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Module 3 Patient Assessment
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Patient Assessment Scene Size Up Initial Assessment
Physical Examination Patient History On-Going Assessment
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Scene Size Up Body Substance Isolation Is the Scene Safe?
Mechanism of Injury /Nature of Illness? How many patients involved? Additional Resources Needed?
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Body Substance Isolation
“Body substance isolation (BSI) precautions must be taken on every call.”
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Rescuer Wears Protective Eyewear
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Rescuer Dons Gloves
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Rescuer Wears Simple Surgical Mask
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Rescuer Wears HEPA Mask
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Is the Scene Safe? “An assessment of the scene and surroundings will provide valuable information to the First Responder and will ensure the well-being of the First Responder.”
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Unstable Situation
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HazMat Situation
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Violent Situation
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If the scene is unsafe, make it safe.
Scene Safety Personal Protection. Protection of the patient. Protection of bystanders. If the scene is unsafe, make it safe. Otherwise, DO NOT ENTER.
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Mechanism of Injury An evaluation of the forces that caused an injury.
May be beneficial in determining the presence of internal injuries. Determined from the patient, family or bystanders and inspection of the scene.
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Trauma Patient
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Impact # 1
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Impact # 2
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Impact # 3
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Nature of Illness Medical. Determined from patient, family or bystanders. Why was EMS called?
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Obtain additional help prior to contact with patients.
How many patients? Obtain additional help prior to contact with patients. Fire Rescue Police ALS Utilities
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Assess Responsiveness
Initial Assessment General Impression Assess Responsiveness Airway Breathing Circulation Update EMS
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Initial Assessment “The initial assessment is completed to assist the First Responder in identifying Immediate Threats to Life.”
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General Impression Based on the First Responder’s immediate assessment of the environment and the patient’s chief complaint.
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General Impression
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Assess Responsiveness
Stabilize spine if trauma is suspected! Alert Verbal Painful Unresponsive
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Establish responsiveness with patient prone.
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Establish responsiveness with patient supine.
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Assess Airway Status Open the airway Inspect the airway
Clear airway, as needed
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Open airway; perform head-tilt/chin-lift maneuver.
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Open airway; perform jaw thrust.
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Suction with rigid tip.
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Insert oropharyngeal airway.
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Assess the patient’s breathing
Look at the effort of breathing. Look, listen, and feel for presence of ventilations. Ventilate as needed.
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Assess breathing; look, listen, feel.
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Mouth-to-mask Ventilations
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Assess the Patient’s Circulation Assess for Major Bleeding
Assess Pulse Assess for Major Bleeding Assess Skin
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Pulse
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Check for a carotid pulse.
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Assess circulation by checking brachial pulse (infant).
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Locate bleeding.
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Rescuer controls hemorrhage.
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Skin Temperature
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Update responding EMS Age and sex Chief Complaint Responsiveness
Airway / Breathing Circulation ETA?
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Physical Examination “The First Responder Physical Exam is designed to locate and begin the initial management of the signs and symptoms of illness or injury.”
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Physical Examination The First Responder should complete a physical exam on all patients following the initial assessment. Patient and injury specific.
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Physical Examination Deformities Open injuries Tenderness Swelling
Inspect and palpate for DOTS. Deformities Open injuries Tenderness Swelling
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Physical Examination Head Neck Chest Abdomen Pelvis Extremities
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Assess the head.
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Assess the neck.
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Assess the chest.
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Assess the abdomen.
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Rescuer palpates pelvis.
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Rescuer palpates pubic symphysis.
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Rescuer palpates lower extremity.
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Rescuer palpates upper extremity.
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S.A.M.P.L.E. History “For medical patients the S.A.M.P.L.E. history may be completed prior to the physical exam.
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Rescuer takes history from patient.
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Signs / Symptoms Allergies Medications Pertinent Past History Last Oral Intake Events
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Ongoing Assessment “While awaiting the additional EMS resources, the First Responder should continue to assess the patient.”
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Ongoing Assessment Repeat Exam as needed Check Interventions
Repeat Initial Assessment Repeat Exam as needed Check Interventions Calm and Reassure Hand Off Report
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For an unstable Patient
Ongoing Assessment Repeat Every 15 minutes For A Stable Patient Repeat Every 5 minutes For an unstable Patient
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Handoff Report
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Hand Off Report Age and Sex Chief Complaint Responsiveness
Airway and breathing status Circulation status Physical findings SAMPLE history Interventions provided
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