Initial Medical Assessment and Care
Section 2 - PRIMARY CARE
2.01 INITIAL MEDICAL ASSESSMENT AND CARE
Level of Consciousness
|A - Alert|
|V - Responds to Verbal stimuli|
|P - Responds to Painful stimuli|
|U - Unresponsive|
ORIENTATION x 4/4
|4/4 - Person, place, time, incident|
|3/4 - One faculty absent|
|2/4 - Two faculties absent|
|1/4 - Three faculties absent|
Altered Mental Status (AMS) is defined as an alteration in either the patient’s LOC or Orientation.
|AIRWAY||Establish and maintain airway. Utilize cervical spine precautions when indicated.|
|BREATHING||Provide oxygen or assist ventilations as indicated.|
|CIRCULATION||Check pulses, skin & control any external hemorrhage.|
FOCUSED AND DETAILED HISTORY AND PHYSICAL EXAM:
- Obtain history of present illness and past medical history.
- Record allergies and medications. Record name, dosage & frequency of medications.
- Systematic head-to-toe and neurological assessment.
- Establish a baseline set of vitals signs. Initial set of vitals must be obtained manually.
PERFORM INITIAL MEDICAL CARE SIMULTANEOUSLY WITH THERAPIES:
- Loosen tight clothing and reassure patient.
- Place patient in position of comfort if not contraindicated.
- OXYGEN: Nasal cannula, NRB mask, or BVM as appropriate for patient condition:
- Provide supplemental OXYGEN, assist ventilations, intubate and suction as indicated by inadequate breathing / impaired gas exchange.
- Once a medication route has been established, administer medication as indicated per Practice Parameters, (i.e., IV, IO, IN).
- CARDIAC MONITOR LD II, MCL I, or 12 LEAD ASSESSMENT if available. Record strips at least every 5-10 minutes, AND before and after pharmacological or electrical intervention.
- Establish IV or IO of 9% NaCl at KVO, or IV Lock system as indicated by patient condition.
- Attempt X 2 unless situation demands further repeated attempts. Failure to obtain IV access does not preclude the intervention of other definitive therapy.
- Apply pulse oximeter, if available, to all patients with potential cardiac or respiratory emergencies.
- Apply EtCO2 monitor device to patients with potential cardiac or respiratory emergencies.
- Assess blood glucose with glucometer as indicated per Practice Parameters. Repeat vital signs and assess patient EVERY 10 MINUTES (STABLE) or 5 MINUTES (UNSTABLE).
- Document each ALS INTERVENTION and their corresponding times.
Document the patient's condition or behaviors which result in a variance to Practice Parameters. If no response to Practice Parameters, contact Medical Control for consult.