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Module 3 Patient Assessment

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Page 1: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Module 3

Patient Assessment

Page 2: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Patient Assessment Scene Size Up

Initial Assessment

Physical Examination

Patient History

On-Going Assessment

Page 3: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Scene Size Up

Body Substance Isolation

Is the Scene Safe?

Mechanism of Injury/Nature of Illness?

How many patients involved?

Additional Resources Needed?

Page 4: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Body Substance Isolation

“Body substance isolation (BSI) precautions must be taken on

every call.”

Page 5: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Rescuer Wears Protective Eyewear

Page 6: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Rescuer Dons Gloves

Page 7: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment
Page 8: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Rescuer Wears Simple Surgical Mask

Page 9: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Rescuer Wears HEPA Mask

Page 10: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

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.”

Page 11: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Unstable Situation

Page 12: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

HazMat Situation

Page 13: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Violent Situation

Page 14: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Scene Safety

Personal Protection.Protection of the patient.Protection of bystanders.

If the scene is unsafe, make it safe.If the scene is unsafe, make it safe.Otherwise, DO NOT ENTER.Otherwise, DO NOT ENTER.

Page 15: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

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.

Page 16: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Trauma Patient

Page 17: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Impact # 1

Page 18: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Impact # 2

Page 19: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Impact # 3

Page 20: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Nature of Illness

Medical. Determined from patient, family or bystanders.

Why was EMS called?

Page 21: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment
Page 22: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

How many patients?

Obtain additional help prior to contact with patients.

FirePolice

Rescue

ALS Utilities

Page 23: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Initial Assessment

General Impression

Assess Responsiveness

Airway

Breathing

Circulation

Update EMS

Page 24: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Initial Assessment

“The initial assessment is completed to assist the First

Responder in identifying Immediate Threats to Life.”

Page 25: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

General Impression

Based on the First Responder’s immediate assessment of the environment and the patient’s

chief complaint.

Page 26: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

General Impression

Page 27: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Assess Responsiveness Stabilize spine if

trauma is suspected!

AlertVerbalPainfulUnresponsive

Page 28: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Establish responsiveness with patient prone.

Page 29: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Establish responsiveness with patient supine.

Page 30: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Assess Airway Status

Open the airway

Inspect the airway

Clear airway, as needed

Page 31: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Open airway; perform head-tilt/chin-lift maneuver.

Page 32: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Open airway; perform jaw thrust.

Page 33: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Suction with rigid tip.

Page 34: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Insert oropharyngeal airway.

Page 35: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Assess the patient’s breathing

Look at the effort of breathing.

Look, listen, and feel for presence of ventilations.

Ventilate as needed.

Page 36: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Assess breathing; look, listen, feel.

Page 37: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Mouth-to-mask Ventilations

Page 38: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Assess the Patient’s Circulation

Assess Pulse

Assess for Major Bleeding

Assess Skin

Page 39: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Pulse

Page 40: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Check for a carotid pulse.

Page 41: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Assess circulation by checking brachial pulse (infant).

Page 42: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Locate bleeding.

Page 43: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Rescuer controls hemorrhage.

Page 44: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Skin Temperature

Page 45: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Update responding EMS

Age and sex

Chief Complaint

Responsiveness

Airway / Breathing

Circulation

ETA?

Page 46: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

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.”

Page 47: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Physical Examination The First Responder should complete a physical exam on all patients following the initial assessment.Patient and injury specific.

Page 48: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Physical Examination Inspect and palpate for DOTS.

Deformities

Open injuries

Tenderness

Swelling

Page 49: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Extremities

Pelvis

Abdomen

Chest

Neck

Physical Examination

Head

Page 50: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Assess the head.

Page 51: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Assess the neck.

Page 52: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Assess the chest.

Page 53: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Assess the abdomen.

Page 54: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Rescuer palpates pelvis.

Page 55: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Rescuer palpates pubic symphysis.

Page 56: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Rescuer palpates lower extremity.

Page 57: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Rescuer palpates upper extremity.

Page 58: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

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.

Page 59: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Rescuer takes history from patient.

Page 60: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Signs / Symptoms

Allergies

Medications

Pertinent Past History

Last Oral Intake

Events

Page 61: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Ongoing Assessment

“While awaiting the additional EMS resources, the First

Responder should continue to assess the patient.”

Page 62: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Repeat Initial Assessment

Repeat Exam as needed

Check Interventions

Calm and Reassure

Hand Off Report

Ongoing Assessment

Page 63: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Ongoing Assessment

Repeat Every 15 minutesFor A Stable Patient

Repeat Every 15 minutesFor A Stable Patient

Repeat Every 5 minutesFor an unstable Patient

Repeat Every 5 minutesFor an unstable Patient

Page 64: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

Handoff Report

Page 65: Module 3 Patient Assessment. Scene Size Up Initial Assessment Physical Examination Patient History On-Going Assessment

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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