ch 10 Flashcards
What is the purpose of the patient assessment process
to identify and treat life threats and determine priority for transport
What are the five main parts of the patient assessment process
scene size-up primary assessment history taking secondary assessment reassessment
What is the first step in patient assessment
scene size-up
What is included in the scene size-up
scene safety BSI precautions MOI/NOI number of patients and need for additional resources
What is MOI
mechanism of injury (trauma-related)
What is NOI
nature of illness (medical-related)
What is BSI
body substance isolation (e.g.
What is the primary assessment
the initial evaluation to identify and correct life threats
What are the components of the primary assessment
general impression level of consciousness airway breathing circulation transport decision
What does AVPU stand for
Alert Verbal Pain Unresponsive
What does ABC stand for
Airway Breathing Circulation
What is the general impression
first impression of patient’s condition based on appearance position and environment
What is the purpose of assessing LOC
to determine mental status and if the brain is perfusing properly
What does assessing airway include
ensuring it is open and not obstructed
What does assessing breathing include
rate rhythm quality and need for oxygen or ventilation
What does assessing circulation include
pulse rate and quality skin color/temp/condition and controlling bleeding
What is the transport decision based on
patient’s condition severity and need for rapid transport
What is the history-taking phase
gathering information using SAMPLE and OPQRST
What does SAMPLE stand for
Signs/Symptoms Allergies Medications Past history Last oral intake Events leading up
What does OPQRST stand for
Onset Provocation Quality Radiation Severity Time
What is the secondary assessment
head-to-toe physical exam to find other injuries or conditions
When is a rapid exam used
in trauma patients with significant MOI or altered LOC
What is a focused assessment
detailed exam on a specific area based on chief complaint
What is the reassessment
repeating primary assessment vital signs and interventions
How often do you reassess stable patients
every 15 minutes
How often do you reassess unstable patients
every 5 minutes
What is the purpose of reassessment
to monitor changes and assess effectiveness of treatment
What is a pertinent negative
symptoms the patient denies that help rule out conditions
What are baseline vital signs
the first set of vitals taken for comparison later
What are normal adult vital signs
pulse: 60–100 bpm respirations: 12–20 BP: 90–140 systolic
What is capillary refill
time it takes for color to return to nailbed after pressure (should be <2 seconds)
Why is trending important
to track the patient’s condition over time and guide treatment decisions
What does DCAP-BTLS stand for
Deformities Contusions Abrasions Punctures Burns Tenderness Lacerations Swelling
What is the purpose of DCAP-BTLS
to remember what to look for during physical exam
What does PEARL stand for
Pupils Equal And Reactive to Light
When do you perform a full-body scan
when the patient is unresponsive or has significant trauma
What should you always do before and after an intervention
reassess the patient
What is the difference between medical and trauma assessment
medical focuses more on history and trauma on physical exam
What should you ask about allergies
medications, foods, environment, latex
What should you ask about medications
prescribed, over-the-counter, herbal, recreational
What kind of medical history should you ask about
chronic conditions, surgeries, hospitalizations
What does last oral intake include
food, drinks, medications, and TIME they were taken
What should you ask for Onset
When did it start? What were you doing when it started?
What should you ask for Provocation/Palliation
What makes it better or worse?
What should you ask for Quality?
Can you describe the pain (sharp, dull, burning, tearing etc.)?
What should you ask for Radiation
Does the pain move anywhere else?
What should you ask for Severity
On a scale from 0 to 10, how bad is it?
What should you ask for Time
Has it changed since it started? Constant or comes and goes?
SAMPLE example
S: Chest pain, shortness of breath
A: Allergic to penicillin
M: Takes lisinopril for high blood pressure
P: History of hypertension and mild heart attack 2 years ago
L: Ate breakfast at 8:00 AM, pain started at 9:30 AM
E: Was walking upstairs when chest pain began
OPQRST example
O: Started suddenly while walking upstairs
P: Worse with deep breaths, better when sitting still
Q: Described as pressure, like “an elephant sitting on my chest”
R: Radiates to left arm and jaw
S: 8 out of 10 pain
T: Has lasted 20 minutes and is not going away
What is the difference between a medical and trauma patient
medical = illness/history focused and trauma = injury/mechanism focused
Why is the general impression important
it helps identify life threats within seconds of patient contact
What’s the first thing to check in the primary assessment
responsiveness and immediate life threats
What should you do if a patient is unresponsive and not breathing
immediately begin CPR and use AED
What should you do if a patient has noisy breathing
open the airway and suction if needed
What are signs of inadequate breathing
shallow breaths cyanosis use of accessory muscles and nasal flaring
What are signs of poor perfusion
cool/pale/clammy skin delayed cap refill and weak/absent pulses
What do you assess for circulation in an unresponsive patient
pulse major bleeding and skin signs
What’s the goal of the secondary assessment in trauma
find all hidden injuries
What’s the goal of the secondary assessment in medical calls
focus on systems related to the chief complaint
What body systems might be focused on in medical calls
respiratory cardiovascular neurologic
What should you include when documenting patient assessment
all findings interventions vitals and changes over time
When should you perform a head-to-toe exam
when MOI is significant or patient is unresponsive
What is a pertinent positive
a symptom the patient does have that helps confirm a condition
What is trending
watching for changes in vitals and condition over time
Why is reassessment critical
patient condition can rapidly change and treatments may need adjusting
What is the best way to gather accurate patient history
ask open-ended questions and listen
Why is capillary refill not always reliable
it can be affected by environment age and other factors
What skin signs indicate shock
cool pale and diaphoretic (sweaty)
What’s an early sign of brain hypoxia
altered mental status
What’s an important first question on most medical calls
What seems to be the problem today?
What’s a sign of potential airway obstruction
gurgling stridor or absent breath sounds
What’s the highest priority in all patient assessments
managing life-threatening issues immediately
