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Lesson 3: Secondary Assessment Emergency Reference Guide p

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1 Lesson 3: Secondary Assessment Emergency Reference Guide p. 20-22

2 Objectives State the importance of taking a personal history from victim & know how to do it Demonstrate taking a personal history Demonstrate a hands on physical exam Demonstrate how to take vital signs Demonstrate how to document information gathered

3 Getting the Whole Picture
After primary assessment comes a hands on secondary assessment Goal is to find EVERY problem Consider environment when removing clothing during checks Single person does exam, second person records results – why? SAMPLE history taken at this time

4 Getting the Whole Picture (cont’d.)
If patient can talk, take SAMPLE first If patient can’t talk, check with other members, use medical forms for info (i.e. allergies, medications, etc.) Document signs & symptoms Look for signs of injury Listen to victims words & responses Feel body parts

5 Taking a SAMPLE History
S = Signs & symptoms: Ask what hurts? What pain do they have, nausea, lightheadedness? A = Allergies: do they have any? Did they contact anything they are allergic to? M = Medications: on any, last time taken? P = Pertinent medical history: anything like this happened before? Existing conditions?

6 Taking a SAMPLE History (cont’d.)
L = Last intake & output: Last time ate or drank? Last time urinated or defecated? E = Events: What led up to this injury (Mechanism Of Injury)?

7 Skill Practice Break into pairs, one victim, one care giver Scenario:
“While clearing some downed limbs from the trail, a person is apparently stung by a bee.” Practice taking, and recording SAMPLE

8 Why Documentation is Important?
Responder’s ability to remember details is reduced due to stress/confusion Specific info helps rescue personnel know what they are facing Retention for legal/medical reasons Using a form helps you remember everything you need to look for/ask about

9 Documentation (cont’d.)
SOAP: S = subjective info (complaints) O = Objective info (i.e. physical exam, vital signs, SAMPLE A = Assess patient & situation, what do you think is wrong? P = Plan, what care do you give & how? Stay or evacuate?

10 Performing Hands On Physical Exam
Using MOI or SAMPLE record circumstances & estimate injuries Do not make assumptions about MOI Systematically check from head to toe Ask where it hurts Check all body parts, don’t cause unneeded pain

11 Performing Hand On Physical Exam (cont’d.)
Examples of Signs & Symptoms: Pale sweaty skin Nervousness Unnatural position of limbs Patient guarding an area or unable to move body part Looks for “DOTS”

12 DOTS DOTS stands for: D = Deformities, depressions, indentations and discoloration O = Open injuries, penetrating wounds, cuts, scrapes T = Tenderness S = Swelling

13 Performing Hands On Physical Exam
Check Circulation, Sensation, Motion Ask about pain first, then touch Note medical ID bracelets, necklaces Check pulse away from injury & away from heart (i.e. on hand or foot) Check for circulation in hands & feet Pinch & check for capillary refill (nail bed) If head/neck/back injury possible, ask patient to not move, help restrain from moving

14 Head to Toe Assessment

15 Head to Toe Assessment(cont’d)

16 Physical Exam Practice Session
Form into groups of 3: One victim 2 rescuers Perform SAMPLE Head to toe check

17 Taking Vital Signs Vital signs are a measure of the processes needed for life Changes in time indicate patient condition changing Take & record vital signs regularly Basic Set: Level of Responsiveness Breathing Rate Pulse Skin Color, Temp, Moisture (SCTM)

18 Level of Responsiveness
AVPU: Alertness A + Ox4: knows who, where, when, what A + Ox3: knows who, where, when A + Ox2: knows who, where A + Ox1: knows who V = Responds to verbal stimuli P = Responds to pain U = Unresponsive

19 Respiratory Rate/Heart Rate
Respiratory: Number breaths/min., note rhythm and quality: Normal for adults Place hand on chest to measure Note any unusual sounds Heart Rate (pulse): Measure at wrist, brachial artery, or neck Use 2 fingers (no thumb) Count for 30 seconds Note rhythm, quality (strength)

20 Skin Color, Temp, Moisture
Note any differences from normal: Skin Color should be pink (non-pigmented areas) Temperature should be warm Moisture: skin should be dry

21 Practice Session Form into groups of 3 One victim
One takes vital Signs One records

22 Re-Checking Resources
After patient assessment: Observe changing conditions in environment Getting unsafe for patient or you? Getting difficult to get help? What resources do you have, how can you use them? Do you need to move the patient?

23 Questions??? What else could you add to your First Aid Kit?

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