Medical assessment

SANTA ROSA JUNIOR COLLEGE

EMT-B PATIENT ASSESSMENT/MANAGEMENT-MEDICAL Evaluator states: “You are to demonstrate an appropriate assessment of a medical patient. Check your equipment and let me know when you are ready to begin. You have ten minutes to complete your assessment and will be notified when you have two minutes remaining.”

DETERMINE PROPER BSI

ACTION/VERBAL RESPONSE

POINTS

I am taking appropriate BSI precautions.

* Takes or verbalizes appropriate body substance isolation precautions (CRITICAL CRITERIA)

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SCENE SIZE UP

ACTION/VERBAL RESPONSE I am determining if the scene is safe.

I am determining the nature of illness.

I am determining the number of patients.

I am determining the need for additional help.

I am taking/directing appropriate c-spine precautions.

* Assess scene safety (CRITICAL CRITERIA) Determine nature of illness Determine number of patients Assess need for additional help Take cervical spine precautions as necessary

INITIAL ASSESSMENT

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ACTION/VERBAL RESPONSE

Verbalizes general impression of patient

I observe an approximately ___ year old male/female patient who appears to be in mild/moderate/severe distress (determine one and state it).

EYES OPEN/AWAKE: “Hello, my name is _________ and I am an EMT, I am going to take care of you.” What is your name?

How old are you?”

I have determined the patient is awake and alert (if eyes are open but patient seems confused, state it).

EYES CLOSED: Determine responsiveness using: Alert - Verbal - Painful - Unresponsive “What seems to be the problem?”

I am identifying and managing apparent life threats.

IF PATIENT SPEAKS TO YOU: I have determined the airway is patent.

IF PATIENT DOES NOT SPEAK OR IS UNCONSCIOUS: I am assessing the airway for patency.

I am assessing breathing for: adequate rate & tidal volume, labored or easy.

At this time, I would initiate oxygen therapy if appropriate. (specify the device and appropriate flow rate) I am assessing for presence of a pulse at the carotid artery (unconscious pt.) or radial artery (conscious pt.), assessing approximate rate, strength, and regularity.

I am assessing for and controlling severe bleeding.

Determines responsiveness/level of consciousness

Determines chief complaint Identify apparent life threats * Assess airway/initiate appropriate airway management (CRITICAL CRITERIA) * Assess breathing/initiate appropriate oxygen therapy (CRITICAL CRITERIA) * Assess circulation (CRITICAL CRITERIA)

* Assess and control severe bleeding (CRITICAL CRITERIA)

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Assess skin signs

I am assessing the skin for color, temperature and moisture.

(Assess capillary refill time in patients under the age of 6) At this time I have determined the patient is low or high priority (select one)

State priority of patient for transport

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DETERMINE APPROPRIATE ASSESSMENT PATH Performs focused physical examination (assesses affected body part/system, or if indicated, completes rapid assessment)

FOCUSED HISTORY-PHYSICAL or RAPID MEDICAL ASSESSMENT I am focusing my examination on the body part or body system of chief complaint. In the case of moderate/severe distress I may differ this until enroute to the hospital and move to a rapid assessment, which would consist of a quick head-toe survey of any life threatening problems.

Obtains S.A.M.P.L.E. history if patient is conscious. (Otherwise, moves to rapid medical assessment.)

Signs and Symptoms (assess history of present illness) “O” - Onset “P” - Provocation “Q” - Quality “R” - Region/radiation “S” - Severity “T” - Time

Allergies Medications Past pertinent history Last oral intake Event leading to present illness (rule out trauma)

Vitals Signs

When did it start? What was the patient doing?

Does anything make it better or worse?

What does it feel like? (ie: tight, sharp, dull, etc..)

Where is it? Does it move or go anywhere?

How bad is it, on a 1-10 scale?

How long does it last?

Is the patient allergic to foods or medications?

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Does the patient take any medications? (prescribed/nonprescribed including vitamins, herbal remedies, birth control pills, illegal drugs).

Has this ever happened before? Was the patient seen by a physician? Diagnosis? Do they have history of diabetes, high blood pressure, cardiac or breathing problems, or seizures?

What and when did the patient last eat?

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What happened today that led the patient or someone to call 911?

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I will now obtain Baseline Vital Signs: Blood pressure: by auscultation Respirations: rate, depth, and quality.

Pulse: rate, regularity, and quality.

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Interventions

I will perform or delegate the following interventions (etc.)

Transport (re-evaluates the transport decision)

At this point I feel the patient is emergent and should be transported immediately OR non-emergent and does not require immediate transport (select one).

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Rev. 01/03

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DETAILED PHYSICAL EXAMINATION Place an “X” in the box if the student performs an appropriate physical exam while stating the appropriate findings.

I am examining the head for symmetry, scars I am examining the face for equality of facial muscles I am examining the eyes for size, equality, reactivity to light, color, pink-moist conjunctiva.

I am examining the ears for drainage (color).

I am examining the nose for flaring, drainage (color), singed nostrils, and foreign body.

I am examining the mouth for loose/broken teeth, foreign body, blood or mucus, pink & moist soft tissue.

I am examining the neck for, stoma, jugular vein distention, tracheal deviation, medical alert necklace, scars, and accessory muscle use.

I am examining the chest for chest rise (barrel hoop), lung sounds, subcutaneous emphysema, retractions, and scars.

I am examining the abdomen for distention, scars, rigidity, referred pain, guarding, and pulsating mass.

I am examining the pelvis for incontinence of urine, pregnancy (crowning, bloody show, water broke).

I am examining the legs for distal circulation-sensation-motor function, scars, track marks, medical alert jewelry, equal pulses bilaterally, pedal edema.

I am examining the arms for distal CSM, scars, track marks, medical alert bracelet, and equal pulses bilaterally.

I am examining the back for scars, sacral edema.

Head Face Eyes Ears Nose Mouth Neck

Chest Abdomen Pelvis Legs

Arms Back

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ONGOING ASSESSMENT (verbalized) Repeats initial assessment

I will now repeat my initial assessment of the patient to determine if there has been any change in their condition.

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Obtain secondary vital signs

I would obtain and record a second set of vital signs and compare with the baseline vitals.

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Repeats focused assessment regarding patient complaint or injuries

I would repeat a focused assessment on the patient to determine any other complaints or injuries not found or reported previously.

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TOTAL POINTS ( 52 pts.)

PASSING: 80% = ( 42 pts.)

* = CRITICAL CRITERIA (Must Perform to Pass)

Start Time: _________

Date: ____________

Stop Time: _________

Student’s Name: ____________________________________________________________

Evaluator’s Name: __________________________________________________________

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Rev. 01/03