Patient Assessment EMS

Assessment

The process of gathering and interpreting information to identify a patient's condition and guide treatment.

Scene Size-Up

The initial evaluation of the scene to ensure safety, determine resources needed, and identify hazards before patient contact.

Scene Safety

Confirming that the scene is safe for rescuers, patients, and bystanders before entering.

Personal Protective Equipment (PPE)

Protective equipment worn to reduce exposure to hazards such as bloodborne pathogens and other dangers.

Mechanism of Injury (MOI)

The force or event that caused a traumatic injury and helps predict possible injuries.

Nature of Illness (NOI)

The medical condition or illness responsible for a patient's signs and symptoms.

Primary Assessment

A rapid assessment to identify and treat immediate life threats using the patient's level of consciousness and ABCs.

General Impression

Your overall initial assessment of the patient's appearance, age, sex, level of distress, and condition.

Chief Complaint

The primary problem or reason the patient called EMS.

Level of Consciousness (LOC)

A measure of a patient's awareness of themselves and their surroundings.

AVPU

A rapid method of assessing responsiveness: Alert, Verbal, Pain, Unresponsive.

Airway Assessment

Evaluation to determine whether the patient's airway is open and can be maintained.

Head Tilt-Chin Lift

The preferred maneuver for opening the airway when spinal injury is not suspected.

Jaw-Thrust Maneuver

An airway-opening technique used when spinal injury is suspected while minimizing cervical spine movement.

Respiratory Distress

Increased work of breathing while ventilation remains adequate.

Respiratory Failure

A condition in which oxygenation or ventilation is inadequate to meet the body's needs.

Positive Pressure Ventilation (PPV)

Artificial ventilation provided when a patient is not breathing adequately.

Circulation Assessment

Evaluation of pulse, skin signs, capillary refill, and severe bleeding.

Capillary Refill

A test of peripheral circulation by observing how quickly color returns to a blanched nail bed.

Arterial Bleeding

Bright red blood that spurts with each heartbeat and requires immediate bleeding control.

Venous Bleeding

Dark red blood that flows steadily from a vein.

Tourniquet

A device used to control severe extremity bleeding when direct pressure is ineffective or impractical.

Golden Hour

The period following serious injury during which rapid treatment and transport improve patient outcomes.

Platinum 10 Minutes

The goal of completing assessment, treatment, and packaging of a critical trauma patient within approximately 10 minutes.

History Taking

The process of obtaining information about the patient's illness, injury, and medical history.

OPQRST

A mnemonic used to investigate pain: Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, Time.

SAMPLE History

A mnemonic used to obtain a patient's medical history: Signs/Symptoms, Allergies, Medications, Past Medical History, Last Oral Intake, Events Leading Up.

Secondary Assessment

A systematic physical examination used to identify injuries or illnesses not found during the primary assessment.

Inspection

Examining the patient by looking for abnormalities.

Palpation

Examining the patient by feeling for abnormalities such as tenderness or deformities.

Auscultation

Listening to internal body sounds with a stethoscope.

DCAP-BTLS

A mnemonic for the physical exam: Deformities, Contusions, Abrasions, Punctures/Penetrations, Burns, Tenderness, Lacerations, Swelling.

Pulse Oximetry

Measurement of the percentage of hemoglobin saturated with oxygen.

Capnography

Monitoring exhaled carbon dioxide to assess ventilation, circulation, and metabolism.

Blood Glucometry

Measurement of blood glucose concentration using a glucometer.

Glasgow Coma Scale (GCS)

A neurological assessment tool that scores eye opening, verbal response, and motor response.

PEARRL

Pupils Equal And Round, Regular in size, Reactive to Light.

Hypotension

Blood pressure that is lower than normal and may indicate inadequate perfusion.

Hypertension

Blood pressure that is higher than normal.

Reassessment

A repeat evaluation of the patient's condition, interventions, and vital signs throughout care.

Reassessment Interval

Reassess unstable patients every 5 minutes and stable patients every 15 minut