P.S.E. 1-A

PATIENT ASSESSMENT MEDICAL

SCENE SIZE-UP

“Is the scene safe?”

“Am I wearing enough BSI/PPE?”

“What is the MOI or NOI?”

“How many patients do I have?”

“Do I need additional resources?”

PRIMARY ASSESSMENT

L - Identify any Life threats if patient is unconscious / Determine chief complaint

I - General Impression (describe what you see about the patient i.e. age, sex, position)

S - Spinal precautions(have someone hold head stabilization if needed)

A- Establish A.V.P.U.(Person, Place, and Time of day)

AIRWAY (Done at the mouth)

O –OPEN the airway (Jaw Thrust for Trauma)

C – CLEAR (Suction as necessary)

M – MAINTAIN (Airway adjunct if needed –OPA/ NPA) or Pt. can self-maintain?

BREATHING(Done at the chest)

LOOK - Inspect the chest (expose as needed, look for chest rise and fall, and any visible trauma)

LISTEN - Auscultate lungs (mid-clavicle or mid-axillary; for equal and bilateral sounds)

FEEL - Palpate the chest (feel the entire chest)

GAS- Giveoxygen. If breathing is Adequate,useN.R.B. 15 lpm orif breathing is

Inadequate,use B.V.M 15lpm

CIRCULATION

V - Voids (check for major bleeding and by asking pt. if they have bloody stool/urine/vomit)

C -Carotid pulse (ONLY if unconscious)

R -Radial pulses (check BOTH wrists)

S - Skin Color, Temperature, Condition, Capillary Refill (CTCC)

Treat for shock (as needed), treat for hypo-perfusion (keep warm and elevate the feet)

IDENTIFY PRIORTY PATIENTS

Update responding EMS UNIT with brief report.

Critical … Unstable … Potentially unstable … Stable

C,U, or P = LOAD and GO! Rapid Body Scan (collar/backboard Pt.)

S = STAY and PLAY = Thorough Assessment of Present Injury/Illness

HISTORY / SECONDARY ASSESSMENT

ASSESS APPROPRIATE BODY SYSTEM

  • Cardiovascular
/
  • Integumentary

  • Pulmonary
/
  • GI/GU

  • Neurological
/
  • Reproductive

  • Musculoskeletal
/
  • Psychological/Social

O -Onset “When did this episode or problem begin?”

P- Provokes “What makes it worst and/or better?”

Q -Quality “In your own words how does this episode or problem feel?”

R -Radiate “Does this episode move and/or affect you somewhere else?”

S- Severity “On a scale of 1-10, 10 being the worst, how would you rate this episode?”

T -Time“Have you had the symptoms the whole time or has it/they come and gone?”

Baseline set of vitalsB.E.R.P.S

S- Signs and Symptoms “Is there anything else bothering you?”

A- Allergies “Are you allergic to any Medications, Foods or Environment?

M -Medications “Are you taking any Medications?”

P- Past/Pertinent History “Have you had this problem before?”

L- Last Oral Intake “When was the last time you ate or drank anything?”

E -Events Leading To Injury or Illness “Tell me how this all started?”

RE-STATE GENERAL IMPRESSION

Interventions

Assist or Administer Medication as per PROTOCOLS (5 rights)

RE-ASSESSMENT

Consists of repeating and / or reassessing:

Re-assess Vitals

Re-assess Injuries / Interventions

Re-assess Primary assessment (ABCs)

Update Other EMS/Receiving Hospital

5 min. for Unstable Pt.

15 min. Stable Pt.

VERBALIZEpatient reporttonext appropriate care giver.

*ALL IN 10 MINUTES*