Patient Assessment Components

Overview

This lecture covers the five main components of patient assessment, detailing each step from initial scene evaluation to ongoing reassessment during patient care.

The Five Parts of Patient Assessment

• Patient assessment includes: scene size-up, primary assessment, history taking, secondary assessment, and reassessment.
• Assessment begins upon arrival at the scene and continues until care is transferred at the hospital.

Scene Size-Up

• Confirm scene safety before approaching the patient (scene cleared by police or deemed safe by dispatch).
• Take standard precautions (gloves, mask, gown as needed).
• Determine the mechanism of injury (MOI - trauma) or nature of illness (NOI - medical).
• Identify the number of patients and the need for additional resources or specialized equipment.

Primary Assessment

• Expose the patient, especially in trauma cases, to identify major issues quickly.
• Form a general impression of the scene and patient.
• Assess level of consciousness (alert, responds to voice, pain, or unresponsive).
• Address life-threatening bleeding immediately before airway and breathing.
• Check airway—open and maintain airway (head-tilt-chin-lift for medical, jaw thrust for trauma), clear and secure as necessary.
• Evaluate breathing—look for chest rise/fall, abnormal sounds (stridor, wheezing), and respiratory effort.
• Assess circulation—check pulse, skin condition, and control major bleeding.
• Use mnemonic DCAP-BTLS during rapid trauma exam to find Deformities, Contusions, Abrasions, Punctures, Burns, Tenderness, Lacerations, Swelling.
• Make a transport decision based on patient severity.

History Taking

• Use SAMPLE mnemonic: Signs/Symptoms, Allergies, Medications, Past medical history, Last oral intake, Events leading up to incident.
• Use OPQRST mnemonic for chief complaint: Onset, Provokes, Quality, Radiation, Severity, Time.
• Document pertinent negatives (symptoms that are absent but relevant to the condition).

Secondary Assessment

• Conduct a detailed head-to-toe physical exam, looking for trauma and changes.
• Examine head, ears (battle signs), pupils, nose, mouth, neck (spine), lungs (listen for abnormal sounds), chest, abdomen, pelvis, legs, arms, and back.
• Check pulses and reassess for any new findings.

Reassessment

• Continuously reassess the patient, repeating vital signs (BP, pulse, respiratory rate, blood glucose, capnography, pulse oximetry).
• Continue physical exams and update care as needed.
• Communicate critical patient updates to the hospital in advance (radio patch).

Key Terms & Definitions

• Scene Size-Up — Initial evaluation of safety, resources, and patient factors at the scene.
• Primary Assessment — Rapid check for life-threatening conditions.
• SAMPLE — Mnemonic for history taking (Signs/Symptoms, Allergies, Medications, Past history, Last oral intake, Events).
• OPQRST — Mnemonic for assessing pain/chief complaint (Onset, Provokes, Quality, Radiation, Severity, Time).
• DCAP-BTLS — Trauma exam mnemonic for Deformities, Contusions, Abrasions, Punctures, Burns, Tenderness, Lacerations, Swelling.
• Pertinent Negative — Relevant symptoms or findings that are absent.

Action Items / Next Steps

• Learn and practice the five parts of patient assessment.
• Memorize and apply the SAMPLE, OPQRST, and DCAP-BTLS mnemonics.
• Prepare to reassess patients and communicate critical updates during transport.