TRAUMA Patient Assessment (Conscious PT)

Question 1

Scene Size-Up Steps

Answer 1

1. BSI, Scene safety
2. Have trained assistant stabilize the patients neck
3. Determine the patient’s mechanism of injury, how patient’s you have and any other resources you may need and call for ALS
4. Introduce yourself to the patient and ask them what happened

Question 2

Primary Assessment Steps

Answer 2

1. Determine a generalized impression of the patient
2. Check the patient’s mental status to see if they are alert, responsive to verbal stimuli, responsive to pain, or if the are unconscious (AVPU). Since the patient is conscious ask them what happened, what month we are in, what year it is, what time of day is it, where are we right now, and how many quarters are in a dollar.
3. Determine the patient’s chief complaint and have trained assistant tend to and deformities the patient might have by stabilizing it and splinting the injury.
4. Airway- Determine that the patient’s airway is open due to them talking. Ask the patient to open their mouth to see if there is anything in their throat that might cause an airway obstruction or any loose or lost teeth.
5. Breathing- Check the patients lung sounds in the 4 spots, compare their breathing to mine by placing your hands on theirs and your abdomen and breathing. Check for equal lung expansion by placing hands under the patient’s ribs and asking them to take a deep breath. Expose the patients chest to check for any penetrating chest trauma. Place the patient on oxygen with a non-rebreather mask set to 12-15 liters of oxygen per minute. And if the NRB is too much give the patient a nasal cannula with the oxygen set to 6 liters per minute.
6. Circulation- check if the patient has a pulse, their skin color, temperature, and condition; and check to see if there is any blood in the voids
7. Decide to rapidly transport the patient to the hospital, update crew by radio about the patient’s condition and their injuries (if any)
8. Perform a rapid head to toe assessment of the patient

Question 3

History and Secondary Assessment Steps

Answer 3

1. Obtain a SAMPLE from the patient; Determine their signs and ask if they are having any symptoms of then their chief complaint, Ask if the have any allergies, taking any medications currently, their past medical history, the last time they ate something before the accident, and if they remember what happened before their accident occurred.
2. Perform a full body assessment on the patient: Check their head for any abrasions or lacerations, check their face for any bruising, lacerations and if the jugular veins are distended, check their ears for any blood or fluid and battle signs behind the ears, check their nose to see if there is any blood or fluid. Palpate the patient’s abdomen to check for any distention or lacerations, re-check the patient’s breath sounds. Palpate the patients shoulder to check for contusions or abrasions, Palpate l&r arms for any lacerations, abrasions or contusions, check for PSM (pulse, motor sensory) ask the patient what finger your touching, have them wiggle their finger and check for a pulse AGAIN, Palpate l&r legs for any lacerations, abrasions or contusions, check for PSM (pulse, motor sensory) ask the patient what finger your touching, have them wiggle their toes or push foot down like pressing on a gas pedal and check for a pulse AGAIN
3. Assess the patient’s hips for any fractures or dislocations by pressing in and down. Also check if there is any fluid or blood (females) or an erection (males) present.
4. Log roll the patient over onto their side to check the patients spine, back of both arms and legs and butt for any deformities, lacerations or contusions. Have trained assistant place a backboard underneath the patient to help with assisting the patient to the stretcher.
5. ASK for the patient’s blood pressure, pulse rate and quality, respirations rate and quality. Re-say that the patient’s skin is pink, warm and dry
6. Update crew via radio about the patients condition and that we have a rapid transport to the hospital

Question 4

Reassessment Steps

Answer 4

1. Update crew via radio about the patients condition and that we have a rapid transport to the hospital
2. Re-check the patient’s vitals everything 15 minutes, re-check the patients ABC’s and load the patient and transport rapidly to the hospital