Patient Assessment Part 1

Patient Assessment Overview

• Patient assessment includes the entire 911 call process, from dispatch to final checks before transferring care to hospital staff.

• Five main components of patient assessment:

  • Scene Size Up

  • Primary Assessment

  • History Taking

  • Secondary Assessment

  • Reassessment

Scene Size Up

• Purpose: Assess safety and necessary resources before entering the scene.

• Considerations:

  • What are we about to walk into?

  • What people and equipment do we need?

  • Do we require specialized resources?

Primary Assessment

• Focus on first impressions and immediate threats.

• Key Steps:

  • Establish a general impression of the patient and scene.

  • Identify and treat any life-threatening conditions immediately.

  • Conduct a rapid examination to evaluate how critical the patient is and determine transportation needs.

History Taking

• Goal: Gather pertinent information to assist in treatment and communication with hospital staff.

• Mnemonic: SAMPLE

  • S: Signs and Symptoms

  • A: Allergies

  • M: Medications

  • P: Past medical history

  • L: Last oral intake

  • E: Events leading to present illness/injury

Secondary Assessment

• Involves a detailed physical examination after identifying immediate threats.

• Goal: Ensure no injuries are missed.

• Important Note: Always expose the patient to adequately assess their condition.

Reassessment

• Purpose: Periodically evaluate the patient after initial treatment and during transport.

• Look for changes in condition and administer necessary treatments accordingly.

Information Gathering

• Collect information from various sources: dispatch, bystanders, family members, the patient, and examinations.

• Use this data to form a field impression of the patient's condition, guiding hospital choice and mode of transport.

Key Terms

• Symptoms: Subjective information reported by the patient (e.g., "I have chest pain").

• Signs: Objective findings observable or measurable (e.g., unequal chest rise).

Patient Case Examples

Case 1: 68-Year-Old Male

• Presentation: 10/10 crushing chest pain, tripod position, diaphoretic.

• Medical History: Diabetic, hypertensive.

• Signs/Symptoms: Pain radiating down the left arm.

• Assessment: Likely myocardial infarction (heart attack).

  • Symptoms: Crushing pain is alarming; risk factors include age, diabetes, and hypertension.

Case 2: 35-Year-Old Female

• Presentation: 10/10 sharp chest pain, struggles with sentences, recent long flight.

• Medical History: Smoker, on birth control.

• Assessment: Likely pulmonary embolism due to risk factors (smoking, prolonged immobility).

Case 3: Patient with Possible Tension Pneumothorax

• Presentation: 10/10 right-sided chest pain, accessory muscle use, absent lung sounds on the right side, JVD.

• Scenario: Involved in a head-on motor vehicle accident.

• Assessment: Indicators suggest tension pneumothorax due to trauma and related symptoms.