Module 3 Practical

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

SCENARIO 1 - RAPID TRAUMA ASSESSMENT (MARK QUESTION N/A)

• Dispatch Info – You are dispatched to Gunpowder Falls State Park for a trauma injury. On arrival you are directed to a nearby trail and find an 18 y/o white male lying supine next to a large rock with a bicycle lying next to him. He is not wearing a helmet and appears to be unconscious. <br><br>Scene Safety – No obvious hazards present<br><br>BSI – (Student should be wearing gloves and verbalize any other BSI considered)<br><br># Pt’s – 1<br><br>MOI/NOI – Bicycle Accident with potential spinal injury<br><br>Additional Resources – (Student should request an Engine & ALS)<br><br>General Impression – 18y/o white male, 135 lbs, poor condition<br><br>AVPU – Unconscious (Student should attempt to determine patient status)<br><br>Airway – Gurgling is heard on inspiration (Student should open airway using modified jaw thrust & verbalize suctioning patient). Suctioning does resolve blood in airway. There was also broken teeth removed during suctioning.<br><br>Breathing:<br>Rate – 30<br>Rhythm – Regular<br>Quality – Shallow, rapid<br><br>Circulation:<br>Rate – 122 (Student should check carotid and radial pulses simultaneously)<br>Rhythm – regular<br>Quality – Thready<br><br>Dense Bleeding – None noted<br><br>Patient Priority – (Student should verbalize patient as a PRIORITY 1)<br><br>Rapid Trauma Assessment (Student should verbalize DCAP-BTLS)<br>HEENT – (Fluid, Pupils, Crepitis) Pupils are PERRL, no fluid, no other findings.<br>NECK – (Crepitis, JVD, TD, Stoma, Medic Alert); No findings; (Student should size and place cervical collar)<br>CHEST – (Lung Sounds, Paradoxal Movement, Crepitis). (=) L/S, (=) Chest Rise, no other findings.<br>ABD – (Rigidity, Distension, Guarding). (+) Rigidity ULQ, ½ dollar sized contusion RLQ.<br>PELVIS – (Crepitis, Pelvic Stability) Pelvis is stable; (Student should complete 3-point stability check on pelvis).<br>GROIN – (Blood, Urine, Feces, Fluid, Foreign Obj) No findings.<br>LOWER EXTREM – (Crepitis, PMS); (-) Pulse (L) leg, Obvious deform of (L) Tib/Fib. (Student should note injuries and move on)<br>UPPER EXTREM – (Crepitis, PMS); (+) Pulses both extrem, deformed (R) Radius/Ulna.<br>BACK – (Crepitis); No findings.<br><br>Vital Signs<br>Pulse – 122 Thready<br>Respirations – (12 IF BVM ventilations started by student during airway assessment) or (30 and very labored if no BVM)<br>B/P – 92/64<br>Skin – Pale, cool, diaphoretic<br>PSO2 - 99% if BVM / 86% if no BVM<br>B/S – 122 dL<br><br>Detailed Physical Exam – (Student should verbalize completing an in-depth full assessment)<br><br>Ongoing Assessment:<br>Reassess ABC’s – Airway is intact, breathing controlled through BVM ventilations, pulse is regular and decreased to 92. <br>Check Interventions – BVM ventilations continue without issue.<br>Reassess Vital Signs – P-92, R-12 (BVM), B/P-102/68, Skin- Pale, cool, diaphoretic, B/S-118 dL<br>Consult with Hospital – (Student should verbalize intention to consult)

  Yes

  No

  N/A

INITIAL ASSESSMENT

• Determines SCENE SAFETY.

  Yes

  No

  N/A

• Demonstrates proper BSI

  Yes

  No

  N/A

• Determines the NUMBER OF PATIENTS.

  Yes

  No

  N/A

• Determines the MOI / NOI.

  Yes

  No

  N/A

• Initiates (considers) SPINAL STABILIZATION.

  Yes

  No

  N/A

• Requests (considers) appropriate ADDITIONAL RESOURCES.

  Yes

  No

  N/A

• Determines the patient's level of responsiveness. AVPU

  Yes

  No

  N/A

PRIMARY ASSESSMENT

Airway

• Determines if the AIRWAY IS OPEN and patent.

  Yes

  No

  N/A

• Inserts an AIRWAY ADJUNCT if appropriate.

  Yes

  No

  N/A

• SUCTIONS patient's airway if appropriate

  Yes

  No

  N/A

Breathing

• Determines the RATE, RHYTHM, & QUALITY of breathing.

  Yes

  No

  N/A

• Applies OXYGEN using the appropriate device and at the correct flow rate.

  Yes

  No

  N/A

• Demonstrates / Ensures proper VENTILATION of patient.

  Yes

  No

  N/A

Circulation

• Determines the RATE, RHYTHM, & QUALITY of circulation.

  Yes

  No

  N/A

• Assesses SKIN (Color, Temperature, Condition)

  Yes

  No

  N/A

Dense Bleeding

• Assesses / Controls DENSE BLEEDING.

  Yes

  No

  N/A

Patient Priority

• Identifies patient PRIORITY/ Makes transport decision

  Yes

  No

  N/A

FOCUSED ASSESSMENT & PHYSICAL EXAM

Rapid Trauma Assessment

• HEENT -Iinspects and palates the scalp and ears.

  Yes

  No

  N/A

• HEENT - Assess the eyes and PUPILS.

  Yes

  No

  N/A

• HEENT - Assess the face including oral and nasal areas

  Yes

  No

  N/A

• NECK - Inspects and palates the neck.

  Yes

  No

  N/A

• NECK - Assess for JVD.

  Yes

  No

  N/A

• NECK - Assess for TD.

  Yes

  No

  N/A

• NECK - Assess for STOMA.

  Yes

  No

  N/A

• NECK - Assess for MEDIC ALERT necklace.

  Yes

  No

  N/A

• NECK - Sizes and applies appropriate CERVICAL COLLAR.

  Yes

  No

  N/A

• CHEST - Inspect and palate chest

  Yes

  No

  N/A

• CHEST - Auscultate LUNG SOUNDS.

  Yes

  No

  N/A

• CHEST - Assess for PARADOXICAL MOVEMENT.

  Yes

  No

  N/A

• ABD - Inspect and palate abdominal region.

  Yes

  No

  N/A

• ABD - Assess for RIGIDITY.

  Yes

  No

  N/A

• ABD - Assess for DISTENTION.

  Yes

  No

  N/A

• ABD - Assess for GUARDING.

  Yes

  No

  N/A

• PELVIS - Assess PELVIC STABILITY (Three point assessment)

  Yes

  No

  N/A

• GROIN - Inspect groin for BLOOD

  Yes

  No

  N/A

• GROIN - Inspect groin for URINE.

  Yes

  No

  N/A

• GROIN - Inspect groin for FECES.

  Yes

  No

  N/A

• GROIN - Inspect groin for FLUID.

  Yes

  No

  N/A

• GROIN - Inspect groin for FOREIGN OBJECTS.

  Yes

  No

  N/A

• EXTREM - Inspects / Palpates all four extremities.

  Yes

  No

  N/A

• EXTREM - Assess PMS (all extremities).

  Yes

  No

  N/A

• BACK - Inspects / Palpates posterior surface.

  Yes

  No

  N/A

Vital Signs

• Assess PULSE

  Yes

  No

  N/A

• Assess RESPIRATIONS.

  Yes

  No

  N/A

• Assess BLOOD PRESSURE (BP)

  Yes

  No

  N/A

• Assess SKIN (Color, Temperature, Condition)

  Yes

  No

  N/A

SAMPLE / OPQRST

• Obtains SAMPLE History

  Yes

  No

  N/A

• Obtains OPQRST

  Yes

  No

  N/A

DETAILED PHYSICAL EXAM

• Verbalized completion of detailed physical exam.

  Yes

  No

  N/A

ONGOING ASSESSMENT

• Repeats INITIAL & PRIMARY ASSESSMENTS.

  Yes

  No

  N/A

• Repeats FOCUSED ASSESSMENT based on patient complaints.

  Yes

  No

  N/A

• Checks INTERVENTIONS.

  Yes

  No

  N/A

• Re-assesses VITAL SIGNS (5 min for unstable / 15 min for stable patients)

  Yes

  No

  N/A

EVALUATOR FEEDBACK

Critical Fail Points (If answered YES Evaluator must explain in detail)

• Failed to take BSI precautions.

  Yes

  No

  N/A

• Failed to determine SCENE SAFETY.

  Yes

  No

  N/A

• Failed to consider C-SPINE STABILIZATION (If applicable)

  Yes

  No

  N/A

• Completion of rapid trauma assessment or detailed assessment before initial or primary assessment.

  Yes

  No

  N/A

• Failed to ensure adequate ventilation.

  Yes

  No

  N/A

• Failed to initiate / delayed initiation of OXYGEN delivery.

  Yes

  No

  N/A

• Failed to initiate rapid transport on critical patient.

  Yes

  No

  N/A

• Failed to find or address LIFE THREATS or CHIEF COMPLAINT.

  Yes

  No

  N/A

• Failed to assess / control MAJOR BLEEDING.

  Yes

  No

  N/A

• VITAL SIGNS are outside of allowable 10 point range

  Yes

  No

  N/A

SCENARIO 2 - FOCUSED ASSESSMENT (MARK QUESTION N/A)

• Dispatch Info – You are dispatched to 1325 Church Road for a chest pain patient. On arrival you find a 84 y/o Hispanic female sitting in her garden in front of a large single family home with a well kept yard. <br><br>Scene Safety – No obvious hazards present<br><br>BSI – (Student should be wearing gloves and verbalize any other BSI considered)<br><br># Pt’s – 1<br><br>MOI/NOI – CHest Pain<br><br>Additional Resources – (Student should request ALS)<br><br>General Impression – 84 y/o Hispanic female, 155 lbs, good condition<br><br>AVPU – Alert (Student should attempt to determine patient status)<br><br>Airway – Open and patent<br><br>Breathing:<br>Rate – 18<br>Rhythm – Regular<br>Quality – Mild dyspnea<br><br>Circulation:<br>Rate – 68 (Student should check carotid and radial pulses simultaneously)<br>Rhythm – regular<br>Quality – bounding<br><br>Dense Bleeding – None noted<br><br>Patient Priority – (Student should verbalize patient as a PRIORITY 1)<br><br>Vital Signs<br>Pulse – 68 regular<br>Respirations – 18<br>B/P – 108/64<br>Skin – Pale, cool, diaphoretic<br>PSO2 - 99% on NRB / 90% if no NRB<br><br>SAMPLE:<br>S- CP in mid-sternum radiating to left arm<br>A - Sulfa drugs, bee stings<br>M - Nitroglycerin, Lipitor, Norvasc, Prozac<br>P - Angina, hypertension, high cholesterol, anxiety disorder<br>L - Lunch (PB&J sandwich) at 1:30 pm<br>E - Gardening in the front yard<br><br>OPQRST:<br>O - 20 mins ago<br>P - nothing can change the pain<br>Q - sharp and squeezing<br>R - Left shoulder and arm<br>S - 8/10<br>T - 20 mins / Took 2 nitro PTA of EMS and it has not helped!<br><br><br>Detailed Physical Exam – (Student should verbalize completing an in-depth full assessment)<br><br>Ongoing Assessment:<br>Reassess ABC’s – Airway is intact, breathing controlled, pulse is regular and has maintained at 68. <br>Check Interventions – High flow O2 via NRB has helped the dyspnea. Increased PSO2 to 99%<br>Reassess Vital Signs – P-70, R- 16 (NRB), B/P-102/68, Skin- Pale, cool, diaphoretic<br>Consult with Hospital – (Student should verbalize intention to consult)

  Yes

  No

  N/A

INITIAL ASSESSMENT

• Determines SCENE SAFETY.

  Yes

  No

  N/A

• Demonstrates proper BSI

  Yes

  No

  N/A

• Determines the NUMBER OF PATIENTS.

  Yes

  No

  N/A

• Determines the MOI / NOI.

  Yes

  No

  N/A

• Initiates (considers) SPINAL STABILIZATION.

  Yes

  No

  N/A

• Requests (considers) appropriate ADDITIONAL RESOURCES.

  Yes

  No

  N/A

• Determines the patient's level of responsiveness. AVPU

  Yes

  No

  N/A

PRIMARY ASSESSMENT

Airway

• Determines the RATE, RHYTHM, & QUALITY of breathing.

  Yes

  No

  N/A

• Inserts an AIRWAY ADJUNCT if appropriate.

  Yes

  No

  N/A

• SUCTIONS patient's airway if appropriate

  Yes

  No

  N/A

Breathing

• Determines the RATE, RHYTHM, & QUALITY of breathing.

  Yes

  No

  N/A

• Applies OXYGEN using the appropriate device and at the correct flow rate.

  Yes

  No

  N/A

• Demonstrates / Ensures proper VENTILATION of patient.

  Yes

  No

  N/A

Circulation

• Determines the RATE, RHYTHM, & QUALITY of circulation.

  Yes

  No

  N/A

• Assesses SKIN (Color, Temperature, Condition)

  Yes

  No

  N/A

Dense Bleeding

• Assesses / Controls DENSE BLEEDING.

  Yes

  No

  N/A

Patient Priority

• Identifies patient PRIORITY/ Makes transport decision

  Yes

  No

  N/A

FOCUSED ASSESSMENT & PHYSICAL EXAM

Vital Signs (ALL must be within 10 of actual - Evaluator to document ACTUAL & STUDENT ASSESSED vital signs)

• Assess PULSE

  Yes

  No

  N/A

• Assess RESPIRATIONS.

  Yes

  No

  N/A

• Assess BLOOD PRESSURE (BP)

  Yes

  No

  N/A

• Assess SKIN (Color, Temperature, Condition)

  Yes

  No

  N/A

SAMPLE

• Signs & Symptoms

  Yes

  No

  N/A

• Allergies

  Yes

  No

  N/A

• Medications

  Yes

  No

  N/A

• Past Medical History

  Yes

  No

  N/A

• Last Oral Intake

  Yes

  No

  N/A

• Events leading to illness / injury

  Yes

  No

  N/A

OPQRST

• Onset

  Yes

  No

  N/A

• Provocation

  Yes

  No

  N/A

• Quality

  Yes

  No

  N/A

• Radiation

  Yes

  No

  N/A

• Severity

  Yes

  No

  N/A

• Time / Trending

  Yes

  No

  N/A

DETAILED PHYSICAL EXAM

• Verbalized completion of detailed physical exam.

  Yes

  No

  N/A

ONGOING ASSESSMENT

• Repeats INITIAL & PRIMARY ASSESSMENTS.

  Yes

  No

  N/A

• Repeats FOCUSED ASSESSMENT based on patient complaints.

  Yes

  No

  N/A

• Checks INTERVENTIONS.

  Yes

  No

  N/A

• Re-assesses VITAL SIGNS (5 min for unstable / 15 min for stable patients)

  Yes

  No

  N/A

EVALUATOR FEEDBACK

Critical Fail Points (If answered YES Evaluator must explain in detail)

• Failed to take BSI precautions.

  Yes

  No

  N/A

• Failed to determine SCENE SAFETY.

  Yes

  No

  N/A

• Failed to consider C-SPINE STABILIZATION (If applicable)

  Yes

  No

  N/A

• Completion of focused assessment or detailed assessment before initial or primary assessment.

  Yes

  No

  N/A

• Failed to ensure adequate ventilation.

  Yes

  No

  N/A

• Failed to initiate / delayed initiation of OXYGEN delivery.

  Yes

  No

  N/A

• Failed to initiate rapid transport on critical patient.

  Yes

  No

  N/A

• Failed to find or address LIFE THREATS or CHIEF COMPLAINT.

  Yes

  No

  N/A

• Failed to assess / control MAJOR BLEEDING.

  Yes

  No

  N/A

• VITAL SIGNS are outside of allowable 10 point range

  Yes

  No

  N/A

General Comments

Suggested Student Outcome

• Student A

  PASS

  FAIL

• Student B

  PASS

  FAIL

Evaluator Signature

• Evaluator

  Sign