Medical Assessment Principles

Goals of Assessment

• Gather key information regarding the patient's condition.
• Evaluate the patient's health status systematically.
• Understand the patient's medical history.
• Assess overall health to inform treatment decisions.

Key Patient Information

• Essential details to collect include name, age, gender, and race.

Chief Complaint

• The primary symptom reported by the patient, which may not reflect its overall significance.

Symptoms and Signs

• Symptoms are problems or complaints indicated by the patient.
• Signs are observable conditions that can be seen, heard, felt, smelled, or measured.

SAMPLE History

• Acronym representing key history elements:
  • Signs/Symptoms
  • Allergies
  • Medications
  • Pertinent past history
  • Last oral intake
  • Events leading to illness/injury

OPQRST

• A mnemonic for assessing pain:
  • Onset
  • Provocation
  • Quality
  • Radiation
  • Severity
  • Time

Baseline Vital Signs

• Always includes:
  • Respiration rate
  • Pulse
  • Blood Pressure (BP)
  • Lung sounds

Additional Vital Signs

• May include skin temperature, capillary refill, pupil response, and level of consciousness (LOC).

Respiratory Assessment

• Assessments should include rate, quality, rhythm, effort, noise, and depth.
• Normal adult respiration: 12-20 breaths per minute.
• Normal child respiration: 15-30 breaths per minute.
• Normal infant respiration: 25-50 breaths per minute.

Pulse Oximetry

• Measures oxygen saturation of hemoglobin; normal reading is 95% or higher.
• Assess pulse based on rate, strength (bounding, strong, thready), and regularity.

Normal Pulse Rates

• Adult pulse: 60-100 beats per minute (bpm).
• Child pulse: 70-150 bpm.
• Infant pulse: 100-160 bpm.

Skin Assessment

• Evaluate color, temperature, and moisture of the skin.

Capillary Refill Check

• Squeeze the tip of a finger for 2 seconds, then release.
• Poor perfusion is indicated if refill takes longer than 2 seconds; useful in pediatric assessments.

Blood Pressure Insights

• A drop in blood pressure can indicate:
  • Blood loss
  • Loss of vascular tone
  • Cardiac pumping issues.
• Diastolic pressure indicates relaxation of ventricles; systolic pressure indicates blood pressure during ventricular contraction.
• Blood pressure expressed as systolic/diastolic in mmHg, with a healthy reading at 120/80.

Patient Assessment Methodology

• AVPU scale: Alert, Verbal, Pain response, Unresponsive.
• PEARRL assessment for pupils: Equal and round, regular in size, reactive to light.

Reassessment Intervals

• Stable patients require reassessment every 15 minutes.
• Unstable patients should be reassessed every 5 minutes.

Patient Assessment Components

• Scene size-up
• Primary assessment
• History taking
• Secondary assessment
• Reassessment

Body Substance Isolation (BSI)

• Recognizes risks from all body fluids.
• Equipment includes gloves, eye protection, masks, and gowns.

Scene Size-Up Considerations

• Review dispatch information, inspect the scene, identify safety concerns, determine mechanism of injury/nature of illness, triage patients, and request additional resources.

Potential Hazards

• Be aware of oncoming traffic, unstable surfaces, gas leaks, electrical hazards, potential violence, fires, smoke, hazardous materials, and crime scenes.

Scene Safety Protocols

• Prioritize safety of personnel and bystanders, park in a safe area, communicate with law enforcement, and call for additional resources if necessary.

Mechanism of Injury (MOI) and Nature of Illness (NOI)

• Assess MOI to evaluate possible injury extent based on force, duration, and affected body areas.
• For NOI, gather clues and listen for the chief complaint.

Subjective vs. Objective Data

• Symptom: Subjective data reported by the patient, family, or bystander.
• Sign: Objective data that can be observed or measured directly.

Additional Resources

• Can include requests for additional units, air transport, non-medical support, fire suppression, and rescue services.