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Patient Assessment Patient Assessment Plan

The document outlines a 6-step process for patient assessment: 1) Scene size-up to ensure safety and identify injuries, 2) Initial assessment of responsiveness and ABCs, 3) Physical exam from head to toe, 4) Obtaining patient history, 5) Ongoing reassessment, and 6) Endorsement with findings and treatment. It also describes signs of adequate, inadequate, and absent respiration to monitor patient breathing during the assessment.

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Kevin Padillo
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153 views3 pages

Patient Assessment Patient Assessment Plan

The document outlines a 6-step process for patient assessment: 1) Scene size-up to ensure safety and identify injuries, 2) Initial assessment of responsiveness and ABCs, 3) Physical exam from head to toe, 4) Obtaining patient history, 5) Ongoing reassessment, and 6) Endorsement with findings and treatment. It also describes signs of adequate, inadequate, and absent respiration to monitor patient breathing during the assessment.

Uploaded by

Kevin Padillo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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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

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