Patient Assessment Script Flashcards
(15 cards)
BSI SCRNE SAFETY
ENAMES
Environment, Number of Patients, Additional resources, Mechanism of Injury/Nature of Illness, Extrication Needs, Consider Spinal Precautions
Primary Assessment
General Impression:
What does my gut tell me?
What do I see as I approach?
Level of Consciousness
Alert? Verbal? Pain? Unresponsive?
Alert and Oriented
Person - Can you tell me your name?
Place - Do you know where you are?
Time - Do you know what the date is? Month?
Event - Can you tell me why me and my partner are here?
CC ALT
Chief complaint
Apparent life threats
A
Airway:
Open
Clear
Maintained
B
Breathing-
Are they breathing? Is it adequate?
Rate Rhythm Quality
Expose and treat
Lung sounds
O2 sat
O2 admin
C
Circulation-
Skin
CCT
Condition
Color
Temperature
Pulse- rate rhythm quality
Bleeding sweep
Capillary refill
Treat for shock
D
Decision
Stay and play of load and go
Big sick vs little sick
Medical - Secondary assessment
OPQRST
Onset- what were you doing when the pain started?
Provocation- does anything make the pain better or worse?
Quality- What does it feel like in your own words?
Radiation- point to where it hurts, does it move?
Severity- on a scale of 1-10 how bad does it hurt?
Time- how long have you been feeling this pain?
SAMPLE
Signs(self) and symptoms(patient)
Allergies
Medications, otc, prescription, recreational
Pertinent medical history- when was the last time you were in the hospital and why?
Events leading up to- what were you doing before the pain started
VIIRR
Vitals
Impression
Interventions
Reassess
Report
Report- radio
Age
Gender
Cc
Vitals(bp, rr, hr, pulse, spo2?)
Interventions
ETA
Report- TOC
TOC- transfer of care
Age
Gender
Cc
Hx
MOI/NOI
Sample
Vitals(full set)
Intervention
Trauma - Secondary Assessment
Rapid head to toe
Emphasis on kill zones
Attempt to obtain sample
