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    Niki Cheeru

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    Niki Cheeru
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    01 PDF

    Uploaded by

    Niki Cheeru

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    © All Rights Reserved
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    of 1

    Patient Assessment/Management—Trauma

    Start Time: ________________

    Stop Time: ________________ Date: _____________________


    Candidate’s Name: _________________________________________________________
    Points Points
    Evaluator’s Name:__________________________________________________________ Possible Awarded
    Takes, or verbalizes, body substance isolation precautions 1
    SCENE SIZE-UP
    Determines the scene is safe 1
    Determines the mechanism of injury 1
    Determines the number of patients 1
    Requests additional help if necessary 1
    Considers stabilization of spine 1
    INITIAL ASSESSMENT
    Verbalizes general impression of the patient 1
    Determines responsiveness/level of consciousness 1
    Determines chief complaint/apparent life threats 1
    Assessment 1
    Assesses airway and breathing Initiates appropriate oxygen therapy 1
    Ensures adequate ventilation 1
    Injury management 1
    Assesses/controls major bleeding 1
    Assesses circulation Assesses pulse 1
    Assesses skin (color, temperature and condition) 1
    Identifies priority patients/makes transport decision 1
    FOCUSED HISTORY AND PHYSICAL EXAMINATION/RAPID TRAUMA ASSESSMENT
    Selects appropriate assessment (focused or rapid assessment) 1
    Obtains, or directs assistant to obtain, baseline vital signs 1
    Obtains SAMPLE history 1
    DETAILED PHYSICAL EXAMINATION
    Inspects and palpates the scalp and ears 1
    Assesses the head Assesses the eyes 1
    Assesses the facial areas including oral and nasal areas 1
    Inspects and palpates the neck 1
    Assess the neck Assesses for JVD 1
    Assesses for tracheal deviation 1
    Inspects 1
    Assesses the chest Palpates 1
    Auscultates 1
    Assesses the abdomen 1
    Assesses the abdomen/pelvis Assesses the pelvis 1
    Verbalizes assessment of genitalia/perineum as needed 1
    1 point for each extremity 4
    Assesses the extremities includes inspection, palpation, and assessment of motor,
    sensory and circulatory function
    Assesses the posterior Assesses thorax 1
    Assesses lumbar 1
    Manages secondary injuries and wounds appropriately 1
    1 point for appropriate management of secondary injury/wound
    Verbalizes reassessment of the vital signs 1

    TOTAL 40
    Critical Criteria
    ___ Did not take, or verbalize, body substance isolation precautions
    ___ Did not determine scene safety
    ___ Did not assess for spinal protection
    ___ Did not provide for spinal protection when indicated
    ___ Did not provide high concentration of oxygen
    ___ Did not find, or manage, problems associated with airway, breathing, hemorrhage or shock (hypoperfusion)
    ___ Did not differentiate patient’s need for transportation versus continued assessment at the scene
    ___ Did other detailed physical examination before assessing airway, breathing and circulation
    ___ Did not transport patient within (10) minute time limit

    Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company

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