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Patient Assessment—Medical Patient

26 January 2019 - 21:58 | Version 2 | | , |

Skill
CPI
Scene Size-up   
Details
Initial arrival on scene of accident/injury, assessment of site, and contact with patient:
  1. Scene Safe - Determine scene is safe
  2. Introduce/Permission - Introduce yourself and ask permission to check out
  3. Standard Precautions
  4. MOI
    /
    NOI
    - Chief Complaint
  5. LOR
  6. General impression
Determines scene is safe  
Introduces self, obtains permission to help/treat.   
Script
"Hi, my name is … and I'm with the ski patrol. Is it alright if I examine you and see what we can do to help you out?"
Initiates Standard Precautions   
Related
Removing Contaminated Gloves
Determines the MOI (mechanism of injury) and/or NOI (nature of illness)—patient’s chief complaint.  
Identifies the number of patient(s) and the
LOR
of each.  
Forms general impression—evaluates any extrication issues for each patient(s); considers c-spine stabilization/immobilization.  
Primary Assessment  
Assesses airway, breathing, circulation (
ABCDs
)   
Details
ABCDs
Assists breathing, manages/treats life threats.  
Confirms and monitors
LOR
(
AVPU
or GCS).  
Calls for transport, equipment, and/or additional assistance, EMS if needed.  
Secondary Assessment  
Performs detailed head-to-toe body assessment physical exam
DCAP-BTLS
.   
Details
DCAP-BTLS
Obtains SAMPLE history   
Details
SAMPLE
Based on the chief complaint, gathers information by asking OPQRST questions.   
Details
OPQRST
Obtains baseline set of vitals.  
Provides interventions per protocols.  
Treats for shock.  
Maintains spinal immobilization if applicable.  
Prepares patient for transport  
Reassesses vital signs and primary assessment  

Chapter: 7
Page: 255

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