Jugular venous distension Tracheal position Spinal tenderness Retractions Breath sounds wall deformity Abdomen/Back Flank/abdominal tenderness or bruising Abdominal distension Extremities Edema Pulses Deformity Neurologic Mental status/orientation Motor/sensory Obtain Baseline Vital Signs (An initial full set of vital signs is required: pulse, blood pressure, respiratory rate, neurologic status assessment) Neurologic status assessment [see ] involves establishing a baseline and then trending any change in patient neurologic status Glasgow Coma Score (GCS) is frequently used, but there are often errors in applying and calculating this score. With this in consideration, a simpler field approach may be as valid as GCS. Either AVPU (Alert, Verbal, Painful, Unresponsive) or only the motor component of the GCS may more effectively serve in this capacity Patients with cardiac or respiratory complaints Pulse oximetry 12-lead EKG should be obtained early in patients with cardiac or suspected cardiac complaints Continuous cardiac monitoring, if available Consider waveform capnography (essential for patients who require invasive airway management) or digital capnometry Patient with altered mental status Check blood glucose Consider waveform capnography (essential for patients who require invasive airway management) or digital capnometry Stable patients should have at least two sets of pertinent vital signs. Ideally, one set should be taken shortly before arrival at receiving facility Critical patients should have pertinent vital signs frequently monitored Obtain OPQRST history: Onset of symptoms Provocation – location; any exacerbating or alleviating factors Quality of pain Radiation of pain Severity of symptoms – pain scale Time of and circumstances around onset Obtain SAMPLE history:
de Dolor Source: Hybrid of scales by authors. Reproduction of the FACES® material requires licensing at www.wongbakerfaces.org. Pediatric-Appropriate Pain Assessment Tools Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale Appropriate age for use (per guideline): less than 4 Categories Scoring 0 1 2 Face No particular expression or smile Occasional grimace or frown, withdrawn, disinterested Frequent to constant frown, clenched jaw, quivering chin Legs Normal position or relaxed Uneasy, restless, tense Kicking, or legs drawn up Activity quietly, normal position, moves easily Squirming, shifting back and forth, tense Arched, rigid, or jerking Cry No cry (awake or asleep) or whimpers, occasional complaint Crying steadily, screams or sobs, frequent complaints Consolability Content, relaxed Reassured by occasional touching, hugging, or being talked to, distractible Difficult to console or comfort Each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability is scored from 0-2, which results in a total score between zero and ten. © 2002, The Regents of the University of Michigan. All Rights Reserved. Instructions: Patients who are awake: Observe for at least 1-2 minutes. Observe legs and body uncovered. Reposition patient or observe activity, assess body for tenseness and tone. Initiate consoling interventions if needed Patients who are asleep: Observe for at least 2 minutes or longer. Observe body and legs uncovered. If possible reposition the patient. Touch the body and assess for tenseness and tone. Face Score 0 point if patient has a relaxed face, eye contact and interest in surroundings