Focused assessment

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Facilitator:
Medics:
Patients: Unresponsive pt
Time: 20 mins; 1340-1400
Actual time:
Learning Objectives:
Materials: Butcher paper, markers, Readers, SAMPLE butcher paper.

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Introduction

Facilitator

goes back to chart paper with Rosehip patient assessment triangle.¹

Facilitator says

You assessed the scene for danger and assessed the patient for life threats. You controlled the scene, used back-up, and did life-saving interventions.

You're somewhere between five seconds and several minutes into your intervention.

At this point, all you know is whether you can continue to operate in the scene and whether the person has emergency red flags.²

You can't start first aid until after you learn more about the person and her injury or illness. If you find urgent red flags, the person will need to be assessed by someone with emergency medical experience beyond this training.³

The focused physical examination involves inspecting and pressing on areas outside the area of concern and then inspecting and pressing on the areas of concern. A focused history is a conversation that explores the patient's chief complaint and includes enough important background history to put the patient (and her complaint) in context. What you learn in focused patient assessment will guide how you do first aid, patient care, and aftercare education. It is where you start problem-solving collaboratively with the patient.⁴

Focused assessment only takes a few minutes.⁵

Focused assessment letters

Facilitator writes

focused assessment letters in the Patient Assessment Triangle.

F

for Full exam (or focused exam).

G

for Get vitals.

H

for History.

Trauma or medical?

Facilitator says

If the chief complaint is medical, you take the history before doing the exam.

Rapid or focused?

Facilitator says

You use the same skills to conduct a rapid assessment as to conduct a trauma assessment.

• If you don't call 911, you must do a focused history and physical exam for medical or trauma. Use focused assessment to look for red flags and learn enough to make a plan for first aid interventions and aftercare education.

• If you call 911, do a rapid trauma or medical assessment while you wait. Stop and fix any ABC-level problems. Tell paramedics any essential info, especially if the person's level of responsiveness dropped after you asked questions, and she can no longer reliably answer history questions.

Full exam

Facilitator says

Explain what you will be doing to the patient. Be prepared to answer questions about why.⁶ Maintain informed consent as you proceed. Pay attention to patient privacy. Don't harm or repeat harmful maneuvers.

Head to toe exam (not hurt bits)

Facilitator says

"Heeead, shoulders, knees and toes (knees and toes)! Heeead, shoulders, knees and toes (knees and toes)! Eyes and ears, a mouth, and a nose! Heeead, shoulders, knees and toes (knees and toes)!"

IF you have consent, press on each major bone in the body, from head to toe, checking for pain, blood, or anything else out of the ordinary: DCAPBTLS or AFU.⁷ (head, shoulders, upper arm, elbow, lower arm, hands, rib cage from front and back, abdomen, lower back, hips, upper legs, lower legs, feet).

Trainer models

rapid head to toe trauma exam on unresponsive patient.

Trainer models

joking with seated alert and oriented patient who sustained 10-inch bruises over his kidneys while doing focused head to toe trauma exam.

Examine red flags and requested body parts

Facilitator says

After establishing a general picture, examine red flags and requested body parts more closely. We'll practice examining common injuries and doing first aid this evening, and we'll practice examining signs associated with medical issues tomorrow morning.

Get vitals

Facilitator says

Great for health-fairs, clinical care, checking grandma's blood pressure, and other community health work, basic vitals are pretty easy to learn but not essential to know for basic urban first aid.⁸

History

Facilitator says

The history is where you learn about the chief complaint, the history of the presenting complaint, and critical background history.

SAMPLE patient history

Facilitator says

⁹ The SAMPLE history is a time consuming and detailed interview that may begin in the first few moments of patient care and continue until you walk through the doors at the emergency room. Good SAMPLE histories can be disorderly and divergent. They go off on tangents. They explore deeper than the basic questions. They encourage the patient to talk and elaborate when the patient is able.¹⁰

S

for Symptoms.

A

for Allergies.

M

for Medications.

P

for Past medical history.

L

for Last food and drink (and last shit and piss).¹¹

E

for Events.

Facilitator says

Run through SAMPLE in your head every time you take a history to make sure you cover all your bases, even if you ask questions out of order. Memorize this acronym.

Trainers model SAMPLE

Facilitator says

¹² Let's see what we can learn by taking a SAMPLE history.

3 students

volunteer. Each gets a Reader opened to Sophia's SAMPLE practice sheet. Each student gets to pick which patient they want to be without telling trainers.

Trainer buddy pair

interviews each student in front of class.¹³

Students model SAMPLE

6 more students

volunteer. They come up in front of the class in pairs and each of 3 students playing medics interviews each of 3 students playing Sophia's patients.

OPQRST pain history

You don't get much information by asking, "What are your symptoms." There's lots of good questions for zooming in on the chief complaint. The most useful is one more string of letters, from later in the alphabet.

O

for Onset.

P

for Provokes/Palliates.

Q

for Quality.

R

for Region/Radiates/Refers.

S

for Severity (1-10).

T

for change over Time.

Documentation

Jot it down -- if you need to document care, it stays with the patient.

• Write the time a dressing was applied and your initials on the dressing with a Sharpie, and tell the patient when he is supposed to change it.

• Stick a piece of duct tape on the patient's jeans and jot important findings on it.

• Write "Allergies: Morphine" on both of the patient's arms, where paramedics will see it before starting an IV.

• Write the patient's medications and emergency contact phone numbers on a clearly labeled piece of paper and let the patient carry it with her to the hospital.