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Patient Assessment

Vital signs and patient presentation

QuestionAnswer
normotension 120/80 mmHg
eupnea 12-20 respirations per minute
normoglycemia 70-120 mg/dL
normocardia 60-100 bpm
euthermia 98.6 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 CO2 range 35-45 EtCO2
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
 

 



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