Assessment OEC 101808 Rev 2

8/8/2019 Assessment OEC 101808 Rev 2

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POWDER RIDGEPOWDER RIDGE

SKISKIPATROLPATROL

Fall 2008 Connecticut Region

Patroller OEC Refresher

PATIENT

ASSESSMENT

(10/18 &10/25)


2/13

AssessmentAssessmentHarry Frank

Enchanted Forest Nordic Ski Patrol

Red River, New Mexico

adapted from


3/13

The Importance ofThe Importance of

Assessment inAssessment inEmergency CareEmergency Care

Treat and transport according to

your assessment.

Recognize compromises in

patients anatomy and physiology,

especially life-threatening ones

ASSESSMENT.

Understand normal anatomy and

physiology.

Establish safety of patient, rescuer

and bystanders.


4/13

OverviewOverview

Scene

Size-up

BSI & Scene Safety

MOI / NOI

Request Additional AssistanceConsider C-Spine Immobilization

Determine Number of Patients

BSI & Scene Safety

MOI / NOI

Request Additional AssistanceConsider C-Spine Immobilization

Determine Number of Patients

Initial

Assessment

General Impression of Patient

LOR

Assess & Stabilize ABCs

Initiate Transport DecisionIdentify Priority Patients

General Impression of Patient

LOR

Assess & Stabilize ABCs

Initiate Transport DecisionIdentify Priority Patients

Rapid BodySurvey

Baseline Vitals

SAMPLE History

Rapid Transport

Rapid BodySurvey

Baseline Vitals

SAMPLE History

Rapid Transport

Focused or RapidBody Survey

Baseline Vitals

SAMPLE History

Rapid Transport

Focused or RapidBody Survey

Baseline Vitals

SAMPLE History

Rapid Transport

History of IllnessSAMPLE History

Focused Physical

Exam

Baseline Vitals

Rapid Transport

History of IllnessSAMPLE History

Focused Physical

Exam

Baseline Vitals

Rapid Transport

Detailed Physical ExamDetailed Physical Exam(Whole Body Survey)(Whole Body Survey)

Detailed Physical ExamDetailed Physical Exam(Whole Body Survey)(Whole Body Survey)

Monitor patient for changes in

Vitals

CMS

Skin color, temperature, moisture

Monitor patient for changes in

Vitals

CMS

Skin color, temperature, moisture

UnresponsiveUnresponsive

PatientPatient

UnresponsiveUnresponsive

PatientPatientResponsiveResponsive

Trauma PatientTrauma Patient

ResponsiveResponsive

Trauma PatientTrauma Patient


Medical PatientMedical Patient


Medical PatientMedical Patient

Ongoing AssessmentOngoing AssessmentOngoing AssessmentOngoing Assessment


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Unresponsive PatientUnresponsive Patient

Scene SizeScene Size--UpUpScene SizeScene Size--UpUp

Initial SurveyInitial SurveyInitial SurveyInitial Survey

Rapid Body SurveyRapid Body Survey(Down, Out, & Back)(Down, Out, & Back)

HeadHead PelvisPelvis

NeckNeck Lower ExtremitiesLower Extremities

ChestChest

Upper ExtremitiesUpper Extremities AbdomenAbdomen BackBack

DeCAP BoTtLeSDeCAP BoTtLeS CMSCMS

DDeformitieseformities

CContusionsontusions

AAbrasionsbrasions

PPuncturesunctures/ P/ Penetrationsenetrations

BBurnsurns/ B/ Bleedingleeding

TTendernessenderness

LLacerationsacerations

SSwellingwelling

CCirculationirculation

MMotionotion

SSneezingneezing


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Vital SignsVital Signs

Respirations

Pulse Blood Pressure

Temperature

Skin temperature and condition Cap refill

Pupillary Reaction

LOR AV

PU, Glasgow Coma


7/13

Unresponsive PatientUnresponsive Patient

Baseline Vital SignsBaseline Vital Signs

Provide Needed TreatmentProvide Needed Treatment

Reevaluate Transport DecisionReevaluate Transport Decision


SAMPLE HistorySAMPLE History(from witnesses, companions, family)(from witnesses, companions, family)

SSigns /igns / SSymptomsymptomsAAllergiesllergies

MMedicationsedications

PPast medical historyast medical history

LLast oral intakeast oral intake

EEvents leading up to incidentvents leading up to incident


8/13

Responsive Trauma PatientResponsive Trauma Patient



Significant MOISignificant MOI

Rapid Body SurveyRapid Body SurveyDeCAP BoTtLeSDeCAP BoTtLeS

CMSCMS


SAMPLE HistorySAMPLE History

ImmediateImmediate

TransportTransport


9/13

Responsive Trauma PatientResponsive Trauma Patient



Significant MOISignificant MOI No Significant MOINo Significant MOI

Rapid Body SurveyRapid Body SurveyDeCAP BoTtLeSDeCAP BoTtLeS

CMSCMS

Focused Body SurveyFocused Body SurveyBased on ChiefBased on Chief

ComplaintComplaint



ReevaluateReevaluate

Transport DecisionTransport Decision

ImmediateImmediate

TransportTransport

Detailed Physical ExamDetailed Physical ExamWhole Body SurveyWhole Body Survey

DeCAP BoTtLeSDeCAP BoTtLeS

CMSCMS

Detailed Physical ExamDetailed Physical ExamWhole Body SurveyWhole Body Survey

DeCAP BoTtLeSDeCAP BoTtLeS

CMSCMS



10/13

History of IllnessHistory of IllnessFeverFever

Pain (including headache)Pain (including headache)

Variation from Normal FunctionVariation from Normal Function

Responsive Medical PatientResponsive Medical Patient



OOnsetnset

PProvocationrovocation

QQualityuality

RRadiationadiation

SSeverityeverity

TTimeime


NonspecificNonspecificweakness, fever, sleep habits,weakness, fever, sleep habits,

appetite, weight loss, etcappetite, weight loss, etc

RespiratoryRespiratory DigestiveDigestive

CirculatoryCirculatory GenitourinaryGenitourinary

Musculoskeletal / CNSMusculoskeletal / CNS CutaneousCutaneous

OPQRSTOPQRST


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Responsive Medical PatientResponsive Medical Patient

HeadHeadInspect pupils, throat, tonsils.Inspect pupils, throat, tonsils.

NeckNeckPalpate for tenderness, enlarged nodes, swelling.Palpate for tenderness, enlarged nodes, swelling.

Ask patient to touch chest with chin.Ask patient to touch chest with chin.

Listen for hoarseness.Listen for hoarseness.

ChestChestListen for wheezes, rattles, crackling, etc.Listen for wheezes, rattles, crackling, etc.

Inspect & note color of oral or nasal discharge fromInspect & note color of oral or nasal discharge from

productive cough.productive cough.Abdomen & PelvisAbdomen & Pelvis

Palpate for distention, rigidity, masses, tenderness.Palpate for distention, rigidity, masses, tenderness.

Listen for gurgles.Listen for gurgles.

Skin & ExtremitiesSkin & Extremities

Inspect for wounds, swelling, redness, tenderness,Inspect for wounds, swelling, redness, tenderness,

discharge or red streaks.discharge or red streaks.

Inspect ankles for edema.Inspect ankles for edema.Compare strength of symptomatic limb with nonCompare strength of symptomatic limb with non-- symptomaticsymptomatic

limb.limb.

BackBackPalpate for tenderness or muscle rigidity in flanks.Palpate for tenderness or muscle rigidity in flanks.


Provide Needed TreatmentProvide Needed TreatmentReevaluate Transport DecisionReevaluate Transport Decision

Detailed Physical ExamDetailed Physical ExamDetailed Physical ExamDetailed Physical Exam


Medical Focused Physical Exam (per chief complaint)Medical Focused Physical Exam (per chief complaint)


12/13

If at Any Time in the Assessment

Patient

y Looks Seriously Illor

y Exhibits Abnormal ABCs

or

y Presents Poor Impression

yArrange forimmediate transport

to medical care

If at Any Time in the Assessment

Patient

y Looks Seriously Illor

y Exhibits Abnormal ABCs

or

y Presents Poor Impression

yArrange forimmediate transport

to medical care


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SUMMARY

Scene Size-Up

SCENE SAFETY BSI

Initial Assessment

LOR-AVPU, ABCs

Look for life threatening injuries/illness

Transport decision

Assessment of Unresponsive,

Responsive-Trauma/Med

Vitals, SAMPLE, DCAPBTLS, OPQRST

Detailed & Ongoing Assessment

SUMMARY

Scene Size-Up

SCENE SAFETY BSI

Initial Assessment

LOR-AVPU, ABCs

Look for life threatening injuries/illness

Transport decision

Assessment of Unresponsive,

Responsive-Trauma/Med

Vitals, SAMPLE, DCAPBTLS, OPQRST

Detailed & Ongoing Assessment

Documents

Assessment OEC 101808 Rev 2