PATIENT ASSESSMENT/MANAGEMENT – TRAUMA PATIENT
Student: ______________________________ Examiner: _______________________
Date: ________________________________ Initials: __________________________
SCENE SIZE UP
Yes
Takes body substance isolation precautions ;
Determines the scene is safe ;
Determines the mechanism of injury / nature of injury
Determines the number of patients
Requests additional help if necessary
Considers stabilization of the spine ;
INITIAL ASSESSMENT
Verbalizes general impression of the patient (sex, estimated weight, age, distress
level)
Determines responsiveness / level of consciousness ;
Determines chief complaint / apparent life threats
Assesses Airway ;
Assures airway is patent and will remain so
Assesses general rate, rhythm and tidal volume †
Consider oxygen therapy †
Assesses Breathing ;
Assures that ventilation is adequate †
Injury management †
Assesses for and controls major bleeding †
Assesses general pulse rate (normal, slow or fast) †
Assesses Circulation ;
Assesses basic rhythm (regular or irregular) †
Assesses basic quality (full or weak) †
Assesses general skin (color, temp. and moisture) †
Identifies priority level of patient / transport decision ;
FOCUSED HISTORY/PHYSICAL EXAM OR RAPID TRAUMA ASSESSMENT
Selects appropriate assessment (focused or rapid assessment) ;
Obtains or direct assistant to obtain baseline vital signs – (BP, pulse, resp and pupil)
Obtains SAMPLE history: ; S – Signs and Symptoms A – Allergies MMedications P – Past pertinent history L – Last oral intake E – Events leading to
present illness
Must transport patient within 10 minutes ;
Continue on reverse
No
PATIENT ASSESSMENT/MANAGEMENT – TRAUMA PATIENT
Continued
DETAILED PHYSICAL EXAMINATION
Yes
No
Inspects and palpates the scalp and ears †
Assesses the head ;
Assesses the eyes †
Assesses the facial area including oral/nasal area †
Inspects and palpates the neck. † Checks for JVD †
Assesses the neck ;
Checks for tracheal deviation †
Inspects †
Assesses the chest ;
Palpates †
Auscultates the chest †
Assesses the abdomen †
Assesses the abdomen /
Assesses the pelvis †
pelvis ;
Verbalizes assessment of genitalia †
Left arm †
Includes inspection, palpation and
Right arm † assessment of pulses, sensory and
Assesses the extremities ;
Left leg †
motor/grip activity.
Left leg †
Manages secondary injuries and wounds appropriately
Verbalizes reassessment of the vital signs
ATTEMPTS
1
2
3
PASS _____ FAIL _____
INSTRUCTOR COMMENTS:
; = CRITICAL CRITERIA.
Denote whether:
MidTerm
or
NOTE: ASST. INSTRUCTORS, PLEASE MAKE SKILL LOG ENTRY.
Final