EMR Trauma Patient Assessment

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Author:
Scott57
ID:
274559
Filename:
EMR Trauma Patient Assessment
Updated:
2014-05-16 01:19:03
Tags:
Patientassessment trauma
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Description:
EMR Trauma Patient Assessment
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  1. FIRST STEP
    BSI!!!!
  2. Scene Size up
    • 1. Determines the scene is safe
    • 2. Determines mechanism of injury/nature of illness
    • 3. Requests additional EMS if necessary
    • 4. Considers stabilization of spine
  3. Primary Assessment
    • 1. Determine responsiveness/ level of Consciousness.
    • 2. Determine Chief complaint/ apparent life-threats.
    • 3. Assess Airway
    • 4. Assess Breathing
    • 5. Assess circulation
    • 6. Identifies patient Priority and makes treatment/ transport decision.
  4. Assess Airway
    • Open and assess the airway
    • Insert Adjunct as indicated
  5. Assess Breathing
    • Assess Breathing
    • Initiates appropriate oxygen therapy
    • Assures adequate ventilation
    • Manages any injury which may compromise breathing/ ventilation.
  6. Assess Circulation
    • Check Pulse
    • Assess skin (color, temperature, condition)
    • Assesses for and controls major bleeding if present
    • Initiates shock management (positions properly, and conserves body heat)
  7. History Taking
    Attempts to obtain SAMPLE history
  8. Secondary Assessment
    • Head
    • Neck
    • Chest
    • Abdomen/Pelvis
    • Lower Extremities
    • Upper Extremities
    • Posterior Thorax, Lumbar and Buttocks
  9. Head
    • Inspects and palpates scalp and ears
    • Inspects mouth, nose, and assesses facial areas.
    • Assesses eyes
  10. Neck
    • Checks position of trachea
    • Checks Jugular veins
    • Palpates Cervical Spine
  11. Chest
    • Inspect chest
    • Palpate Chest
    • Auscultates chest
  12. Abdomen/ Pelvis
    • Inspects and Palpates abdomen
    • Assesses the pelvis
    • Verbalizes assessment of genitalia as needed
  13. Lower extremities
    Inspects, palpates and assesses motor, sensory, and distal circulatory function.
  14. Upper Extremities
    Inspects, palpates and assesses motor, sensory, and distal circulatory function.
  15. Posterior Thorax, Lumbar and Buttocks
    • Inspects and palpates posterior thorax.
    • Inspects and palpates lumbar and buttocks areas.
  16. Vital Signs
    • Obtain baseline vital signs (Blood Pressure, Pulse, Respiration rate)
    • Manages secondary injuries and wounds appropriately.
  17. Reassessment
    Demonstrate how and when to reassess the patient.

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