Lesson 3 Secondary Assessment

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Presentation transcript:

Lesson 3 Secondary Assessment

Objectives State the importance of taking a personal history from victim and know how to do it Demonstrate taking a personal history Demonstrate a hands on physical exam Demonstrate how to take vital signs Demonstrate how to document info gathered

Getting the Whole Picture After primary assessment comes a hands on secondary assessment Goals are to find EVERY problem Consider environment when removing clothing during checks Single person does exam, second person records results SAMPLE history taken at this time

Getting the Whole Picture If patient can talk take SAMPLE first If patient can’t talk, check with other members, use medical forms for info (allergies, medications, etc) Document signs and symptoms Look for signs of injury Listen to victims words and responses Feel body parts

Taking a SAMPLE history S = Signs and symptoms, Ask what hurts? What pain do they have, nausea, lightheadedness? A = Allergies, do they have any? Did they contact anything they are allergic to? M = medications, on any, last time they took it? P = Pertinent Medical History, any like this happened before? Any existing conditions?

Taking a SAMPLE history L = Last intake and output? Last time ate or drank? Last time urinated or defecated? E = Events, What led up to this injury?

Skill Practice Break into Pairs, one victim, one care giver Scenario: “while clearing some downed limbs from the trail a person is apparently stung by a bee” Practice taking and recording SAMPLE

Documentation Responder’s ability to remember details is reduced due to stress and confusion Specific info helps rescue personnel know what they are facing Retention for legal and medical reasons Using a form helps you remember everything you need to look for/ask about

Documentation SOAP: S = subjective info (complaints) O = Objective info (physical exam, vital signs, SAMPLE A = Assess patient and situation, what do you think is wrong? P = Plan, what care do you give and how? Stay or evacuate?

Performing Hands On Physical Exam Using MOI or SAMPLE record circumstances and estimate injuries Do not make assumptions about MOI Systematically check from head to toe Ask where it hurts Check all body parts, don’t cause unneeded pain

Performing Hand on Physical Exam Ex of signs and Symptoms: Pale sweaty skin Nervousness Unnatural position of limbs Patient guarding an area or unable to move body part Looks for “DOTS”

DOTS DOTS stands for D = Deformities, depressions, indentations O = Open injuries, penetrating wounds, cuts, scrapes T = Tenderness S = Swelling

Performing Hands On Physical Exam Check circulation, sensation, motion Ask about pain first then touch Note medical ID bracelets, necklaces Check pulse away from injury and away from heart (ex on hand or foot) Check for circulation in hands and feet pinch and check for capillary refill If head/neck/back injury possible, ask patient to not move

Physical Exam Practice Session Groups of 3 One victim 2 rescuers Perform SAMPLE Head to Toe Check

Head to Toe Assessment

Taking Vital Signs Vital signs are a measure of the processes needed for life Changes in time indicate patient condition changing Take and record vital signs regularly Basic Set Level of Responsiveness Breathing Rate Pulse Skin Color, temp, moisture

Level of Responsiveness AVPU: Alertness A + Ox4: knows who, where, when, what A + Ox3: knows who, where, when A + Ox2: knows who, where A + Ox1: knows who V = Responds to verbal stimuli P = Responds to pain U = Unresponsive

Respiratory Rate/Heart Rate Respiratory: Number breaths/min. Note rhythm and quality. Normal 12-20 for adults Place hand on chest to measure Note any unusual sounds HearRate (Pulse): Measure at wrist, brachial artery, or neck Use 2 fingers (no thumb) Count for 30 sec Note rhythm, quality (strength)

Skin Color, Temp, Moisture Note any differences from normal: Color should be pink (non-pigmented areas) Temperature should be warm Dry

Practice Session Groups of 3 One victim One takes vital Signs One records

Rechecking Resources After patient assessment: Observe changing conditions in environment Getting unsafe for patient or you? Getting difficult to get help? What resources do you have, how can you use them? Do you need to move the patient?