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Patient Assessment
Objective: To demonstrate the proper assessment of a patient, to determine a baseline, and to select the appropriate transport method.

27 January 2019 - 02:58 | Version 2 | | Assessment, Skill Guide | Assessment

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
Checks for and controls any major bleeding.   
Related
Controlling Bleeding
Confirms and monitors
LOR
(
AVPU
or GCS).  
Calls for transport, equipment, and/or additional assistance.  
Secondary Assessment  
Performs detailed head-to-toe body assessment physical exam
DCAP-BTLS
.   
Details
DCAP-BTLS
Obtains
SAMPLE
history from patient and/or witness (if available).   
Details
SAMPLE
Obtains baseline set of vitals.  
Provides interventions per protocols.  
Treats for shock.  
Maintains spinal immobilization if applicable.  
Prepares patient for transport  

Chapter: 7
Page: 252

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