Patient Assessment System



|Patient Assessment System | |Major Problems |

|STOP: Check scene/personal safety. | |Unconscious & unresponsive: ABCDE, sugar & water, descend, |

|Glove up, get consent, triage. | |heat/cooling, treat obvious causes. Look to MOI or history for |

|STOP: Assess immed. life threats. | |clues. |

|AVPU, open Airway & Breathing, Circulation (pulse & bleeding), | |CPR: Do not begin if hypothermic. |

|Disability (spine & extremities), Exposure (hypothermia). | |Stop if unsafe or after 30 fruitless minutes unless drowned or |

|STOP: make transport decisions. | |lightning strike. Use face mask. |

|STOP: exam, history, SOAPnote. | |Open airway: (jaw thrust if spine in danger, otherwise head |

|Subjective: Give TLC! | |tilt & chin lift), check breathing, do 2 breaths. Finger sweep |

|Mechanism Of Injury, Chief Complaint, History of Illness. | |& abdominal thrusts if airway still obstructed & restart. |

|Name, age, sex, height, weight | |Check neck pulse, do compressions 15:2 or 5:1, reassess after |

|Location, terrain, weather, time & date, available resources on| |4 cycles. |

|scene. | |Aspirated vomit is deadly – turn patient on side & finger |

|Objective: Watch trends! | |sweep. |

|Vitals: LOC: AVPU (Alert & Oriented x (person, place, time, | |Head injury: (LOC. Monitor vitals for shock, pressure, watch |

|event), responds to Verbal stimuli, Pinch stimuli, or | |airway. Evac on side for vomiting. |

|Unresponsive). | | |

|Heart Rate: rhythm & quality. | | |

| | | |

|Common Problems | |Other Problems |

|Stomachache: gas (moves, gurgles), blockage (ask), UTI (hurts | |Soft Tissue Injuries: control bleeding with direct pressure & |

|peeing), appendix (localized), pregnancy, trauma, evac if blood| |elevation, bicep/thigh pressure pts. |

|in stool, urine, or vomit or rigidity, tenderness, localized | |Prevent infection by scrubbing with brush, gauze, or pressure |

|pain > 12hrs. | |irrigation. |

|Sprains, Strains, Dislocations, Fractures: RICE! Reduce if | |If large, pack with gauze to draw out fluid – soak to remove |

|necessary via traction in-line – gently reposition, stop if | |later. |

|pain increases. Padded splint on joint above & below. Wrap to | |Leave flaps attached. Keep severed parts moist & cold & with |

|body. Monitor distal CSMs. Tylenol. | |patient. Leave impaled objects in. Bleed punctures to clean. |

|Femur (life threat) – traction splint. | |Protect blisters. |

|Allergies: remove allergen, give antihistamines, watch for | |Evac if gaping & longer than ½”, cuts ligaments/tendons, or |

|systemic (hives or swelling). Epinephrine if airway closing, | |facial. |

|then more antihist. | |Infection: SHARP+. |

|Bites & Stings: Animal: wash & get rabies shots. Venomous: | |Swelling, Heat, Aching, Red, Pus – hot salty water, allow to |

|wash, calm, splint & evac. Allergic: give antihistamines, | |drain. |

|watch anaphylaxis. | |Streaking & swollen lymph nodes – apply antibiotics & think |

| | |evac. |

| | |Fever, chills, shock – get ‘em out. |

| | |Poison: remove poison, wash area, dilute with water unless |

| | |corrosive. |

| | |Drowning: CPR, treat hypothermia. |

|Shock: LOC: hyperaware, anxious, disoriented ( unconscious. | |Respiratory Rate: rhythm & quality. |

|RR: rapid ( rising, shallow. | |Blood Pressure: capillary refill, pulses in feet & wrists. |

|HR: rapid ( rising, weak, thready. | |Skin: Color, Temperature, Moisture. |

|BP normal ( falling. | |Pupils: Equal & Reactive to Light. |

|Skin: pale, cool, clammy ( shivering, feet tingling/numb. | |Head to toe exam: look, listen & palpate entire body, chk |

|Nausea, vomiting. | |extremity Circulation, Sensation, & Motion. |

|Rx: Treat cause, monitor ABC’s, raise feet, keep warm, hydrate,| |Pain: location, onset, duration, frequency, quality, quantity |

|feed sugar, give TLC. | |(1-10), exacerbations, reliefs, history. |

|Spine: Look at MOI, pain, (LOC, guarding, numbness, locking. | |AMPLE: Allergies, Medications, Past pertinent history, Last |

|Apply cervical collar. Immobilize & litter out. Use log roll if| |oral in/out, Events preceding injury. |

|alone. | |Assessment: problem list, locations. |

|Clearing the spine: reliable patient (A&Ox3, no distracting | |Plan: how to address each problem. |

|injuries), no back/neck pain on palpation, CSM in extremities, | |STOP: monitor on-going vitals – every 5 min for serious |

|painless rotation & flexion, full ROM. | |patients. |

|Long-term: constant attention – food, H2O, warm, comfy, | |Patient may refuse treatment if A&Ox3 & understand risks. |

|pee/poop. | |If leaving, use recovery position. |

|Watch vitals for shock, check distal CSMs, chk bandages for | |Public domain – By Tom Shields – |

|bleeding. | | |

|Public domain – By Tom Shields – | | |

| | | |

|Eyes: flush thoroughly, check for injuries, bandage both eyes. | |Heat/dehydration: headache, dark urine – cool, rest, hydrate! |

|Burns: cold soak to stop burning. | |Shocky: jello & salt in water or rice water. |

|Remove jewelry/clothing. Monitor ABC’s, watch for shock. | |Hypothermia: feed’em & beat’em. Dry & hypowrap if losing |

|Hydrate. | |control. |

|Do not pop blisters, evac if blisters or charred area > 1 sq | |Frostbite: skin rewarm unless solid. |

|inch. Apply aloe and moist, airtight dresssing. | |Trenchfoot: loosen shoes, warm & dry feet – don’t sleep in wet |

|Chest wounds: cover sucking wounds, leave impaled objects in. | |socks! |

|Monitor for hypoxia & evac fast. | |Warm with skin-to-skin contact. |

|Broken rib: point tenderness, sharp stabbing pain – sling & | |Sunburn: antihistamines, anti-inflammatories, cool the skin. |

|swathe. | |Cold/cough: rest, hydrate, check allergies & give appropriate |

|Abdominal wounds: no oral intake! Prevent dehydration by | |meds. |

|breathing through wet cloth. Compress & ice to reduce | |Diarrhea: replace electrolytes, hydrate. Evac if fever, |

|bleeding. Don’t stim circulation by walking. | |vomiting. |

|Lightning: CPR, check for trauma. | |Asthma: wheezing – use inhaler, caffeine, calm. If life threat,|

|Relax, think, keep yourself healthy – don’t create a second | |epinephrine – no antihistamines. |

|victim! | |Altitude: headache, fatigue, (LOC coughing. Rest, hydrate, go |

|Public domain – By Tom Shields – | |down. |

| | |Krause’s Principle: If you’re not having fun any more, go home!|

| | |Public domain – By Tom Shields – |

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