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Patient Assessment
Vital signs, patient presentation, and patient assessment acronyms
| Question | Answer |
|---|---|
| normotension | 120/80 mmHg |
| eupnea | 12-20 respirations per minute |
| normoglycemia | 70-120 mg/dL |
| normocardia | 60-100 bpm |
| euthermia | 97-99 F |
| normal capillary refill | less than 2 seconds |
| A and O x4 | Alert and Oriented to: person, place, time, and event |
| hypothermia | internal body temperature below 95 F |
| hyperthermia | internal body temperature 104 F |
| the top number for BP | systolic (120 is normal) |
| the bottom number for BP | diastolic (80 is normal) |
| normal End Tidal CO2 range | 35-45 mmHg |
| AVPU | Alert, Verbal, Painful, Unresponsive |
| cyanosis | abnormal condition of blue skin |
| pallor | abnormal condition of pale skin |
| jaundice/cirrhosis | abnormal condition of yellow skin |
| utricaria | hives |
| diaphoretic | sweaty |
| SCTM | skin color, temperature, and moisture |
| emesis | vomit |
| miosis | pinpoint pupils (less than 4 mm) |
| mydriasis | dilated pupils (bigger than 4 mm) |
| PERRL | Pupils Equal, Round, and Reactive to Light |
| Normal pupil size | 4 mm is normal |
| laceration | cut |
| contusion | bruising |
| hematoma | blood under the skin (larger bruising) |
| ecchymosis | another word for bruising |
| melena | dark, tarry stool |
| hematuria | blood in the urine |
| glycosuria | sugar in the urine |
| hematemesis | bloody vomit (might look pink or dark brown/coffee grounds texture) |
| edema | fluid in the body |
| Primary assessment | find and treat life threats |
| Secondary assessment | further investigation of chief complaint |
| Chief complaint | Main problem patient is having |
| Differential diagnosis | method of ruling out potential diagnoses as you gain more information |
| Which part of patient assessment do you use ABCDE? | Primary Assessment |
| Which part of patient assessment do you use SAMPLE? | History Taking |
| Which part of patient assessment do you use OPQRST? | History Taking |
| What is the purpose of reassessment? | Tracking a patient's progress with treatment |
| General impression | First look at a patient |
| Transport decision | Load and go or stay and play |
| Scene size up | Dispatch information, BSI, scene safety, additional resources |
| NOI | Nature of illness |
| What type of calls have an NOI? | Medical |
| MOI | Mechanism of injury |
| What type of calls have an MOI? | Trauma |
| Symptom | What the patient feels (ex: chest pain, nausea, shortness of breath) |
| Sign | What you can see (ex: diaphoresis, tachycardia, agonal respirations) |
| What is assessed during the A of ABCDE? | Airway: is it patent (open)? If the patient is talking = patent airway |
| What is assessed during the B of the ABCDE? | Breathing: is the patient breathing? What is the work of their breathing (labored, shallow, tripoding, etc)? |
| What is assessed during the C of ABCDE? | Circulation: does the patient have radial pulses that are equal and present? If not, do they have a carotid? What is the patient's skin condition? What is their cap refill? |
| What is assessed during the D of ABCDE? | Disability: Are there any neurological issues? Do you need to do a stroke exam on this patient? Are they alert and oriented x 4? |
| What is assessed during the E of ABCDE? | Environment: Is the environment harming the patient (bugs, allergies found in nature, heat, cold, etc)? Expose: Do we need a better look at the patient (lifting pant legs, taking off layers of clothing, etc) to find any threats? |
| If anything concerning is found in the ABCDE, what is the transport decision? | Load and go |
| If nothing concerning is found in the ABCDE, what is the transport decision? | Stay and play |
| What is the point of history taking? | Seeing if the patient has any medical conditions, allergies, recent activities, or medications that might be why they called 911 |
| Pertinent negative | Something the patient denies which gives you more information to figure out what's wrong (ex: chest pain but denies shortness of breath) |
| Differential diagnosis | Process of ruling out potential diagnoses as you gain more information |
Created by:
santafecollegeemt