Module 3: Patient Assessment

By the end of this module, you will be able to:

• Perform systematic primary and secondary assessments.

• Accurately obtain and interpret vital signs.

• Identify life-threatening conditions during initial assessment.

• Apply assessment findings to formulate a patient care plan.

Importance of Scene Size-Up

• Safety First: Ensuring the scene is safe for you, your partner, and others.

• Personal Protective Equipment (PPE) : Gloves, masks, eye protection.

Components of Scene Size-Up

1. Scene Safety

• • Hazards: Traffic, fire, hostile environment.

  • Universal Precautions: Infection control practices.

2. Mechanism of Injury (MOI)/Nature of Illness (NOI)

• • MOI: How trauma occurred (ex., fall, car accident).

  • NOI: Medical reasons for illness (ex., chest pain).

3. Number of Patients

• • Triage: Prioritize care when multiple patients are present. (START Triage System)

4. Additional Resources

• • ALS Backup: Request advanced support if needed.

  • Specialized Equipment: Extrication tools, hazardous materials team.

Purpose

• Identify and manage life-threatening conditions immediately.

Components

• General Impression

  • Age, Sex, Position Found

  • Level of Distress

• Level of Consciousness (LOC)

  • AVPU Scale:

    • Alert

    • Verbal Response

    • Pain Response

    • Unresponsive

• Assess Airway

  • Is the airway open?

  • Look for obstructions.

• Assess Breathing

  • Rate, Rhythm, Quality

  • Adequate chest rise?

• Assess Circulation

  • Pulse: Rate and quality.

  • Skin: Color, temperature, moisture.

  • Bleeding: Control any severe bleeding.

• Determine Priority of Patient Care

  • Transport Decision: Rapid transport if critical.

Purpose

• To identify non-life-threatening conditions and gather detailed information.

Types

• Focused Assessment

  • Used for Responsive Patients

  • Specific complaint area

• Full Body Scan

  • Used for Unresponsive/Responsive Patients

  • Head-to-toe examination

Techniques

• Inspection: Visual examination.

• Palpation: Feeling with hands.

• Auscultation: Listening with stethoscope.

Vital Signs

• Pulse: Normal adult rate 60-100 bpm.

• Respirations: Normal rate 12-20 breaths per minute. (Respiratory rate / breaths per minute)

• Blood Pressure: Normal adult BP is anywhere from 90/60 mmHg to 120/80 mmHg.

• Temperature: Normal 98.6°F (37°C).

• Oxygen Saturation: Normal 95-100%. (Spo2, blood oxygen)

Using SAMPLE

• Signs/Symptoms

• Allergies

• Medications

• Past Medical History

• Last Oral Intake

• Events Leading Up

Using OPQRST for Pain

• Onset: “Did your pain start suddenly or gradually get worse and worse?” This is also a chance to ask, “What were you doing when the pain started?”

• Provokes or Palliates: Instead of asking, “What provokes your pain?” use real, casual words. Try, “What makes your pain better or worse?”

• Quality: Asking, “Is your pain sharp or dull?” limits your patient to two choices, when their pain might not be either. Instead ask, “What words would you use to describe your pain?” or “What does your pain feel like?”

• Radiates: This is another chance to use real, conversational words during the assessment. Asking, “Does your pain radiate?” sounds silly and pompous to the patient. Instead use this question, “Point to where it hurts the most. Where does your pain go from there?”

• Severity: Remember, pain is subjective and relative to each individual patient you treat. Have an open mind for any response from 0 to 10.

• Time: This is a reference to when the pain started or how long ago it started.

Purpose

• Monitor changes in patient condition.

• Adjust care as necessary.

Frequency

• Critical Patients: Every 5 minutes.

• Stable Patients: Every 15 minutes.

Components

• Repeat the primary assessment.

• Reassess vital signs.

• Re-evaluate interventions.

• Update the patient care plan as needed.