Patient Assessment Abbreviations Flashcards
BSI
Body Substance Isolation (BSI). Those items that act as a barrier to body fluids, ie. latex gloves.
NOI
Nature Of Illness (NOI): This describes a medical emergency.
MOI
Mechanism Of Injury (MOI) This describes a trauma.
C-Spine
Cervical Spine
LOC
Level Of Consciousness measured using AVPU. Are they alert, verbal, respond to pain, or are they unresponsive.
AVPU
What you use to determine Level Of Consciousness (LOC). Are they (A) alert, (V) verbal, respond to (P) pain, or are they (U) unresponsive.
CC
Chief Complaint. What the patients main complaint is, ie. my chest hurts, or my leg is injured.
CAB
THE MOST IMPORTANT THING!!! When you see your patient for the first time you need to immediately check to see if the have blood (C) circulating in their body - typically done by checking the pulse. Check to see if they have an open (A) airway - nothing in the way of their breathing. You need to check to see if they are (B) breathing - and breathing fast enough.
SAMPLE
SAMPLE is used to help you remember what you need to ask your patient. S = Signs and Symptoms (Know the difference between signs and symptoms) A = Questions about allergies. M = Questions about medication. P = Past pertinent history. L = Last oral intake - when did the patient last eat or drink. E = Events leading to the medical/trauma problem.
S in SAMPLE
In SAMPLE. S = Signs and Symptoms. Signs are things you see on your patient, ie. sweat, blue skin, hives, rash.
A in SAMPLE
In SAMPLE. All questions you ask your patient about (A) allergies. “Are you allergic to anything?”
M in SAMPLE
In SAMPLE. All questions you ask your patient about (M) medications, ie. Are you on any medications? Are you on any new medications? Are you taking any recreational drugs? Have you recently stopped taking any drugs?
P in SAMPLE
In SAMPLE. All questions you ask your patient about (P) past pertinent history, ie. Has this happened before? Is this related to anything?
L in SAMPLE
In SAMPLE. All questions you ask your patient about their (L) last oral intake, ie, when was the last time you ate something? When was the last time you drank something?
E in SAMPLE
In SAMPLE. All questions you ask your patient about (E) events leading up to the medical/trauma problem.
OPQRST
OPQRST is used to help you remember what you need to ask your patient. O = Onset. P. Provoke. Q = Quality of Pain. R = Radiates.
S = Severity of Pain (1-10 scale). T = Time oriented questions
O in OPQRST
In OPQRST. When was the onset of this problem? When did this problem start?
P in OPQRST
In OPQRST. What provoked this problem? What made it hapen?
Q in OPQRST
In OPQRST. What is the quality of the pain? Describe the pain to me. Is it a sharp pain, a dull pain?
R in OPQRST
In OPQRST. Is the pain radiating? Does the pain or sensation move.
S in OPQRST
In OPQRST. What is the severity of the pain. On a scale of 1 to 10, 10 being the worst pain you ever felt, and 1 almost no pain, how would you rank it?
T in OPQRST
In OPQRST. Any time questions. How often? How far apart?
hx.
History
R/O
Rule Out. Based on the questions I asked I know what the problem isn’t. I have ruled it out.
O2T
Oxygen Therapy. Anytime you administer (give) oxygen.
NC
Nasal Canula is the tube that goes in the nostrils to deliver oxygen
NRM
None Rebreather Mask. The mask with the sack that delivers high flow oxygen to a patient that is breathing.
BVM
Bag Valve Mask is the oxygen delivery devise you squeeze to force oxygen into your patient.
BVMA
Bag Valve Mask Assist. When you use the BVM to assist someone in breathing - used when the patient is breathing too fast or too slow.
BVMV
Bag Valve Mask Ventilate. When you use the BVM to breath for a patient that is NOT breathing on their own.
DCAPBTLS
DCAPBTLS is used to remind you what to look for when checking the patients body.
D in DCAPBTLS
In DCAPBTLS. Deformities. Anything that loo
C in DCAPBTLS
In DCAPBTLS. Contusion - a big bruise.
A in DCAPBTLS
In DCAPBTLS. Abrasion - a scrape.
P in DCAPBTLS
In DCAPBTLS. Puncture - a hole in the body created by the penetration of a sharp object.
B in DCAPBTLS
In DCAPBTLS. Burns or bruises
T in DCAPBTLS
In DCAPBTLS. Tenderness. Always ask the patient if what you are inspecting hurts.
L in DCAPBTLS
In DCAPBTLS. Laceration - A slice in the skin or flesh.
S in DCAPBTLS
In DCAPBTLS. Swelling - Something that is larger than normal due to an injury, ie. a swollen ankle.
GSW
Gun Shot Wound
FX
Fracture - a broken bone
CSM
Circulation - Sensory - Motor: What you need to check for in the hands and foot.
C in CSM
In CSM - Circulation: There is a pulse and capillary refill under the nail bed.
S in CSM
In CSM - Sensory: Check to see the patient can feel which finger or toe you are touching.
M in CSM
In CSM - Motor: Check to see the patient is able to move fingers and toes.
JVD
Jugular Vein Distention - Jugular veins in the neck sticking out. Sign of heart problem.
ETA
Estimated Time of Arrival - When you will be arriving.
