Assessments Flashcards
Primary survey
Danger - Environmental, agitated patient, bystanders, animals, debris, chemicals etc
Response - AVPU only
Airway - Patent or obstructed? Are they protecting their airway?
Breathing - Adequate? Snapshot only, look for signs like tripoding or obvious breath sounds to the unassisted ear.
Circulation - Adequate? Snapshot only, look for active bleeding, loss of consciousness, pallor.
Vital signs (adult)
Heart rate: 60-100 bpm
Respiratory rate: 12-18 breaths per minute
Blood pressure: Systolic 100-140, diastolic 60-90
Blood glucose level: 4-8 mmoL/L
Oxygen saturation: 96-100%
Temperature: 36.6-37.5
SAMPLE
Signs and symptoms
Allergies
Medications
Past history
Last ins and outs
Events leading up to emergency call
Perfusion status assessment
Pulse, skin, blood pressure, level of consciousness
Neurological status assessment
GCS, vital signs, pulse, motor, sensory
Respiratory status assessment
Consciousness
Appearance
Pulse
Effort
Rate
Rhythm
Skin
Speech
Sounds
GCS
Eyes: 4 - spontaneous, 3 - opens to speech, 2 - opens to pain, 1 - no response
Speech: 5 - oriented, 4 - confused, 3 - inappropriate words, 2 - incomprehensible sounds, 1 - no response
Motor: 6 - follows commands, 5 - localises to pain, 4 - withdraws from pain, 3 - abnormal flexion, 2 - abnormal extension, 1 - no response
OPQRST
Origin
Provocation/palliation
Quality
Region/radiation/referral
Severity
Timing
NIHSS-8
APGAR
Appearance
Pulse
Grimace
Activity
Respiration
Mental status examination
Modified Rankin scale
NEXUS criteria
Midline tenderness
Evidence of intoxication
ALOC
Focal neurological deficit
Distracting injury
Sedation assessment tool
VIRCA
Voluntary
Informed
Relevant
Capacity
Advice
