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EMT > Assesment > Flashcards

Assesment Flashcards

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1
Q

Level of consciousness

A 
Speech
  Quantity
  Rate
  Volume
  Articulation
  Fluency
Mood
Orientation
  Time
  Place
  Person
  Event
Memory
  Recent
  Long term
Reliability
   Do I believe the patient
   Does patient have appropriate decision making for consent
   Is the patient oriented
Chief complaint
   Why did you call us
   What is the duration of this episode
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2
Q

OPQRST - O

A

Onset

When did this begin
Was it sudden or gradual

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3
Q

OPQRST - P

A

Provokes

What brought this on
Anything that makes it better or worse

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4
Q

OPQRST - Q

A

Quality

How would you describe your pain or symptoms
Has there been any change in your pain or symptoms since this began

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5
Q

OPQRST - R

A

Region/radiation

Can you point and show me where your pain or symptoms are located
Does the pain move or radiate anywhere else

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6
Q

OPQRST - S

A

Severity

How would you rate your level of discomfort right now 1 to 10
Using the same scale how was your level of discomfort when this began

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7
Q

OPQRST - T

A

Timing

When did your pain or symptoms begin
Is it constant or how does it change over time

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8
Q

Setting questions

A

Is there anything unique to place or events with this episode

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9
Q

Treatments question

A

Have you taken anything to treat this problem

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10
Q

Pertinent negatives

A

Any signs or symptoms NOT present

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11
Q

Converges

A

Moves history from broad to focused to field impression

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12
Q

SAMPLE - S

A

Symptoms and Signs

Any signs / symptoms not present that should be

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13
Q

SAMPLE - A

A

Allergies

Any allergies to meds, food, other things

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14
Q

SAMPLE - M

A

Medications

What prescribed meds
What over-the-counter meds/vitamins/herbs/home remedies
When did u take the last dose/ how much
Do you take all meds as prescribed
Do you have any frequent use OD alcohol, tobacco, or drugs

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15
Q

SAMPLE - P

A

Pertinent past history

What is your general health status
What other similar episodes were there
Is this an acute or chronic illness
What medical care do you currently receive for this illness
"                                                                               " other illnesses
What previous surgeries have you had
Nutritional status
Any psyc history
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16
Q

SAMPLE - P(family)

A

Any pertinent family medical history

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17
Q

SAMPLE - L

A

Last oral intake

Have you taken anything to treat this problem

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18
Q

SAMPLE - E

A

Events

Anything unique to place or events with this episode

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19
Q

Vitals - BP

A

Normal:
90-120/?-80 (Adult)

Hypotensive:

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20
Q

Vitals - Pulse

A 
Radial
Carotid
Pedal
Amplification:
Rate:
    Normal:
                   60-100(A), 
                   60-105(11-14), 
                   70-110(6-10), 
                   80-120(3-5),
                   80-130(1-3), 
                   90-140(0-12 mos)
                   120-160(newborn)
       Tachycardia
       Bradycardia
Rhythm:
    Regular
    Alternating
    Irregular
Quality:
    Strong
    Thready
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21
Q

Vitals - Respirations

A 
Tidal Volume
   Equal/Left volume only/Right volume only
   Adequate/inadequate
Rate, Rythem, & Quality
    Normal: 
          12-20(11-Adult)
          15-30(6-10)
          18-30(3-5)
          20-30(6 mo-3)
          25-40(0-5 mos)
   Bradypnea
   Tachypnea(rapid shallow)
   Hyperpnea (rapid deep)
   Cheyne - Stokes Breathing(deep and periods of apnea)
   Ataxic (irregular)
   Kussmaul (deep due to metabolic acidosis)
   Sighing (punctuated by deep sigh)
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22
Q

Vitals - Temperature

A 
Method 
   Oral (Mercury, digital, IR/other)
   Rectal (Mercury, digital, IR/other)
   Tympanic (Mercury, digital, IR/other)
   Forehead (Mercury, digital, IR/other)
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23
Q

Vitals - skin

A 
Color
   Flushed
   Jaundiced
   Pallor
   Cyanotic
Moisture
   Dryness 
   Sweating
   Oily
Temperature
   Hot
   Med
   Cool
Turgor
Lesions
    Types
    Locations
   Arrangement
Nails
   Condition
   Cleanliness
   Growth
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24
Q

Vitals - Eyes

A 
Size
Equality
Reactive
Acuity
   Clear
   Free of disturbance
Appearance
   Color
   Iris clear
Extraocular movement
   Up
   Down
   Both sides
   Fixed
   Flutter around
25
Q

Physical Assessment - Head and Neck

A 
Hair
Scalp
Skull
Face
Ears
  External Ear
  Ear Canal - drainage (clear, blood, none), (both, right, left)
  Hearing - present, impaired, absent
Nose
   Deformity
   Air movement - Full, partial, obstructed
Mouth
   Opens Willingly
   Jaw Tension - Absent, mild, severe
   Mucosal Color - Clear, cloudy, green, blood tinged, bloodied
   Moisture - Dry, moist, draining
   Upper airway patent
Neck
   Trachea midline
   Jugular veins distended
26
Q

Physical Assesment - Chest

A 
Movement / expansion - minimal, mild, excessive
Skin color
Integrity
   Wounds
   Rib stability
   Presence / absence of pain
Lower Airway
   Auscultation - anterior
      Tracheal
      Bronchial
      Bronchovesicular
      Vesicular
      Strider
      Rails
      Crackles
      Snoring
      Gargling
   Auscultation - posterior
      Tracheal
      Bronchial
      Bronchovesicular
      Vesicular
      Strider
      Rails
      Crackles
      Snoring
      Gargling
27
Q

Physical Assesment - Heart

A 
Apical pulse
   Sounds
       S1
       S2
Arterial pulses - equal, tachycardic, bradycardic, normal
    Chorotid - full, thready, none
    Radial - full, thready, none
    Femeral - full, thready, none
    Pedal - full, thready, none
28
Q

Physical Assessment - Abdomen

A 
Color
Wounds - Open, Closed
Size
Symmetry
Shape
Scars
Distention
Auscultation 
Palpation - masses, tenderness, rigidity, 
   Region - URQ, ULQ, LRQ, LLQ
29
Q

Physical Assessment - Back

A 
Color
Wounds - Open, Closed
Size
Symmetry
Shape
Scars 
Palpation - masses, tenderness, rigidity,
30
Q

Physical Assessment - Pelvis

A

Stability

31
Q

Physical Assesment - Genitals

A

Male
Wounds, rashes, external lesions (ask)
Drainage (ask)
Female
Wounds, rashes, external lesions (ask)
Drainage (ask)
Bleeding or discharges (ask)

32
Q

Physical Assesment - Musculoskeletal (Legs & Feet)

A 
Symmetry
Range of motion
Deformity
Skin
    Color
    Closed wounds
    Open wounds
Pulses
    Femeral
    Popliteal
    Dorsalis pedis
33
Q

Physical Assesment - Musculoskeletal (Arms & Hands)

A 
Symmetry
Range of motion
Deformity
Skin
    Color
    Closed wounds
    Open wounds
Pulses
    Brachial
    Radial
34
Q

First Steps

A 
Scene safety
   Personal, crew, patient, Bystanders
BSI
Number of patients
Consider Need for additional resources
   ALS
   Truck unit
MOI / NOI
35
Q

Primary - A

A 
Cervical spine
Open airway
Tidal Volume - adequate, inadequate, bilateral, left, right
Rate, rhythm, quality
Sounds
NPA/OPA
Suction
O2
36
Q

Primary - B & C

A 
Bare the chest
Bleeding
Medical ID
Central & peripheral pulse
Skin - moisture, color, temp
Additional life threats
Shock
O2
Capillary refill
Evaluate treatment / Priority - Stable, Unstable
37
Q

Unstable/High Priority - Trauma

A
  • Focused history & Rapid trauma physical assessment -
Spinal stabilization
Rapid inspection and palpation
    DCAP-BTLS
    Head
    Neck/collar
    Chest
    Abdomen
    Pelvis
    Extremities
    Posterior
Baseline vitals
SAMPLE (if possible)
Rapid packaging
Transport
Final Steps
38
Q

Unstable/High Priority - Medical

A
  • Focused history & Rapid medical physical assessment -
Inspect and palpate areas of complaint  
History of present illness - chief complaint 
SAMPLE (if possible)
Baseline vitals
Decide treatment based on 5 R's
    RPMDD
Treat per protocol
Check interventions / side effects
Reassess vitals every 5 minutes
Rapid packaging
Transport
Final Steps
39
Q

Stable/Low Priority - Trauma

A
  • Focused history & physical exam (trauma) -
Establish chief complaint
Inspect and palpate sites
     DCAP-BTLS
Baseline vitals
Focused history 
SAMPLE/OPQRST for pain
Treat injury
Transport
Final Steps
40
Q

Stable/Low Priority - Medical

A
  • Focused history & physical exam (medical) -
History of present illness - Establish chief complaint
Focused history - SAMPLE/OPQRST for pain
Focused physical exam
   Inspect, auscultate, palpate complaint area
Baseline vitals
Decide treatment based on 5 R's
    RPMDD
Treat per protocol
Check interventions / side effects
Reassess vitals every 15 minutes  
Transport
Final steps
41
Q

Final Steps

A
  • Done Enroute -
Detailed physical exam
Repeat primary
Repeat focused in greater detail
Reassess and record vitals 
Check interventions
Ongoing assessment - repeat:  
     primary, 
     focused history
     physical exam
     Vital signs
     Check Interventions - unstable - 5 min, stable 15 min
42
Q

Vitals - SpO2

A

Mild hypoxia
Moderate hypoxia
Severe hypoxia

43
Q

Vitals - Blood sugar

A 
Normal
   81-119
Hypoglycemic
    60-80
Hyperglycemic
   120-140
44
Q

DCAP-BTLS

A

Deformities
Contusions
Abrasions
Punctures

Burns
Tenderness
Lacerations
Swelling

45
Q

General impression data

A 
Age
Weight
Sex
Ethnic Origin
AVPU - CAO x ?
Chief complaint
Permission to treat
Who called
Source of history
46
Q

Rule of 9s - Adult

A 
Head - 4.5 pere side = 9
Torso - 18 each side = 36
Arm - 4.5 each side = 9 per arm
Legs - 9 each side = 18 per leg
Groin - 1
47
Q

Rule of 9s - child

A 
Head - 4.5 pere side = 9
Torso - 18 each side = 36
Arm - 4.5 each side = 9 per arm
Legs - 9 each side = 18 per leg
Groin - 1
48
Q

Rule of 9s - infant

A 
Head - 9 per side = 18
Chest = 18
Back = 13
Butt = 5
Arm - 4.5 each side = 9 
Legs - 7 each side = 14 each leg
49
Q

During primary assessment you should check the pulse for

A

Less than 30 seconds looking for normal, rapid, or slow pulse

50
Q

A rapid pulse rate in a trauma pt or a slow pulse in a pt with chest pain make them a

A

High priority patient

51
Q

Three patient assessment levels

A

Stable, potentially unstable, unstable

52
Q

Immediate transport priority is indicated by

A

If any life-threatening issue cannot be controlled or threatens to reoccur, or there is an altered level of consciousness, Poor general impression, responsive but not following commands, difficulty breathing, shock, complicated child birth, Chest pain consistent with cardio, uncontrolled bleeding, severe pain.

53
Q

Skin condition is assessed in all patients, capillary refill is also assessed in

A

Children and infants under 6 years

54
Q

Rapid, regular, and full pulse can be the result of

A

Exertion, fright, fever, high blood pressure, first stage of blood loss

55
Q

Rapid, regular, and thready pulse a sign of

A

Shock, later stage of blood loss

56
Q

Slow pulse a result of

A

Head injury, drugs, some poisons, some heart problems, lack of O2 in children

57
Q

A fast pulse in children is a …. Concern

A

Low concern

58
Q

A slow pulse in children can indicate

A

Eminent cardiac arrest

EMT (17 decks)

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