NREMT Patient Assessment / Management Trauma Skill Sheet

Start Time:
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Stop Time:
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Candidate's Name:
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Evaluator's Name:
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Move your mouse over the different steps. Respiratory only at this time. These are EXAMPLES of questions and verbalizations. This is NOT a script. Points
Possible
Points
Awarded
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SCENE SIZE-UP
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Determines the number of patients 1 1 1
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INITIAL ASSESSMENT
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Assessment
Indicates appropriate oxygen therapy
Assures adequate ventilations and injury management
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Assessment of circulation
Assesses and controls major bleeding
Assesses pulse
Assesses skin (color, temperature, and condition)
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FOCUSED HISTORY AND PHYSICAL EXAMINATION/RAPID ASSESSMENT
Selects appropriate assessment (focused or rapid assessment)
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Vitals (obtains baseline vital signs) 1 1 1
Interventions (obtains medical direction or verbalizes standing order for medication inverventions and verbalizes proper additional intervention/treatment) 1 1 1
Transport (re-evaluates the transport decision) 1 1 1
Verbalizes the consideration for completing a detailed physical examination 1 1
ONGOING ASSESSMENT (verbalized)
1Interactivity stops here 1 11
Repeats initial assessment 1 1 1
Repeats vital signs
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Repeats focused assessment regarding patient complaint or injury 1 1 1
Total
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Critical Criteria
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____Did not take, or verbalize, body substance isolation precautions as necessary
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____ Did not determine scene safety
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____ Did not obtain medical direction or verbalize standing orders for medical interventions
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____ Did not provide high concentration of oxygen
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____ Did not find or manage problems associated with the airway, breathing, hemorrhage or shock (hypoperfusion)
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____ Did not differentiate patient's need for transportation versus continued assessment at the scene
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____ Did detailed or focused history/physical examination before assessing the airway, breathing and circulation 1 1 1
____ Did not ask questions about the present illness
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____ Administered a dangerous or inappropriate intervention 1 1 1
I am wearing my gloves and other proper BSI
Is my scene safe? Is traffic managed? airbags gone off? leaking fuel smell?
How did the vehicle impact? At what speed? Were the patients restrained? Did it roll?
How many people are hurt here?
If we need additional EMS crews, fire personnel, law enforcement I would call for it now.
I would likely take c-spine precautions for all occupants based on the severity of the collision
The patient/s appear stable/unstable.
The patient/s are conscious / unconscious
The patient's chief complaint is ____________________
There is a small amount of visible bleeding, the patient's pulse is ______ and their skin is warm, dry and pink.
The patient's airway is open because they are talking to me. They appear to have adequate respirations and I will put them on high flow O2 via non-rebreather mask and begin managing apparent injuries.
I would select a rapid assessment for an unconcious patient and a focused assessment for a patient with an obvious or identifiable complaint.
If I have something to FOCUS on (the patient is conscious and and can tell me what is wrong) I will perform an exam FOCUSED on that complaint. If the patient is unconscious I will do a rapid head to toe assessment.
I will begin the interview process with the conscious patient. Maybe get some history from bystanders of an unconscious patient.
When did you begin having trouble breathing? What were you doing?
Does anything make it feel better or worse?
Can you describe how your breathing feels right now?
Is the breathing difficulty stationary in your chest or does it move?
Where are you at on a scale of 1 to 10 if 1 is very easy to breath and 10 is very hard to breath?
Has the problem been constant since it started or does it come and go?
Have you tried anything to make it feel better?
Are you allergic to anything?
Are you taking any medications? Are you using any herbal supplements or other drugs?
Have you ever had problems like this before? Have other people in your family had any similar problems?
When was the last time you had anything to eat or drink? What did you have?
Have you fallen or been hurt recently? Other than this problem has today been a fairly normal day?
I am going to do a focused exam of the affected body part or system. I will auscultate the lungs for breathing problems, BP for chest pain etc. If I do not have a chief complaint to focus on I will finish a rapid assessment.
I am going to gather baseline vitals with the help of my assistant.
After utilizing online medical control and/or standing orders I will administer/assist with proper interventions. Metered dose inhalers, nitroglycerin, etc.
If the patient's condition is getting worse I might consider a helicopter rendezvous or transport to a closer hospital.
If time is available AND there is a necessity I would do a detailed physical exam.

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