View source for Initial Medical Assessment and Care

__NOTOC__
==Section 2 - PRIMARY CARE==
=== 2.01 INITIAL MEDICAL ASSESSMENT AND CARE===
==== INITIAL ASSESSMENT:====
===== GENERAL IMPRESSION=====

'''Level of Consciousness'''
{| class="wikitable"
|-
| A - Alert
|-
| V - Responds to Verbal stimuli
|-
| P - Responds to Painful stimuli
|-
| U – Unresponsive
|}


'''ORIENTATION x 4/4'''
{| class="wikitable"
|-
| 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.=====
{| class="wikitable"
|-
| 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.
* [[Medical Gases|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.
'''