PATIENT ASSESSMENT/MANAGEMENT

TRAUMA

 

Takes or verbalizes body substance isolation

SCENE SIZE-UP

Determines the scene is safe

Determines the mechanism of injury/nature of illness

Determines the number of patients

Requests additional help if necessary

Considers stabilization of spine

INITIAL ASSESSMENT

Verbalizes general impression of patient

Determines responsiveness/level of consciousness

Determines chief complaint/apparent life threats

Assesses airway and breathing

            Assessment

            Initiates appropriate oxygen therapy

            Assures adequate ventilation

            Injury management

Assesses circulation

            Assesses for and controls major bleeding

            Assesses pulse

            Assesses skin color, temperature and condition

Identifies priority patients/makes transport decision

FOCUSED HISTORY AND PHYSICAL EXAM / RAPID ASSESSMENT

Selects appropriate assessment (focused or rapid assessment)

Obtains or directs assistant to obtain baseline vital signs

Obtains SAMPLE history

DETAILED PHYSICAL EXAMINATION

Assesses the head

            Inspects and palpates the scalp and ears

            Assesses the eyes

            Assesses the facial area including oral and nasal area

Assesses the neck

            Inspects and palpates the neck

            Assesses for JVD

            Assesses for tracheal deviation

Assesses the chest

            Inspects

            Palpates

            Auscultates the chest

Assesses the abdomen / pelvis

            Assesses the abdomen

            Assesses the pelvis

            Verbalizes assessment of genitalia / perineum as needed

Assesses the extremities

            Assesses each arm and leg

            Includes inspection, palpation, and assessment of pulse

            Sensory and motor activities

Assesses the posterior

            Assesses the thorax

            Assesses lumbar

Manages secondary injuries and wounds appropriately

 

 

CRITICAL CRITERIA

 

            Did not take or verbalize body substance isolation technique

            Did not asses for spinal protection

            Did not provide for spinal protection when indicated

            Did not provide high concentration of oxygen

            Did not find or manage problems associated with airway, breathing, hemorrhage or shock, hypoperfusion

            Did not differentiate patient’s needing transportation versus continued assessment at scene

            Does other detailed physical examination before assessing airway, breathing, circulation

            Did not transport patient within 10 minute time limit