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The Patient Assessment consists of three elements:
1. Total Body Survey, tells you what has happened to the patient's body.
2. History Questions, give you information about factors that may effect what has happened to the patient.
3. Vital Signs, tell you how well the patients body is handling what has happened to it.
TOTAL BODY SURVEY:
A quick, but thorough exam of the patient's body, starting at the head and moving
systematically to the feet. The survey should involve checking for pain, tenderness,
blood, fluid, deformity, or any other signs of injury or illness. When done properly
the exam should take only 2 1/2 to 3 minutes. It should include the following:
Head, eyes, ears, mouth, cheeks.
Neck, check for medical tag as well as signs of injury.
Chest, rib spring, collar bones, shoulders.
Abdomine, feel for firmness, examine the four quadrants.
Back, feel for problems, visually check hands for blood.
Arms, check tops and bottoms, look for tags, do a neuro test.
Pelvis, push in and down.
Legs, tops and bottoms, neuro check, look for tags.
General questions should include the patient's full name, what happened to them, and was anyone else involved. Other examples of general history questions include:
Are taking any medications? If so, what for? Do you need to take your medication now?
Have you seen a doctor recently?
Do you have any allergies?
Do you have any chronic medical problems, for example; heart disease or diabetes?
Specific questions should help you focus in on a specific problem or complaint.
An effective effective method for remembering these questions is to use the
"COLDERR" system as show below:
C-Character, of the pain, for example burning or aching.
O-Onset, when did it start?
L-Location, have the patient point to the exact spot.
D-Duration, how long does the pain last?
E-Exacerbate, does anything make it worse?
R-Relief, does anything make the pain feel better?
R-Radiation, does the pain move around the body?
Pulse: (normal 60-80 per min) Check at the carotid artery in the neck. Count number of beats for 15 seconds and multiply by four.
Respirations: (normal 12-20 per min) Watch rise and fall of chest for 15 seconds and multiply by four.
Level Of Consciousness: Pt. should be oriented to person, place, and time.