ASSESSMENTS Flashcards
Neurological
ASSESSMENTS:
- Stroke Scale:
1. Ask PT to say “Can’t teach an old dog new tricks”
2. Ask PT to smile
3. Ask PT to close eyes and hold arms up straight for 5 seconds
GCS
- Assess Mental Status (Person, Place, Time, Event)
- Check PMS in all limbs
- Check pupils (Dilated - Trauma, CNS injury, use of sympathomimetic drugs. Pinpoint - opioid use, organophosphate poison, trauma or stroke)
VITALS:
- Blood Glucose
- Pulse Oximetry
- High BP can suggest stroke
- Widening pulse pressure, bradycardia and irregular respirations can indicated increasing ICP
QUESTIONS:
- MOI
- Did neurological deficit precede trauma or vice-versa?
- Hx of neurological issues (Spinal cord injury, stroke, clotting disorder, A-fib, HTN, seizures, etc.)
- Time of Onset of Symptoms
- Medications: Blood Thinners?
Psychological/Behavioral
ASSESSMENTS: Mental Status (Person, Place, Time, Event)
VITALS:
Blood glucose
Temp (High could indicate UTI/sepsis, excited delirium)
QUESTIONS: Hx: Psych disorders? Drug use? Meds: Compliant with medication? Thoughts of suicide? Any way to commit suicide? Any plan to hurt yourself or others? Do you feel safe at home? History of psych issues?
Skeletal/Muscular
ASSESSMENTS:
Rapid Trauma Assessment (Head to Toe, including mouth, nose, eyes, ears)
Pupils, Lungs
PMS
Mental Status (Person, Place, Time, Event)
VITALS:
QUESTIONS:
Respiratory
ASSESSMENTS:
- Work of breathing (accessory muscle, how many words at a time able to speak)
- Mental Status (altered from baseline/sluggish/lethargic may indicate resp failure)
- Position of PT
- Lung Sounds
1. Ronchi -
2. Rales -
3. Wheezing -
4. Pleural Rub -
5. Stridor - - EKG
VITALS:
- RR
- Capnography - Sharkfin indicates wheezing, low indicates hyperventilation, high indicates hypoventilation
- BP - hypotension could be a sign of anaphylactic or septic shock, hypertension could point to CHF exacerbation
- Temp: fever may indicate pneumonia
QUESTIONS:
- Cough?
- Recently sick or around someone who is sick?
- History of CHF, MI, Asthma, COPD, pneumonia?
-
Cardiac
ASSESSMENTS:
VITALS:
QUESTIONS:
Abdominal
ASSESSMENTS:
- inspect and palpate
VITALS:
- BP: low may indicate internal hemorrhage
- HR: high may indicate compensated shock
QUESTIONS:
- Last oral intake?
- Normal urination and bowel movements?
- Any abnormal smell, color, sensation during urination/defecation?
- Eating, drinking and voiding normally lately?
- Female PT’s: last menstrual period, sexual activity, history of reproductive health issues
- History of any abdominal health problems?
- Drug or alcohol use?
- Recent trauma?
Gastrointestinal
ASSESSMENTS:
Assess skin, tongue, BP and sensation of thirst for dehydration?
VITALS:
BP: low can indicate dehydration, internal bleeding
HR: tachycardia = classic sign dehydration, early sign of shock
QUESTIONS:
1. Onset of symptoms?
2. Last bowel movement?
3. Blood/any other unusual aspect to BM?
4. Have you been eating and drinking normally?
Genitourinary
ASSESSMENTS:
VITALS:
QUESTIONS: Last urination? Last menstrual period? Any blood/abnormal color or smell in urine? Pain on urination? Difficulty urinating?
OB/GYN
ASSESSMENTS:
Abdominal assessment for tenderness, rigidity, etc.
Assess extremities for edema
VITALS:
- BG (uncontrolled can indicate gestational diabetes)
- High BP can indicate pre-eclampsia
- Vital sign ranges different in pregnancy
QUESTIONS:
- PT of childbearing age?
- Known pregnancy? How far along?
- Para/gravida?
- Last menstrual period?
- Sexually active?
- If bleeding present, how many menstrual pads have been soaked in the last day?
- Hx of any OB/GYN medical problems?
- Has PT been getting prenatal care (checking w/ doctor regularly?)
- Vaginal discharge with unusual color, smell, etc?
- Pain on urination?
Endocrine
ASSESSMENTS:
VITALS:
QUESTIONS:
Car Wreck:
Main Checklist:
- Arrive on scene
- Scene Size Up Radio Report (#of vehicles, severity of damage, # of people and their condition at a glance) VDPCA(Vehicles, Damage, Patients, Condition, Additional Ambulances)
- Number of patients?
- Damage to vehicles
- Rapid assessment:
- LOC
- Obvious injuries?
- Head/Neck/Back Pain
- PMS intact?
- Mechanism of wreck?
- Speed of vehicles?
- Seatbelts Worn?
- Airbags deployed?
- Loss of consciousness? - History and VITALS
- Medical History?
- Allergies
- Medications (Blood Thinners!!!)
- Any drugs or alcohol?
- BP, HR, RR, Pain Scale, Pupils, Lungs, Glucose if ALTERED - Do you want to go to the hospital?
- If Refusal:
- Explain refusal form (clears our liability)
- Explain that only a doctor can fully diagnose and treat any underlying injuries or illness that we cannot detect in the field
- Call 911 at any time to be taken to hospital
- Advise on self care at home
Fall:
ASSESSMENTS:
- Mental Status
- Head/Neck/Back Pain?
- Palpate neck and back for tenderness/step-off
- PMS check
- ABC’s
VITALS:
- Pupils (Check for reactiveness)
- Lung sounds (check for pulmonary edema, pneumothorax)
- Temperature (asses for hypothermia)
QUESTIONS:
- Loss of consciousness?
- How long ago did you fall?
- What caused you to fall?
- Did you hit your head?
- Do you take blood thinners?
Altered Mental Status:
ASSESSMENTS:
VITALS:
QUESTIONS:
Sick/General Weakness:
ASSESSMENTS:
VITALS:
QUESTIONS:
Nausea/Vomiting:
ASSESSMENTS:
VITALS:
QUESTIONS:
