NOLS: Patient Assessment System Flashcards
Scene Size-Up
Number 1: whose number 1?
Number 2: what happened to you?
Number 3: Nothing on me.
Number 4: how many more?
Number 5: dead or alive?
Initial Assessment
1: Intro, consent, chief complaint
2: Responsive? Spine control?
3: ABCDE…
A-airway. Anything blocking?
B-breathing. Ribs. Deep breath.
C-circulation. Pulse. Blood?
D-decision. Spine. Velocity, landing, consciousness.
E-expose: treat life threatening injuries.
Secondary Assessment
Head-to-Toe
Vitals
History
Head-to-Toe
Look. Ask. Feel.
Head/neck: in and behind ears, swallow (tracheal alignment)
Shoulders/chest/abdomen/pelvis
Legs/knees/ankles/feet: CSM-peddle and pull back. Pinch a toe. Tingling/numbness?
Arms/elbows/hands: CSM-double pulse. Squeeze and throttle. Tingling/numbness?
Back: roll on three. Piano spine, flat-palm back.
Vitals
LOR: responsive to name, place, time, events OR verbal to pain OR unresponsive
HR: heart rate 50-100 b/m. Rhythm regular. Quality strong.
BP: good if radial/pedal pulse is strong
RR: 12-20 b/m. Rhythm regular. Quality unlabored.
PERRL: pupils are equal, round, reactive to light
Skin: color (eyelid/gums/nailbed), temp, moisture
Temp: check near collarbone.
History
Name. Age. Gender. SAB.
Symptoms: If medical then OPQRST
Allergies?
Medications: (why?) Drugs? Alcohol? Last dose/quantity?
Pertinent history: diabetes, asthma, stroke/seizures, heart?
Last in/out: food and water, pee and poop.
Events leading to injury.
FSA
Focused Spine Assessment
If: MOI for a spine injury AND no S/S AND Remote
1: A&O x 4
2: Sober
3: Not distracted
4: CSM x 4
5: No pain along spine
SOAP
Report should look like:
Name/Age/Gender/SAB
Summary/Subjective: CC and MOI, HPI, Pertinent History
Observations/Objective: Vitals, Head-to-Toe
Assessment: one sentence desc. of the patient, problem list
Plan: Tx & Plan, anticipated issues
