eSigning Occupational First Aid Patient Assessment Made Easy

Signature occupational first aid patient assessment

welcome to EMT prep comm this is the patient assessment management medical skill welcome to the medical patient assessment and management practical assessment here we will evaluate your ability to assess a patient interview them and verbalize the treatment of all conditions you find as you move through the skill evaluation I want you to voice everything you are assessing during the assessment you will have two EMT partners to assist you I may have to clarifies treatments with you during the assessment as they arise you have 15 minutes to complete this skill you may take this time to review the equipment before you you arrive on scene to a 24 year old female who's complaining of difficulty breathing your scene is safe and you may begin the assessment at the patient's side ok psi is my scene save your scene a safe all right so based on my dispatch information my patients nature of illness is respiratory distress or difficulty breathing is this my only patient this is your only patient ok right off the bat I'm going to request an ALS ambulance allas ambulances in route all right based on the nature of illness and my patients presentation I don't think c-spine is something that I need to consider so general impression is I have a 24 year old female seated in the tripod position having difficulty breathing as I walked in the door she's alert and conscious so I'm going to give her an a4 level of consciousness so ma'am my name is Dan I'm with the ambulance what seems to be the problem today my chest just feels really tight okay and it seems like you're having some difficulty breathing is not right yeah okay so her chief complaint is again difficulty breathing so the first thing I'm going to do is move through my ABCs a airway as I listen to her can I hear air moving through just fine do I hear straighter or anything like that she is having difficulty breathing okay she is moving good air okay so she's moving air well enough so breathing I would assess a respiratory rate either with a stethoscope or by staying or watching and counting what what is her respiratory breathing at 24 times per man okay so along with the breathing I also want to listen to lung sounds so can you take a couple of deep breaths for me all right last deep breath okay what are my lung sounds you have wheezes in all fields alright based on that I'm going to go ahead and put my patient on High Flow oxygen right now I'm going to use a non rebreather and go at 15 liters per minute you can verbalize putting the oxygen on the patient okay so after breathing we're going to move on to circulation first I'll check a pulse what is my pulse rate pulse is present and it's at 96 beats per minute okay do I do I know any major bleeding no major bleeding okay and then moving on to skin skin color looks pale do I know any cyanosis anywhere no cyanosis okay and as I feel it does she feel warm does she feel cold normal temperature okay and do I notice is her skin wet is she sweating anything like that no okay so I'm going to go ahead and make this a priority patient will try and transport her as quickly as possible so next I'll move on to my my Oh pqrst so ma'am how long ago to this start okay and what were you doing when this started what provoked this I was just watching TV okay just watching TV and can you describe the feeling for me yeah it just feels really tight in my chest okay and on a scale of one to ten zero being not difficult to breathe ten being I can't breathe it all we're to rate this me about 1/8 okay and again how long has this been going on for for an hour okay so and then after I've got my Opie qrst done I'll move on to my sample and try and get a little bit more information so do you have any allergies yeah I'm allergic to penicillin so you're allergic to penicillin are you in on any medications currently do you take the albuterol okay and past medical history okay you have oh that's probably with the albuterol sport what was the last thing that you took as far as food last oral intake I had breakfast okay all right an events leading up to this what what were you doing again that caused this I was just watching TV just sitting there watching TV alright so next I would move on to my secondary assessment for this patient I really want to listen to one tones again and reassess that so I'll listen again have my lung sounds changed at all with the oxygen no they're still wheezy okay has my patients ability to breathe does she feel a little bit better with the oxygen she is breathing easier with the oxygen so after my secondary assessment I would obtain a baseline set of vitals so first I would check on the acquire pulse rate her pulse is 90 beats per minute 90 beats per minute okay and what's her respiratory rate now as I calibrate is 20 breaths per minute my breaths per minute okay and lastly I would get a blood pressure all right and what is her blood pressure book on page 112 over 70 okay all right so now that I've got my baseline vitals my field impression of the patient is that she's having an asthma attack at this point I would do interventions if if she had her albuterol inhaler with her I could assist her with that and then after that I would continue to reassess a respiratory rate her blood pressure and her pulse as I waited for the ALS ambulance to arrive at this time ALS ambulance has arrived so I'll give a quick report to the ALS a balance so this is my patient she says 24-year old female chief complaint was difficulty breathing she has a past history of asthma she has an albuterol inhaler for the asthma or prescription for the asthma and allergies her penicillin last oral intake was breakfast this morning and she was just sitting on the couch watching TV when this attack happened is there anything else you'd like to do for this patient nope that is it okay thank you