In this presentation students will have the opportunity to learn all definitions and acronyms related to patient assessment. We have links to YouTube videos to further demonstrate various assessments.
3. Basic Definitions:Basic Definitions:
Scene Size‐up :p
Steps taken by first aid providers
hen approaching the emergencwhen approaching the emergency
scene.
Determinee scene safety
Take BSI precautions, noting the
mechanism of injury or patient’s
nature of illness
Determine the number of patients,
and deciding what, if any additional
resources are needed including
BSI stands for body substance
isolation. It means the gloves,
gowns, masks an other objects weg
Advanced Life Support.
gowns, masks an other objects we
use to protect ourselves from our
patients blood, vomit, feces, saliva
and other substances
3Anas Bahnassi PhD CDM CDE
6. Basic Definitions:Basic Definitions:
Focused History and Physical Exam:Focused History and Physical Exam:
In this step you will:p y
Reconsider the mechanism of injury
Determine if the Rapid Trauma Assessment or
a Focused Assessment is neededa Focused Assessment is needed
Assess the patient’s chief complaint
Assess medical patients complaints and signs
and symptomsand symptoms
Obtain a baseline set of vital signs, and
perform a SAMPLE history.
Th t f thi t b lt dThe components of this step may be altered
based on the patient’s presentation.
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10. OPQRST Historiy
Onset
O O t• O = Onset
• When the complaint first
startedstarted.
• The patient’s activities at the
time of onset/immediatelytime of onset/immediately
before
• “What were you doing when this
started”
• Chest pain patient – mowing lawn
• Anaphylaxis patient – stung by beep y p g y
• Diabetic patient – Working in hot day
without food
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12. OPQRST History
Crushing
Quality
• Q = QualityQ Quality
• Subjective
description ofdescription of
complaint in pt
own words
Stabbing
own words
• “Would you please
describe the paindescribe the pain.
What does it feel
like” Burning
• Chest pains –
Crushing, vice‐like,
elephantelephant
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14. OPQRST History
Severity
• Severity• Severity
• 1‐10 scale gauging pain
• “On a scale of 1‐10, 1 ,
being the least pain
you’ve felt and 10 being
the worst pain you’ve
ever felt can you rate the
pain?”
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16. Basic Definitions:Basic Definitions:
Rapid Trauma Assessment:
This is performed on patients with
significant mechanism of injury to
determine potential life threateningdetermine potential life threatening
injuries.
In the conscious patient, symptoms should
b ht b f d d i th R idbe sought before and during the Rapid
Trauma assessment.
You will estimate the severity of the
injuries, re‐consider your transport
decision, reconsider Advanced Life
Support, consider the platinum 10 minutes
and the Golden Hour, rapidly assess the
patient from head to toe.
Obtain a baseline set of vital signs, and
Anas Bahnassi PhD CDM CDE 16
Obtain a baseline set of vital signs, and
perform a SAMPLE history.
18. Basic Definitions:Basic Definitions:
Rapid Medical Assessment:
This is performed on medical patientsThis is performed on medical patients
who are unconscious, confused, or unable
to adequately relate their chief complaint.
This assessment is used toThis assessment is used to
quickly identify existing or potentially life‐
threatening conditions. You will
f h d idperform a head to toe rapid assessment.
obtain a baseline set of vital signs, and
perform a SAMPLE history.
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20. Basic Definitions:Basic Definitions:
Focused History and Physical Exam:Focused History and Physical Exam:‐
Trauma
This is used for patients, with no significant
mechanism of injury, that have been
determined to have no life threateningdetermined to have no life‐threatening
injuries. This assessment would be used in
place of your Rapid Trauma Assessment. You
h ld f th ti t’ hi fshould focus on the patient’s chief
complaint. An example of a patient requiring
this assessment would be a patient who has
sustained a fractured arm with no
other injuries and no life threatening
conditions.
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21. Basic Definitions:Basic Definitions:
Focused History and Physical Exam:Focused History and Physical Exam:‐
Medical
This is used for patients with a medical
complaint who are conscious, and able to
adequately relate their chief complaint toadequately relate their chief complaint to
you, and have no life‐threatening conditions.
This assessment would be used in place of
R id M di l A t Y h ldyour Rapid Medical Assessment. You should
focus on the patient’s chief complaint using
OPQRST, obtain a baseline set of vital signs,
and perform a SAMPLE
history.
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23. Basic Definitions:Basic Definitions:
Detailed Physical Exam: y
This is a more in‐depth assessment that builds on the Focused Physical
E am Man of o r patients ma not req ire a Detailed Ph sical E amExam. Many of your patients may not require a Detailed Physical Exam
because it is either irrelevant or there is not enough time to complete it.
This assessment will only be performed while enroute to the hospital or if
there is time on‐scene while waiting for an ambulance to arrive.
Patients who will have this assessment completed are
patients with significant mechanism of injurypatients with significant mechanism of injury,
unconscious, confused, or unable to adequately relate
their chief complaint. In the Detailed Physical Exam you
will perform a head to toe assessment to find isolatedwill perform a head to toe assessment to find isolated
and non‐life‐threatening problems that were not found
in the Rapid Assessment and also to further explore
h l d d i h R id
Anas Bahnassi PhD CDM CDE 23
what you learned during the Rapid assessment.
24. Basic Definitions:Basic Definitions:
Ongoing Assessment:g g
This assessment is performed during transport on all patients. The
Ongoing Assessment ill be repeated e er 15 min tes for the stableOngoing Assessment will be repeated every 15 minutes for the stable
patient and every 5 minutes for the unstable patient. This assessment
is used to answer the following questions:
1. Is the treatment improving the patient’s condition?
2 Are any known problems getting better or worse?2. Are any known problems getting better or worse?
3. What is the nature of any newly identified problems?
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25. Acronyms used during patient
assessment: MOI – stands for mechanism of injury
AVPU – used to classify the patient’s
mental status:
• A = awake, alert, and orienteda a e, a e t, a d o e ted
• V = alert to voice, but not oriented
• P = alert to painful stimuli only
• U = unresponsive to voice or painfulU = unresponsive to voice or painful
stimuli
CUPS used as an additional tool toCUPS – used as an additional tool to
prioritize the patient for transport:
• C = critical
bl• U = unstable
• P = potentially unstable
• S = stable
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26. Priority Illness/Injury severity Transport
DecisionDecision
Critical Patients either receiving CPR, in respiratory
arrest or requiring and receiving life‐ sustainingarrest, or requiring and receiving life sustaining
ventilatory /circulatory support
C.U.PUnstable
Poor general impression
Scene Size‐up
Unstable
P
Unresponsive with no gag or cough reflexes
Responsive but unable to follow commands
Initial Assessment
Potentially
Unstable
p
Difficulty breathing
Pale skin or other signs of poor perfusion (shock)
Complicated childbirth
Rapid Assessment
And Transport
Complicated childbirth
Uncontrolled bleeding
Severe pain in any area of the body
Severe chest pain especially with aSevere chest pain, especially with a
systolic BP of less than
100 mmHg
I bilit t t f th b d
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Inability to move any part of the body
27. Priority Illness/Injury severity Transport
DecisionDecision
Mi ill i i l t d i j
S
Stable
Minor illness, minor isolated injury,
uncomplicated extremity injuries, and/or any
patient that cannot be categorized as
Scene Size‐up
Critical, Unstable, or Potentially unstable.
Initial Assessment
Focused
Assessment
And Transport
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28. Mechanisms of InjuryMechanisms of Injury
Vehicle‐pedestrian: Collision Motorcycle
crash
Death in the same passenger compartment: High‐speed vehicle
collision
Medium speed vehicle collision Roll‐over of vehicle
(infants and children)
Falls greater than 20 feet (adults): Ejection from vehicle
Falls greater than 10 feet (infants and children): Bicycle collisionFalls greater than 10 feet (infants and children): Bicycle collision
Penetrations of the head, chest, or abdomen: (infants and children)
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