patient assessment vs communication documentation the older folks the younger folks block iii...
TRANSCRIPT
• Patient Assessment• VS• Communication• Documentation• The older folks• The younger folks• Block III written and practical
Scene-Size-up –Initial Assessment –Focused history and physical exam-Detailed Physical Exam-On-Going Assessment-
BSIBSI BSI
BSI BSI
BSI BSIBSI
Scene Size-up – Initial Assessment – Focused Hx. & PE – Detailed Assessment – On-going assessment
Scene Size-up
Initial evaluation of the scene• Continues throughout the scene
Part I SCENE SIZE-UPDefined:
Begins with dispatchInitial evaluation of the scene
Goals:Ensure scene safety
To determine if patient is medical or traumaDetermine total number of patients
• Scene Size-upBegins with Dispatch
demographics: residence - Pull to curbside in front of house
Always remember, scene safety is a component of Scene Size-up
Nature of illness:Number of patients: Considers stabilization
of spineRequests additional help if necessary: ALS
Personal protection• Always perform your own size-up• Observe as you approach and before getting out
of the truck
Nature of Illness• Information can be obtained from
The patientFamily members or bystandersScene
• Mechanism of injury
• Number of patients• Call for additional help if needed
ALS
Collision Scene• Look and listen• Check for power outages• Observe traffic flow• Check for smoke
As you approach:• Look for clues to escape hazourdous
materials• Look for patients on or near the road• Look for smoke not seen at a distance• Look for broken utility poles and downed
lines• Be on the look-out for bystanders• Watch for signals of police officers or other
agency personnel
Danger Zone• No apparent hazard-at least 50ft in all directons• Fuel spill-at least 100 ft. in all directions
uphill and downwindavoid gutter, gullies, ditchesdo not use flares
• Vehicle fire-at least 100 ft. in all directions• Downed wires-area in which contact can be made• Hazardous Materials
Emergency Response Guide BookChemtrec
Crimes Scenes and Acts of ViolenceSignals of violence:• Fighting or loud voices• Visible weapons• Signs of alcohol or other drug use• Unusual silence• Knowledge of prior violence
Nature of call• Illness• Injury
• Part II INITIAL ASSESSMENT• Defined:• Discovering and treating life-threatening conditions• Goals:• Determine if the patient is ill or injured• Triage• Components:• General Impression
• Illness or injury• Mechanism of injury/Nature of illness• Age, sex, race• Identify life-threatening problems
• Mental Status• A lert V erbal Response P ainful Response U
nresponsive• Assess Breathing• Assess Breathing• Triage
• Part III Focused History and Physical Exam• Defined:• To identify additional serious or potentially life-threatening injuries or conditions• Components, Trauma• Reconsider Mechanism of injury
• Index of suspicion• Rapid Trauma Assessment
• Head to toe physical exam quickly conducted• Base-line Vital Signs• Assess S A M P L E history• Components Medical• History of present illness
• O – P – Q – R – S – T• S A M P L E• Rapid Assessment• Base-line Vital Signs• Treat
• IF UNRESPONSIVE:• Rapid Assessment• Base-line Vital Signs• Assess S A M P L E• Care
Focused History and Physical Exam• Onset?• Provokes?• Quality?• Radiates?• Severity?• Time?• Interventions?
S A M P L E history• Signs/Symptoms• Allergies• Medications• PMHx.• Last oral intake• Events leading to the illness/injury
General Impression• Illness or injury• Mechanism of injury/Nature of illness• Age, sex, race• Identify life-threatening problems
Vital Signs• Pulse
Apical• Respirations• Skin color, temp, condition• Pupils• Blood Pressure
AuscultationPalpation
• Mental Status
Communicating with your patient• Position yourself close to the patient• Identify and yourself and reassure• Speak in a normal voice• Learn your patient’s name• Learn your patient’s age
• Part IV Detailed Physical Exam• Defined• Head to toe physical exam that is
performed slower and in a more thorough manner that the rapid assessment
• Components• Head to Toe exam• Reassess vital signs• Continue care
• Part V On-Going Assessment• Defined:• To detect any changes in the patient’s condition• To detect any missed injuries or conditions• To adjust care as needed• Goal:• The initial assessment is repeated• Vital signs are repeated and recorded• Focused assessment repeated for additional complaints• Components:• Repeat Initial Assessment• Repeat focused assessment• Check interventions• Note trends in patient condition
On-going Assessment• Repeats initial assessment• Repeats vital signs:• Repeats focused assessment regarding patient
complaint or injuries:
Scene Size-up – Initial Assessment – Focused Hx. & PE – Detailed Assessment – On-going assessment
Responsive• Four parts
History of present illnessFocused physical exam
OPQRSTSAMPLE
Baseline VS• Prior history• DCAPBTLS
Unresponsive• Patient history from family, bystanders etc.• Rapid assessment
Abd: distension, firmness, rigidityPelvis: Incontinence of urine, feces
• ID bracelets• Baseline VS• Consider need for ALS• History of present illness and SAMPLE
History of present illness and SAMPLE• Patient’s name• What happened
what did family/bystander see• Did patient complain of anything prior• Know illness• Medications