chapter 7

Patient Assessment

Patient Assessment Sequence

Perform scene size-up. Perform initial assessment. Examine patient from head to toe. Obtain SAMPLE history. Perform on-going assessment.

Step I: Scene Size-up

Review dispatch information. Maintain body substance isolation. Maintain scene safety. Determine mechanism of injury or nature of illness. Determine need for additional resources.

Step II: Perform Initial Assessment

Form general impression of patient. Assess responsiveness. Check airway. Check breathing. Check circulation.

Initial Assessment: Assess Responsiveness

AVPU Scale Alert Verbal Pain Unresponsive

Initial Assessment: Check Patients Airway

Head tiltchin lift technique

Jaw-thrust technique
Inspect mouth

Insert airway if needed

Initial Assessment: Check Patients Breathing

If conscious: Check rate and quality. Check for any difficulty. If unconscious: Look, listen, and feel for breathing. Start rescue breathing, if needed.

Initial Assessment: Check Patients Circulation

Check carotid or radial pulse. Check for severe bleeding. Check skin color and temperature: Pale - decreased circulation Flushed - excess circulation Yellow - liver problems

Step III: Physical Examination

Check patient from head to toe for non-life-threatening conditions. Purpose of exam is to locate and begin initial management of injury or illness.

Signs and Symptoms

Sign: A condition you can feel or see. Symptom: A condition the patient tells you. Important signs: Skin condition Pupil size and Respirations reactivity Pulse Level of Capillary refill consciousness

Physical Exam: Examine the Patient from Head to Toe Look and feel for signs of injury: Deformity Open injuries Tenderness Swelling Search all areas of body in a clear, concise, consistent format.

Examine Patients Head and Eyes

Examine head: Use both hands. Do not move patients head. Remove eyeglasses. Remove wigs if necessary. Examine eyes: Cover one eye for 5 seconds. Watch for pupil contraction.

Examine Patients Neck and Chest

Examine neck: Examine each side; check for pain. Check neck veins. Examine for stoma. Check for a medical identification tag.

Examine Patients Chest

Examine chest: Check for pain on inhalation/exhalation.

Look for signs of difficult breathing.

Note injuries, bleeding, or abnormal, unequal, or painful movement.

Check for collarbone or rib fractures.

Examine Patients Abdomen

Look for signs of external bleeding, penetrating injuries, or protruding parts. Check for stomach rigidity or swelling. Check for soiled clothing. Check genital area for external injuries.

Examine Patients Pelvis

Examine pelvis: Check for obvious bruising, bleeding, or swelling. Check for pain if no pain has been reported. Examine back: Stabilize head and neck. Check one side of the back at a time.

Examine the Extremities

Observe the extremity. Examine for tenderness. Check for movement. Check for sensation. Assess the circulatory status.

Step IV: Patients Medical History

Signs/symptoms Allergies Medications Pertinent, past medical history Last oral intake Events associated with or leading to the injury

Step V: On-going Assessment

Monitor patients vital signs:
Every 5 minutes if unstable.

Every 15 minutes if stable.

Maintain an open airway.

Monitor breathing and pulse.

Monitor skin color and temperature.

Hand-off Report
Provide age and sex of patient. Describe incident and chief complaint. Describe patients level of responsiveness. Report vital signs and examination results. Report pertinent medical condition in SAMPLE format. Report interventions provided.