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Patient Assessment Techniques Guide

The document provides an overview of patient assessment, detailing the primary and secondary surveys used in trauma and medical situations. It outlines the steps for assessing the patient's condition, including mechanisms of injury, vital signs, and a structured history taking approach using the SAMPLE acronym. Additionally, it includes specific assessment tools such as the Glasgow Coma Scale and Revised Trauma Score for evaluating patient responsiveness and severity of injury.

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5 views2 pages

Patient Assessment Techniques Guide

The document provides an overview of patient assessment, detailing the primary and secondary surveys used in trauma and medical situations. It outlines the steps for assessing the patient's condition, including mechanisms of injury, vital signs, and a structured history taking approach using the SAMPLE acronym. Additionally, it includes specific assessment tools such as the Glasgow Coma Scale and Revised Trauma Score for evaluating patient responsiveness and severity of injury.

Uploaded by

Reese
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Module 6 Patient Assessment Overview

Patient Assessment Overview

1 PRIMARY SURVEY
MECHANISM OF INJURY (MOI) - TRAUMA

NATURE OF ILLNESS (NOI) - MEDICAL

BSI – BLOOD SUBSTANCE ISOLATION

HHH - ABC (CONSCIOUS PT.) /HHH - CAB (UNCONSCIOUS PT.)

In almost every situation – following steps are excellent guidelines to follow:


H Hazards Is the scene safe to approach the pt.
H Help Send for help if needed – e.g. fire brigade
H Hello
A Airway Is pt. airway clear and free of debris?
B Breathing Is pt. breathing?
C Circulation Does pt. have pulse?
And or obvious bleeding?

TRIAGE

2 SECONDARY SURVEY
GENERAL APPEARANCE
PT. POSITIONING
BEHAVIOUR
OBVIOUS WOUNDS AND DEFORMITIES
SKIN

HISTORY – S A M P L E

Signs and Symptoms Signs is something you see


Symptoms is what the pt. tells you
Allergies Ask – are you allergic to anything like medication like aspirin or food like peanuts
Medication Are you on chronic medication or taking medication for anything like flu or heart
problems
Past medical history This question needs to include the pt. as well as the pt. family
(pt. may not have past heart problems but pt. parents or family may have heart
problems)
Last meal When was the last time the pt. ate or had something to eat
Events leading up to the What was the pt. doing before the pain started
event

HISTORY OF CHIEF COMPLAINT


 Ask the flowing questions: O P Q R S T
Onset When did the pain start / begin?
Provokes What provokes the pain?
E.g. was the pt. exercising?
Quality What is the quality of pain?
Crushing / stabling / feels like someone is sitting on their chest
Radiation / Radiating Is the pain radiating?
i.e. to the jaw, arms, abdomen, back
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Module 6 Patient Assessment Overview

Severity How sever is the pain?


Scale of 1 – 10? 10 being the worse the pt. has ever felt
Time How long has the pain lasted? 1 hour
And is the pain constant or does it come and go and for how long

VITAL SIGNS
 Pulse rate / rhythm / strength
 Respiration rate / rhythm / depth
 Air entry
 Haemoglucose test (HGT)
 Blood pressure
 Pupils
 Glasgow coma scale
 Revised trauma score
 Skin colour and temperature
 Capillary refill

GLASGOW COMA SCALE (VALUE OUT OF 15)

/15 Visual Response Verbal Ability Motor Skills


1 Eyes don’t open None No movement
2 Pain causes eyes to open Incomprehensible words / sounds Abnormal extension to pain
3 Voices cause eyes to open Inappropriate words Abnormal flexion to pain
4 Spontaneous Minimal / confused Withdraws from pain
5 -------------------- Orientated Localizes pain
6 -------------------- -------------------- Moves on command
Lowest score you can get is 3

REVISED TRAUMA SCORE

/12 GCS Systolic BP Resp Rate


4 13 – 15 >90 10-29
3 9 – 12 76 – 89 >29
2 6–8 50 – 75 6–9
1 4–5 1 – 49 1-5
0 3 0 0
Lowest score you can get is 3

HEAD – TO – TOE
Head
Ears
Nose
Eyes
Mouth
Neck
Chest
Abdomen
Pelvis
Genitalia
Extremities

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