Developing good assessment skills is very important in the care of your patient. Assessing is the collection of data about the physical status of the patient. This information is gathered from a variety of sources and are the basis for actions and decisions taken in the treatment of the patient. Skills of observation, interviewing and communication are essential during assessment. Once the data is collected treatments and actions can be prioritized. Assessment skills are developed over time and improve with experience.
Determine responsiveness. Determine chief complaints and/or life threats. Open airway. Assess breathing. Assess and control major bleeding. Assess pulse. Assesses skin (color, condition, temp).
What do you assess first? ALWAYS - ABC's: Airway, Breathing, Circulation
Airway: If your patient's airway is not clear, all other injuries are to be considered small at this time. True, internal bleeding should be a high priority but it takes time to bleed to death. Death from lack of oxygen is much faster. If you find your patient is having a hard time breathing try laying the person down and tilting the head and lift the chin. This will open the airway to its greatest potential. The only exception to this rule if with children. Tilting the head too far back will actually block the air way possibly causing more damage. Next check open any clothing surrounding the neck to insure that this is not contributing to the problem. Next you should look down the airway as far as you can, looking for obstruction. If you suspect blockage try abdominal thrusts. DO NOT pat the patient on the back, this will only get the object stuck farther.
Breathing: Once the airway is open, next you will need to assess the breathing. Is the person breathing? If not start giving breaths one every three to five seconds and check for a pulse. If a pulse is not present, begin chest compressions.
Circulation: If patient has no palpable pulse at the corotid arteries (neck pulse), then chest compressions are necessary to continue blood circulation and oxygenation of the brain. This is also important in cuts and broken bones but should be checked in your assessment. Check for circulation by checking the pulse in the extremity effected. If the pulse is weak there may be partial blockage, attempt adjusting the area until you have a strong pulse. DO NOT splint a bone until you have a strong pulse. If you do splint with a weak or no pulse, circulation will be lost to the area causing the area to die and amputation will be required.
Assess head. Assess neck and cervical spine. Assess chest. Osculates breath sounds. Assess the extremities for circulation, sensation, and motor function. Assess the back and spine. Obtains baseline pulse. Obtains baseline blood pressure. Obtain history, signs/symptoms, allergies, medications, past medical history, last meal, events leading to present injury/illness.
DETAILED PHYSICAL EXAMINATION:
(if patient is stable) Inspect/palpate scalp and ears. Assess eyes (including pupillary response, are pupils equal in size, and reactive to light?). Assess facial area (including oral and nasal area). Inspects and palpates neck. Assess for JVD (Jugular Vain Distention). Assess for tracheal deviation (throat being off set). Inspect and Palpate chest. Osculate the abdomen and assess the pelvis. Assess genitalia as needed. Assess the extremities (including inspection, palpation, and assessment of circulation, sensation and motor function). Asses posterior thorax and lumbar.