Flashcards in Patient Assessment System Deck (15):
SOAP stands for...
- story, scene, MOI, S/Sx
- SAMPLE History if relevant
- Exam findings (see, hear, feel, smell)
- Vital signs
- A, problem list
- A', anticipated problems
- Rx for each existing problem
- Evac and/or monitoring for A'
SAMPLE stands for...
ALLERGIES: meds, food, environment; type, severity of prior reactions)
MEDICATIONS: even vitamins, homeopathic
PERTINENT history: previous similar S/Sx? contributing factors?
LAST ins/outs: food, liquids, normal urine, bowel, menstrual cycle.
EVENTS: what happened? Remember (frame by frame)? TBI? Consider mixed mechanisms.
Pulse: resting adult
Respiration: resting adult
Blood Pressure: normal (systolic/diastolic)
Temperature: normal core
37 degrees Celsius (98.6 F)
Vitals: list 5
Skin (color, temp, moisture)
PAS: 1st Triangle
Scene Size Up
(1) Safety: personal> partner> public> patient
(2) MOI: Trauma, medical, environmental
(3) Number: patients + responders
- Ask Qs! Don't just react, act. "Don't just do something, stand there!" Protect yourself.
PAS: 2nd triangle
Initial (Primary) Assessment: Stabilize Pt, quick, BLS, order of concern depends on scene
(1) Respiratory: Airway, Breathing
(2) Circulatory: Pulse, Bleeding
(3) Nervous: AVPU (LOC?), Spine (MOI?)
PAS: 3rd triangle
Focused History + Physical Exam (secondary assessment)
(1) Physical Exam: Local, Full head to toe
(2) SAMPLE History
(3) Vital Signs
"Complete then Treat" - injury that is most painful and complained about is not necessarily the most important.
3 critical systems and major problems each?
Nervous: Brain Dysfunction
Personal Safety: 3 p's + B + universal precautions
Poop, pee, puke + Blood
Eye protection, gloves, protective clothing...
We do not profile patients; everybody is a walking bag of funk...
HIV- hard to actually get for 1st responders
Hep B - more prevalent in blood (get vaccinated)
Hep A - fecal/oral contact
Hep C - no vaccine
Symptoms: what to ask, look for?
Onset (+ progression)
Provokes - causes, makes worse or better?
Quality- dull, sharp, burning?
Severity - 1 to 10 (relative over time)
Time - change over time
Allergies: Qs to ask
People make up their own allergies…
Q: Ever been to hospital for…?
Q: Ever taken medication for…?
Q: What happens when you come into contact with…?
Q: Allergic to anything else?
Q: What have you eaten today?
Q: When did you eat it?
Q: Who gave it to you?
Ask questions you really want to answers to.