2015 Trumbull Memorial Hospital Demo

Patient Assessment – Medical Patient Assessment – Medical

Steps

Performed? Yes No

1. History of Present Illness including but not limited to:  O – Onset of the problem (how fast did it occur)  P – Provocation/Palliation (what makes it better or worse)

 Q – Quality (Crushing, Pressure, Stabbing)  R – Radiation (does the pain go anywhere)  S – Severity (1-10 scale) and intermittence  T – Time of onset (when did this start)

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2. Provide appropriate interventions as per protocols. Splint injured, painful, or swollen extremities. Apply dressings and bandage all wounds. Consult medical control with any questions, further treatments, or omission of interventions as written. ☐

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Priority Medical Patients Rapid Assessment 1. Rapidly assess the patient from “head to toe” (60-90 seconds total)

 HEENT Exam: Check ears for fluid and foreign bodies, check eyes for pupillary response, check nose for fluid and patency, check neck for pain, stiffness, injury, distended veins, tracheal deviation, pulse, or any other signs of trauma. Consider the need for a cervical collar. 2. Chest and Abdomen  Check chest for visible injury, assess breath sounds as well as chest movement, symmetry, and effort. The chest should be palpated for pain. The abdomen should be assessed for visible injury, pain, tenderness, rigidity, and guarding. The pelvis should be palpated for stability if any history of trauma or possible dislocation. 3. Extremities and Back  The lower as well as the upper extremities should be examined and assessed for presence of pulses, sensation, and motor function. Note if edematous or signs of poor perfusion exist. The back should be examined for signs of pain. For patients with possible spine injury, assess the back during the logroll procedure. 4. A SAMPLE history should also be obtained if possible. This should include:  S – Signs and Symptoms  A – Allergies  M – Medications  P – Past medical history  L – Last oral intake  E – Events of the injury or illness

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5. Obtain baseline vital signs and prepare the patient for transport.

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143

EMR

EMT

AEMT

Paramedic

Extended