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Flashcards in Patient Assessment System Deck (15):
1

SOAP stands for...

Subjective:
- story, scene, MOI, S/Sx
- SAMPLE History if relevant
Objective:
- Exam findings (see, hear, feel, smell)
- Vital signs
Assessment:
- A, problem list
- A', anticipated problems
Plan:
- Rx for each existing problem
- Evac and/or monitoring for A'

2

SAMPLE stands for...

SYMPTOMS: OPQRST
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.

3

Pulse: resting adult

60-100 beats/min

4

Respiration: resting adult

12-24 breaths/min

5

Blood Pressure: normal (systolic/diastolic)

100-140/60-90

6

Temperature: normal core

37 degrees Celsius (98.6 F)

7

Vitals: list 5

Pulse
Respiration
Blood Pressure
Temperature
Skin (color, temp, moisture)
AVPU

8

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.

9

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?)

10

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.

11

3 critical systems and major problems each?

Circulatory: Shock

Respiratory: Failure

Nervous: Brain Dysfunction

12

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

13

Symptoms: what to ask, look for?

OPQRST

Onset (+ progression)
Provokes - causes, makes worse or better?
Quality- dull, sharp, burning?
Radiates
Severity - 1 to 10 (relative over time)
Time - change over time

14

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.

15

Radio: 4 key pieces of info

1- Location, situation, scene
2- Plan + support requested
3- Patient + problem list
4- Additional info as needed