"Patient History and Vitals Form - DOC"
Patient Assessment Patient Assessment Patient assessment is the key to all medical care. You need to evaluate your patient’s condition, determine what is or may be wrong, and implement an appropriate treatment plan with the equipment available. Then you need to make a judgment about whether the person can continue on the trip or whether he or she needs to be evacuated to definitive medical care. When in doubt, be conservative and assume the worst. The patient assessment system (PAS) is designed to provide a comprehensive approach to evaluate the patient’s condition, from a minor cut to multiple traumatic injuries. Patient assessment is a complex skill that can be done well only with practice. Although the general principles of patient assessment are identical, they must be adapted to each situation. The general outline appears below. ASSESS THE SCENE Remember, rescuer safety first. Before approaching a patient, make sure that the scene is safe. You don’t want more victims because people rushed foolishly into a dangerous situation. This may mean waiting for avalanche debris to settle, flood waters to recede, etc. Once the situation is stabilized, approach the victim. If you cannot assure the safety of the scene, you may not be able too treat the patient. Make sure that no one else is any danger. Account for all victims. If the patient is in imment danger (for example, a dangerous forest fore), you may need to move the person to another location before starting your assessment. Take proper precautions to maintain your safety at the scene, including wearing latex gloves (to protect the first aid giver from harmful diseases the patient might have). Look for clues to the cause of injury. PRIMARY ASSESSMENT The goal of the Primary (or Initial) Assessment is to identify any potential life- threatening situations that must be dealt with immediately. The Primary Assessment is prioritized and should be performed in the following order: A (Airway), B (Breathing), C (Circulation), D (Disability). If you find any problem in the Primary Assessment, stop the assessment and treat the patient immediately. The Primary Assessment may last only a few seconds if the patient is alert, walking around, and speaking to you. Here are the basic problems to look for during a Primary Assessment: A = Airway Problem Airway blocked. Check for a clear airway. Open the airway in accordance with your Assessment training in CPR. Look, listen, and feel for breathing. Treatment If not breathing, clear airway and provide Basic Life Support. B = BREATHING Problem Patient not breathing or distressed breathing. Assessment Is air going in and out normally? Treatment If not, make sure airway is clear; provide rescue breathing. C = Circulation Problem No pulse #1 Assessment Check for a pulse at the carotid artery. Treatment If there is no pulse, begin CPR. Problem Severe bleeding. #2 Look for any signs of severe bleeding, especially under body, where Assessment blood can pool in sand and dirt. Treatment Control major bleeding. D = Disability Problem Possible spinal injury. Mechanism of injury: a fall or impact force that could have injured the spine. If there is no mechanism of injury (for example, the person cut his or her hand with a knife), you rule out spinal injury. Assessment Unreliable patient. If the accident is unwitnessed and the patient is unresponsive, lethargic, or combative-in essence, you cannot rely on his or her answers as truthful or accurate-you cannot rule out the possibility that there was a mechanism for spinal injury. Stabilization. For any patient with an unwitnessed injury, or any possible mechanism for spinal injury such as a fall, you should initially assume that an injury exists and treat as such. Ask the patient not to move his or her head and stabilize the Treatment head with your hands to maintain the head and neck in a neutral, in-line position (aligned with the midline of the body). Keep the head and neck in a stabilized position until spinal injury can be ruled out and/or professional rescuers arrive on scene for transport. Secondary Assessment Once all life threatening conditions have been addressed, the an in-depth, head to toe physical exam, record the patient’s vital signs, and ascertain his or her medical history. Patient Exam With some practice, the rescuer can accomplish an effective and thorough exam in minutes. Except in cases of imminent danger, avoid moving an injured patient until the exam has been completed. Make the patient as comfortable as possible with your professional manner, , and protect him or her from inclement environmental conditions. It is best if the examiner is of the same gender as the patient; otherwise having an observer of the same gender can make the patient more comfortable. It is often convenient to have a note-taker record the findings of the patient exam, vitals, and medical history, allowing the rescuer to concentrate on the exam. For the patient exam, keep the following principles in mind: Principles in the Patient Exam Identify yourself; talk to the patient; keep a calm voice; let him or her know what you are doing. Develop a relationship with your patient as the only person performing the exam and any necessary treatment. Avoid moving the patient unnecessarily Watch the patients face for signs of pain or discomfort. Be professional Keep the patient involved-ask questions about medical history and self- assessment. Give the patient a sense of control. A typical exam starts at the head, proceeds down the torso to the toes, and then returns to the arms. Observe for cuts, bruises, burns, or deformity. Look for discoloration and wetness. Listen and smell for anything abnormal. Examine the skin, muscles, and bone by feeling gently with your hands. Check for abnormalities, wetness, and tender areas. Compare symmetric body parts such as hands and feet (especially useful to detect swelling). Flex the joints gently to check for mobility. Be sensitive to potential injuries and stop if there is a sign of pain. As you examine your patient, here are some of the signs and symptoms to look for, and the potential implications of those findings. Head and Neck Examination Signs and Symptoms Possible Implications Palpate scalp Deformity, bleeding Bump on head; skull fracture Check Face Bruises, bleeding Facial fractures; skull fractures Bloody nose; skull fracture; Ears and nose Fluid; bruises behind ears increasing intercranial pressure (ICP) Equal in size? Responsive to Pupils Increasing ICP light? Palpate face and Bruises around eyes Increasing ICP jaw Check inside Broken teeth; vomiting; Airway concerns mouth bleeding Lymph nodes Swollen Infection Deviation of the trachea or Chest wall and/or lung injury; Trachea neck, veins bloated and visible pneumothorax Upper torso Possible Examination Signs and Symptoms Implications Palpate neck and back vertebrae Tenderness or guarding? Spine fracture Paplet shoulders, shoulder Fracture or Stable? Pain? blades and collarbone dislocation Press on rib cage from top, sides, Unstable, pain, grating Chest wall injury and sternum sound Does the chest wall rise Breathing Flail chest symmetrically? Lower Torso Examination Signs and Symptoms Possible Implications Palpate four quadrants of Rigity, pain (local/general, Abdominal injury or abdomen and back under dull ache, stabbing, illness ribe burning) Abdominal injury or Examine skin Color; bruising; lacerations illness Push from top, sides, Pelvic fracture; volume Pelvis/hips rocking. Unstable? Pain? shock Soft tissue injury; urinary Genitals Bleeding, tenderness? tract or yeast infection Extremities Possible Examination Signs and Symptoms Implications Unstable, decreased range of movement? Fracture; dislocation; Arms, legs, Inability to bear weight, weakness? sprain; strain; soft hands, and feet Tenderness, pain? Abnormal circulation, tissue injury sensation, and movement? Vital Signs Measure and record vital signs every 15 minutes. Changes in the vitals provide critical information on the condition of the patient. While each individual will have differing resting vital signs, it is the change in vital signs over time that may indicate injuries or illness. Vital signs include the following: Pulse Record the rate and strength (typical adult: 60 to 80 beats/minute). Respiration Record the rate, strength, and any unusual smell (typical adult: 12 - 20 respirations/minute). Skin Assess skin color (pale/normal/red), temperature (cool/normal/hot), and moisture (dry/normal/clammy/sweaty). Level of consciousness Use the AVPU scale: A = Alert-responds to questions and is completely oriented to the time and place. V = Verbal-responds to questions, but not completely oriented. P = pain-responds to painful stimuli. Rub your knuckles on the sternum. U = Unresponsive-does not respond even to painful stimuli./ Temperature Record temperature. To ensure an accurate reading, shake the thermometer to push the mercury down below the degree markings. Circulation Blood pressure is a measure of how well the body is being perfused with blood. Without a blood pressure cuff, you cannot get an exact reading. However, checking for a pulse in the distal extremities, such as the wrist and the ankle, gives you a general assessment of how well blood is circulating (perusing) in all four limbs. Typically if you get a pulse at the wrist, the systolic blood pressure should be 80 or above. Patient History The purpose of the patient history is to get as much information as you can that will give clues as to the nature of the problem. Use the acronym SAMPLE to remember the categories to cover. Record everything on the SOAP Note (the SOAP Note is covered further below). S = Symptom Is there pain or discomfort? When was the onset of the pain? Was the onset sudden or gradual? Describe the pain: Crampy? Stabbing? Generalized? Burning? Intermitted? What aggravates it? What alleviates it? Are there non pain-related symptoms-tiredness, weakness, dizziness, nausea? A = Allergies Any allergies to foods and medications, as well as urgent allergies such as bee stings? M = Medications What is the patient currently taking and for what conditions? When did he/she last take it? Keep the medication with the patient in the event of an evacuation. P = Past Has anything like this ever happened before? People with chronic problems often know their best treatment. Check any trip documentation, such as health history form or a medic alert tag. L = Last Meal What and when did the patient eat and drink? How much? This can be very important in any case (i.e. diabetic emergencies, heat exhaustion, hypothermia, abdominal problems). E = Events Leading Up to Accident What happened? Obviously, more than one part of the patient exam, vital signs, and history can be done simultaneously. Each situation will determine which questions are more important and appropriate than others. For example, if somebody is complaining of stomach pain and has not fallen, it is not necessary to extensively check the legs for fractures. Assessing the Patients Pain Use the acronym OPQRST as the framework for assessing pain. O = Onset When did the pain begin? P = Provoke What provokes the pain (i.e. moving, eating)? Q = Quality What exactly does the pain feel like? Is it dull? Stabbing? Cramping? R = Radiation Does the pain spread to other parts of the body? S = Severity If 10 is the worst possible pain, and 1 is very mild pain, how does this pain rate from 1 to 10? T = Time Does the pain change over time? Is it constant, or does it come in waves? Does it go away or stay the same? After doing the above, you may now go ahead and treat the patient if all life threatening situations and injuries have been assessed and taken care of. If they have not, treat the life threatening injuries first, or if someone else is treating the life threatening injuries, ask him/her if it is O.K. for you to treat the other injuries while he/she is still working on the patient. If it proves to be too dangerous to treat multiple injuries at once (i.e. providing treatment that requires the patient to be moved while the patient has possible spinal injuries is not a good idea).