BSI
SCENE SIZE UP
STABILIZE SPINE (if warranted)

INITIAL ASSESSMENT
General Impression
What's bothering you today? - Chief Complaint

LABOCAB

If your patient is alert and speaking to you, the initial assessment has pretty much been done.
You already know LOC, that the AIRWAY is open and the patient is BREATHING, (but ask about rate and quality to help you with OXYGEN. Also ask about COPD) and that his or her heart is CIRCULATING blood.

A quick glance over the patient to determine any ARTERIAL or serious bleeding completes this part. Consider BARING THE CHEST if warranted, otherwise the chest and back assessment can be done when listening to lung sounds.

OXYGEN (Ask about COPD)

VITAL SIGNS. Get 2 complete sets

BP
Pulse
Respirations

Skin Color, Temp, Moisture
Lung Sounds (all fields)
Pupils

HISTORY (past and present).

Refer to Chief Complaint.

OPQRST:

Onset: What were you doing when it started.
Provokes it. What caused it, What makes it worse? better?
Quality - What does it feel like - dull, crushing, sharp, burning, stabbing, etc.
Region and Radiates. Where is it? Does it move? Where does it go?
Severity. On scale of 1 to 10, or mild, moderate or severe
Time. When did it start? Has it changed? Is it constant
or intermittent? Did it ever happen before?

Get an AMPLE History

Allergies to drugs, etc.
Medications
Previous medical problems. Physician's name
Last meal, Last menstrual period (if applicable)
Events preceding this problem

Do a Complete Medical (HANDS ON) Physical Exam/ Focused Exam

Face and Neck

Eyes - (bloodshot, yellow)

Respiratory difficulty, nasal flaring, accessory muscles

Mouth - slurred speech, odors

Neck - JVD, tracheal deviation, Medic Alert necklace or bracelet

Chest - respiratory difficulty, shape, surgical scars, urticaria, pacemaker. Ask if anyting hurts and feel rise and fall.

Abdomen - look and feel - all 4 quadrants, pain, masses, aneurysm, guarding, rigid, distended, or soft

Sacral and Pedal Edema

PMS and Neurological check

Organize your findings, provide the proper treatment, position the patient properly for transport, and call the hospital.

S	VS
	1 and 2
L	BP
	P
A	R
	SCT&M
B	LS
	PERL
O	HX
	O
C	P
	Q
A	R
	S
B	T
	.
	A
	M
	P
	L
	E
	.
	Phy or Foc exam
	treat
	position
	ongoing assessment