MW Obs template v2 DRAFT

• Date

  Date
• Location (Auto grab location, enter locus manually in notes if possible)
  Address

• Name

• DOB

• Address

• Contact number & email

SAMPLE

• Age

• Time (of incident / injury)

  Date

• Mechanism or Injury

• Signs and Symptoms

Observations

• Time of Observations

  Date

• AVPU

  Select Alert Voice Pain Unresponsive

  • Alert
  • Voice
  • Pain
  • Unresponsive

• Airway

  Clear

  Noisy

  Obstructed

• Breathing

  Yes

  No

  N/A

• Description

  Select Shallow Normal Fast Difficult

  • Shallow
  • Normal
  • Fast
  • Difficult

• CONSIDER CPR

• Circulation, press for 5 seconds, record refill time, 2 sec refill normal

  Slow

  Normal

  Fast

• Facial Appearance

  Pale

  Normal

  Flushed

• Heart Rate

• SERIOUS - LOW

• CONCERNING - LOW

• Acceptable

• CONCERNING - HIGH

• SERIOUS - HIGH

• Blood Pressure 120/80is normal

• Is Blood Pressure

  High

  Slightly Raised

  Heathy

  Low

• Is patient COPD

  Yes

  No

• SP02 Reading

• Use White venturi adapter and mask (not the reservoir mask) and set to 4 litres per min

• 02 not required unless other symptoms

• SP02 Reading

• Give 02, use Reservoir (trauma, green) mask and set to 15 litres per minute

• Give 02, Use Plain mask (not reservoir) and use Green Venturi adaptor at 15 litres per minute

• 02 not required unless other symptoms

• Cap Refill, press for 5 seconds, record refill time

• Normal

• Abnormal

• Respiration Rate 12-20 is normal

• SERIOUS

• CONCERNING

• Acceptable

• CONCERNING

• SERIOUS

• Temperature 37 is normal

• SERIOUS - LOW

• Low, concerning

• Normal

• Higher than normal

• HIGH

• Pupils

  Small (Small)

  Normal

  Large (Dilated)

  Different sizes

• Pupils responding to light?

  Yes

  No

  N/A

• BM

• Glasgow Coma Scale

  

• GCS Score

• Pain Score out of 10 (1 being the lowest 10 being the worst imaginable)

SAMPLE

• Signs and Symptoms (What do they look like, how do they feel)

• Allergies, does the patient have any allergies

  Yes

  No

• What are the allergies

• Medication - does the patient currently take ?

  Yes

  No

• What are they

• Any medication recently taken?

• Past History

  Select Hospital Admissions Operations Serious Illness Current Illness Other

  • Hospital Admissions
  • Operations
  • Serious Illness
  • Current Illness
  • Other

• Details of Past History

• Last Meal Eaten - When and what was last eaten

• Events, find out the events leading up to the incident

Drugs Formulary

• Indications

  Select Anaphylaxis Life Threatening Asthma Heart Attack Nausea and Vomiting Open Fracture or contaminated wound >1hr from Hospital Mild / Moderate Pain Moderate /Severe Pain Hypoglycaemia Angina or Heart Attack Asthma Seizure .5mins Reverse Opiate Serious illness or injury + abnormal vital signs

  • Anaphylaxis
  • Life Threatening Asthma
  • Heart Attack
  • Nausea and Vomiting
  • Open Fracture or contaminated wound >1hr from Hospital
  • Mild / Moderate Pain
  • Moderate /Severe Pain
  • Hypoglycaemia
  • Angina or Heart Attack
  • Asthma
  • Seizure .5mins
  • Reverse Opiate
  • Serious illness or injury + abnormal vital signs

• ADRENALINE. ROUTE = IM, DOSE = Adult 0.5mg Child 6-11y 0.3mg Repeat after 5 mins. CONTRAINDICATION = NONE

• BUCCASTEM, Buccal, Adult 6mg. CONTRAINDICATIONS = Child under 12. Epilepsy

• ASPRIN, Oral, Adult 300mg, CONTRAINDICATIONS - Allergy NSAIDS, Child under 16, Stroke

• Co-amoxiclav Oral Adult 750mg Child 12-17 375mg CONTRAINDICATIONS Allergy to penacillin, History of jaundice, Child under 11

• Entonox Inhaled Self administered CONTRAINDICATIONS = Unable to elf administer. Head injury + >A on AVPU Pneumothohorax Diving within last 24hrs

  Safe

  At Risk

  N/A

• IBUPROFEN Oral Adult 400mg Child 7-11 years 200mg CONTRAINDICATIONS = Allergy NSAIDS, Shock (no radial pulse) Trauma chest pain, Taking viagra

  Safe

  At Risk

  N/A

• Paracetamol, Oral, Adult 1g, 13-17yo 750mg, 10-12y 500mg, 6-9yo 250mg CONTRAINDICATIONS = Allergy to paracetamol

• Fentanyl Buccal, Adult 800mg lozenge repeat after 20 mins. CONTRAINDICATIONS = Taking anti depressants. Allergy fentanyl. Breathing <10. Shock (no radial pulse). Head injury +>P on AVPU. Child under 18. Injury to mouth

  Safe

  At Risk

  N/A

• Morphine. IM. Adult 10mg. 12-17yo 5mg. Repeat after 1 hour. CONTRAINDICATIONS = Allergy to morphine. Breathing rate >10 Shock (no radial pulse) Head injury + < on AVPU

• Glucose. Oral. 10-20mg CONTRAINDICATIONS = NONE

• GTN Spray. Under tongue. Adult 2 sprays, repeat after 10 mins. CONTRAINDICATIONS = Child under 18. Shock (No radial pulse). Trauma chest pain. Taking Viagra.

• Ipratropium Bromide via Nebuliser Adult 500mcg Child 250mgc CONTRAINDICATIONS = NONE.------------------------------------------Salbutamol via Nebuliser or spacer 2-10 puffs via spacer or 5mg nebulised. Repeat after 5 mins. CONTRAINDICATION = NONE

• Midazolam IM Adult 10mg, 6-9yo 7.5mg. Repeat after 10 mins. CONTRAINDICATION = NONE

• Naloxone IM Adult 400mgc, Child under 6yo 400mgc CONTRAINDICATIONS = NONE

• OXYGEN Inhaled 10-15l non-rebreather mask or 6-8l nebuliser CONTRAINDICATIONS = Does NOT require oxygen if Heart attack or stroke + SP02>94%, or heat exhaustion / heat stroke

Drugs administered

• Drugs / Medication administered

  Yes

  No

  N/A

• Details of drug and dose given

• Select date

  Date