patient assessment

							patient assessment
patient assessment
soapc
Primary
S
subjective
O
objective
A
assessment
P
plan
C
communicate
how to do it!
primary survey
abcde
airway clear?
breathing adequately
pulse?
capillary fill
conscious level
avpu
alert
responds to voice
reponds to pain
no response
gcs
eyes open to what?
none
speech
pain
none
speech
orientated
confused
words
sounds
none
movement
obeys
localises
withdraws
flexes
extends
none
expose
immediate action?
another course!!
secondary survey
subjective
introductions
presenting complaint
story of presenting complaint
which system/s are we in?
flesh out this/these systems
ask about this/these systems first
run thru other systems
cardiac
chest pain
breathlessness
breathessness at night
ankle swelling
respiratory
cough
spit
colour
blood?
gut
weight
indigestion
bowels
bleeding
gu
dysuria
inconinence
haematuria
colour
smell
reproductive
periods
bleeding
pregnancies
cns
fits
strokes
funny feelings
rheumatic
significant injuries
arthritis?
endocrine
diabetes?
thyroid problems?
family history
medicines/pills
may inspire more questions
steroids
strong analgesics
allergies
past medical history
alcohol tobacco and substances
social dimension
occupation
relations
carers
have phone?
ok housing?
record
objective
look
colour
struggling?
sweating?
eyes
worried?
alert
mouth
respiratory rate?
colour of lips
pursed lips?
nose
flaring?
observations
temperature
pulse
bp
sats
resp rate
examine
hands
look
nail colour
nail shape
shape of fingers
unusual palms
feel
sweaty?
warm?
cold?
wrist
feel
pulse at wrist
forearms
elbows
brachial pulse here
upper arms
axillae
lymph nodes?
head
face
eyes
jaundiced?
conjunctiva
ears
drums
mouth
lips
tongue
teeth
throat
scalp
neck
look
feel
nodes
trachea
chest
anterior
look
feel
listen
heart sounds
breath sounds
lateral
look
feel
listen
breath sounds
posterior
look
feel
listen
breath sounds
abdomen
anterior
look
feel
listen
lateral
look
feel
posterior
look
feel
rectal
groins
hernias
nodes
genitalia
thighs
legs
ankles
feet
tests
bg
urinalysis
hpt
ecg
record
assessment
guess/assess/diagnoses?
likely and unlikely
scary and benign
plan
review
think
plan
communicate
to patient
to family
to carers
to other healthcare professionals
considered action
now
by you?
by others?
later
Summary