PATIENT ASSESSMENT

Patient Assessment Plan

1. Scene Size-Up
2. Initial Assessment
3. Physical Examination
4. Patient History
5. Ongoing Assessment
6. Endorsement

1. Scene Size-Up
 Ensures the safety of the people at the scene, identifies MOI/NOI and determines need
for additional assistance
- Arrival on the scene
- Identify yourself
- Immediate Sources of Information
a) Arrival on the Scene
 Personal safety
 Patient safety
 General impression
 Begin initial assessment
 Identify yourself (if responsive)
 Identify life-threatening injuries
 Stabilize and continue to monitor
b) Identify yourself
 State name and organization
 Ask patient if you may help (obtain consent)
c) Immediate sources of Information
 Scene itself
 Patient (if responsive)
 Relative or bystanders
 Mechanism of Injury
 Any deformity/injury
 Sign of illness
2. Initial Assessment
 A process used to identify and treat conditions posing an immediate threat to the
patient’s life.
 Form a general impression
 Check for level of responsiveness (AVPU – Alert, Verbal, Pain and Unconscious)
 Airway
 Breathing
  Circulation
 Patient’s status update
3. Physical Exam
RAPID TRAUMA ASSESSMENT
Use D.O.T.S. (head to toe)
(Deformity, Open Wound, Tenderness, Swelling)
 Head
 Neck
 Chest/Back
 Abdomen
 Pelvis
 Extremities
 Vital signs
- Respirations -Pulse
- Skin -Pupils
- Blood pressure
4. Patient History
“S.A.M.P.L.E.”
 Signs and symptoms
 Allergies
 Medications
 Past medical history
 Last oral intake
 Events leading to injury
5. Ongoing Assessment
 Repeat initial assessment
 If with pain, use OPQRST
 Onset
 Provocation
 Quality
 Radiation
 Severity
 Time
 Repeat physical exam
 Reassess treatment and interventions
 Calm and reassure the patient
6. Endorsement
 Patient’s age and sex
 Chief complaint
 Level of responsiveness
 Patient’s status (Airway, Breathing and Circulation)
  Physical exam findings
 SAMPLE history
 Interventions/Treatment given
 Special reports

SIGNS OF ADEQUATE RESPIRATION

 Chest and abdomen rise and fall with each breath
 Air can be heard and felt exiting the mouth or nose
 Ease of breathing
 Adequate rate

SIGNS OF INADEQUATE RESPIRATION

 Inadequate rise and fall of the chest

 Abnormal breath sounds
 Increased respiratory effort
 Cyanosis-bluish discoloration
 Inadequate rate
 Altered mental status

SIGNS OF ABSENT RESPIRATION

 No chest or abdominal movement

 Air cannot be heard or felt exiting the mouth or nose

Station 1 (Patient Assessment) Station 2 (Taking Vital Signs)

1. Scene size – up Inform patient

- Ensure personal safety * Check respirations
- Identify yourself * Check pulse
2. Initial assessment * Check skin condition
3. Physical exam * Check pupils
4. Patient history * Check blood pressure
5. Ongoing assessment
6. Endorsement