Good Day Class!

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Don’t forget to start a shift today

day we are discussing chapter 1

Patient Assessment
 Scenario

You have responded to a patient who has a history of COPD. The patient tells
you he has asthma and is on home oxygen at 2 lpm. The patient called you today

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as a result of an injured knee. You note some swelling and bruising to the left
knee. The patient has no other injuries or complaints. Which of the
following would be the most appropriate oxygen delivery device to administer to
the patient while transporting to the hospital?

a. A non-rebreather mask at 12-15 lpm.

b. A nasal cannula at 6 lpm.
c. Assist ventilations with a bag-valve-mask.
d. A nasal cannula at 2 lpm.
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The correct answer is:

d. A nasal cannula at 2 lpm.

 Scenario 2

You are dispatched to a funeral home for a 25-year-old male patient with a chief
complaint of difficulty breathing. The patient is the son of the deceased, and you

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note that he is breathing at 30 times per minute and his hands and wrists appear
to be spasming. He has no medical conditions, and his color is good. Which of
the following would be the most appropriate treatment for this condition?

a. Place him on a non-rebreather at 6 lpm.

b. Have him breathe into a paper bag.
c. Attempt to have him slow his respirations.
d. Assist ventilations with a bag-valve-mask.
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The correct answer is:

c. Attempt to have him slow his respirations.

 Scenario 3

You arrive at the home of a 73-year-old female complaining of chest tightness.

She is difficult to arouse, has a rapid pulse, rales in all lung fields, and a blood

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pressure of 92/38. You suspect this patient to have:

a. Cardiovascular compromise.
b. Pleuritic chest pain.
c. Amphetamine overdose.
d. Hypotensive event from fluid loss.
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The correct answer is:

a. Cardiovascular compromise.
 Scenario 4

You are called to the local walk-in clinic where they are treating a 76-year-old
male for shortness of breath. The staff tells you the patient has a history of heart

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attacks. The patient is supine on the clinic bed, in obvious respiratory distress,
with a blood pressure of 218/120. Your assessment of this patient further reveals
a respiratory rate of 28 labored, rales to the top of both lungs, and pedal edema
in both legs. The first thing you should do for this patient is:

a. Place the patient in a Trendelenburg position to lower his blood pressure.

b. Place the patient in Fowler's position to assist in breathing.
c. Calm and reassure the patient and administer glucose.
d. Apply oxygen with a nasal cannula set at 2 liters per minute.
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b. Place the patient in Fowler's position to assist in breathing.
The correct answer is:
 Scenario 5

You are called to the scene of a cardiac arrest, where a 19-year-old patient was

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discovered in a pool face down. The family had taken him out of the pool, started
CPR and called 911. The patient is pale, cold and clammy. There are pulses with
CPR but no pulses without chest compressions. Which of the following should
you do next?
a. Remove all wet clothing, dry him off completely and then attach the AED.
b. Fully immobilize the patient on a backboard and then resume CPR at a 30 to 2
ratio.
c. Dry the patient's chest, attach the AED, turn it on and follow the directions of
the machine.
d. Turn the patient on his side, decompress the stomach and then return to CPR.
 The correct answer is:

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c. Dry the patient's chest, attach the AED, turn it on and follow the directions of the
machine.
Introduction (1 of 3)

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 Patient assessment is very important.
 EMTs must master the patient assessment process.
 Patient assessment is used, to some degree, in every patient encounter.
Introduction (2 of 3)

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 Five main parts:
 Scene size-up
 Primary assessment
 History taking
 Secondary assessment
 Reassessment
Introduction (3 of 3)

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 Rarely does one sign or symptom show you the patient’s status or underlying
problem.
 Symptom: subjective condition the patient feels and tells you about
 Sign: objective condition you can observe about the patient
Scene Size-up

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 Your evaluation of the conditions in which you will be operating
 Maintain situational awareness.
 Scene size-up combines:
 An understanding of the situation and conditions prior to responding
 Dispatcher’s basic information
 Observation of the scene
Ensure Scene Safety (1 of 3)

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 Issues can range from minor difficulties to major dangers.
 Do not enter until the scene is safe for you and your team.
 Typically, the way you enter an area is the way you will leave.
 Wear a high-visibility safety vest on roadways.
Ensure Scene Safety (2 of 3)

 Consider difficult terrain.

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 Consider traffic safety issues.
 Consider environmental conditions.

FIGURE 10-1 At times, you may need to move

patients out of areas with difficult terrain.
Courtesy of the National Ski Patrol.
Ensure Scene Safety (3 of 3)

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 If appropriate, help protect bystanders from becoming patients.
 Hazards range from extreme weather conditions to the threat of physical
violence.
 An emergency scene is a dynamically changing environment.
Determine Mechanism of Injury/Nature of Illness (1 of 5)

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 Calls for assistance can be categorized as medical conditions, traumatic
injuries, or both.
 Mechanism of injury (MOI)
 Type or amount of force
 How long it was applied
 Where it was applied to the body
Determine Mechanism of Injury/Nature of Illness (2 of 5)

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 Blunt trauma
 The force occurs over a broad area.
 Skin is usually not broken.
 Tissues and organs below the area of impact may be damaged.
Determine Mechanism of Injury/Nature of Illness (3 of 5)

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 Penetrating trauma
 The force of the injury occurs at a small point of contact between the skin and the
object.
 Open wound with high potential for infection
Determine Mechanism of Injury/Nature of Illness (4 of 5)

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 For medical patients, determine the nature of illness (NOI).
 Similarities between MOI and NOI
 Talk with the patient, family, or bystanders.
 Use your senses to check for clues.
Determine Mechanism of Injury/Nature of Illness (5 of 5)

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 Be aware of scenes with more than one patient with similar signs or symptoms.
 Example: carbon monoxide poisoning
 Could indicate an unsafe scene for the EMT as well
Importance of MOI and NOI

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 Considering the MOI or NOI early can be of value in preparing to care for the
patient.
 You may be tempted to categorize the patient immediately as either trauma or
medical.
 Take Standard Precautions (1 of 3)

 Wear personal protective equipment

(PPE).

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 Should be adapted to the prehospital
task at hand

FIGURE 10-4 Proper protective equipment is vital when

you are called to a scene in which you may be exposed to
infection or blood or other body fluids.
© Jones & Bartlett Learning. Courtesy of MIEMSS
Take Standard Precautions (2 of 3)

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 Standard precautions have been recommended for use in dealing with:
 Objects
 Blood
 Body fluids
 Other potential exposure risks of communicable disease
Take Standard Precautions (3 of 3)

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 When you step out of the EMS vehicle, standard precautions must have been
already taken or initiated.
 At a minimum, gloves must be in place.
 Consider glasses and a mask.
Determine Number of Patients (1 of 2)

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 During scene size-up, accurately identify the total number of patients.
 Critical in determining the need for additional resources
 When there are multiple patients, use the incident command system, identify
the number of patients, and then begin triage.
 Determine Number of Patients (2 of 2)

 Triage is the process of sorting

patients based on the severity of

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each patient’s condition.

FIGURE 10-5 With multiple patients, use the incident

command system, call for additional resources, and then
begin triage. A multiple casualty incident involving two
trains that collided in 2005.
© David McNew/Getty Images News/Getty Images.
Consider Additional/Specialized Resources (1 of 3)

 Some situations may require:

 More ambulances

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 Specialized resources

FIGURE 10-6 Scenes involving toxic

substances may require specially trained
rescuers with extra protective equipment.
Courtesy of Tempe Fire Department.
Consider Additional/Specialized Resources (2 of 3)

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 Specialized resources include:
 Advanced life support (ALS)
 Air medical support
 Fire departments, who may handle high-angle rescue, hazardous materials, or
water rescue
 Law enforcement
Consider Additional/Specialized Resources (3 of 3)

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 To determine if you require additional resources, ask yourself:
 Does the scene pose a threat to me, my patient, or others?
 How many patients are there?
 Do we have the resources to respond to their conditions?
Primary Assessment

 Begins when you greet your patient

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 The goal is to identify and initiate treatment of immediate or
potential life threats.
 Physically examine the patient and assess:
 LOC
 ABCs
Form a General Impression (1 of 3)

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 Formed to determine the priority of care
 First part of primary assessment
 Make a note of the person’s:
 Age, sex, and race
 Level of distress
 Overall appearance
Form a General Impression (2 of 3)

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 Note the patient’s position.
 Avoid standing over the patient.
 Address the patient by name.
 Introduce yourself.
 Ask about the chief complaint.
 Address life-threats immediately.
Form a General Impression (3 of 3)

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 Determine if the patient’s condition is:
 Stable
 Stable but potentially unstable
 Unstable
Scan for Signs of Uncontrolled Bleeding

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 Uncontrolled external bleeding takes priority over other assessments.
Assess Level of Consciousness (1 of 7)

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 The level of consciousness (LOC) can tell you a great deal about the patient’s
neurologic and physiologic status.
Assess Level of Consciousness (2 of 7)

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 Assessment of an unconscious patient focuses on airway, breathing, and
circulation.
 Sustained unconsciousness should warn you of a critical respiratory, circulatory, or
central nervous system problem.
Assess Level of Consciousness (3 of 7)

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 Conscious with an altered LOC may be due to inadequate perfusion.
 Could also be caused by medications, drugs, alcohol, or poisoning
Assess Level of Consciousness (4 of 7)

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 To assess for responsiveness, use the mnemonic AVPU:
 Awake and alert
 Responsive to Verbal stimuli
 Responsive to Pain
 Unresponsive
 Assess Level of Consciousness (5 of 7)

Test responsiveness to painful stimuli.

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FIGURE 10-9 Methods of gauging a patient’s responsiveness to painful stimuli. A. Gently but firmly pinch the
patient’s ear lobe. B. Press on the bone above the eye. C. Gently but firmly pinch the muscles of the neck.
© Jones & Bartlett Leaning.
Assess Level of Consciousness (6 of 7)

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 Orientation tests mental status.
 Evaluates a patient’s ability to remember:
 Person
 Place
 Time
 Event
Assess Level of Consciousness (7 of 7)

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 Evaluates long-term memory, intermediate-term memory, and short-term
memory
 Altered mental status
 Any deviation from alert and oriented to person, place, time, and event
 Any deviation from the patient’s normal baseline
Identify and Treat Life-Threats (1 of 2)

 Conditions that cause sudden death:

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 Airway obstruction
 Respiratory failure
 Respiratory arrest
 Shock
 Severe bleeding
 Primary cardiac arrest
Identify and Treat Life-Threats (2 of 2)

 In most cases, begin with airway, followed by breathing and

circulation (ABC).

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 In some cases, it may be appropriate to address life threats to
circulation first (CAB).
Assess the Airway (1 of 4)

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 Moving through the primary assessment, stay alert for signs of airway
obstruction.
 Ensure the airway remains open (patent) and adequate.
Assess the Airway (2 of 4)

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 Responsive patients
 Patients who are talking or crying have an open airway.
 Watch and listen to how patients speak.
 If you identify an airway problem, stop the assessment and work to clear the
patient’s airway.
Assess the Airway (3 of 4)

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 Unresponsive patients
 Immediately assess the airway.
 Use the jaw-thrust technique when necessary.
 Use the head tilt–chin lift technique when necessary.
 Relaxation of the tongue muscles is a cause of airway obstruction.
Assess the Airway (4 of 4)

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 Signs of obstruction in an unconscious patient:
 Obvious trauma, blood, or obstruction
 Noisy breathing (snoring, bubbling, gurgling, crowing, abnormal sounds)
 Extremely shallow or absent breathing
Assess Breathing (1 of 5)

 Make sure the patient’s airway is open.

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 Make sure the patient’s breathing is present and adequate.
 Ask yourself:
 Is the patient breathing?
 Is the patient breathing adequately?
 Is the patient hypoxic?
Assess Breathing (2 of 5)

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 Consider providing positive pressure ventilations with an airway adjunct when:
 Respirations exceed 28 breaths/min
 Respirations are fewer than 8 breaths/min
 The goal for oxygenation for most patients is an oxygen saturation of
approximately 94% to 99%.
Assess Breathing (3 of 5)

 Observe how much effort is required for the patient to breathe:

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 Retractions
 Use of accessory muscles
 Nasal flaring
 Two- to three-word dyspnea
 Tripod position
 Sniffing position
 Labored breathing
Assess Breathing (4 of 5)

 Respiratory distress

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 Increased work of breathing
 Increased effort and rate
Assess Breathing (5 of 5)

 Respiratory failure

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 Occurs when the blood is inadequately oxygenated, or ventilation is inadequate to
meeting the oxygen demands of the body
 The ultimate result of respiratory failure if it is not corrected
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Assess Circulation (1 of 11)

 Skin condition
 Mental status
 Pulse
 Assess
Assess Circulation (2 of 11)

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 Assess pulse
 The pulse is the pressure wave that occurs as each heartbeat causes a surge in
the blood circulating through the arteries.
 Palpate (feel) the pulse.
 If you cannot palpate a pulse in an unresponsive patient, begin CPR.
Assess Circulation (3 of 11)

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 Skin condition
 Evaluate the patient’s skin color, temperature, moisture, and capillary refill.
 A normally functioning circulatory system perfuses the skin with oxygenated blood.
Assess Circulation (4 of 11)

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 Skin color
 Determined by the blood circulating through vessels and the amount and type of
pigment present in the skin
 Poor circulation will cause the skin to appear pale, white, ashen, or gray.
Assess Circulation (5 of 11)

 Skin color (cont’d)

 When blood is not properly saturated

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with oxygen, it appears blue.
 Changes in skin color may result from
chronic illness.

FIGURE 10-13 Cyanosis occurs when the

patient has low levels of oxygen in the blood.
© St. Bartholomew’s Hospital, London/Photo Researchers, Inc.
Assess Circulation (6 of 11)

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 Skin temperature
 Normal skin will be warm to the touch.
 Abnormal skin temperatures are hot, cool, cold, and clammy.
Assess Circulation (7 of 11)

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 Skin moisture
 Dry skin is normal.
 Skin that is wet, moist, or excessively dry and hot suggests a problem.
Assess Circulation (8 of 11)

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 Capillary refill
 Evaluated to assess the ability of the circulatory system to restore blood to the
capillary system
 Press on the patient’s fingernail.
 Remove the pressure.
 The nail bed should restore to its normal pink color.
Assess Circulation (9 of 11)

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 Capillary refill (cont’d)
 Should be restored to normal within 2 seconds

FIGURE 10-14 A. To test capillary refill, gently compress

the fingertip until it blanches. B. Release the fingertip, and
count until it returns to its normal pink color.
A., B: © Jones & Bartlett Learning. Courtesy of MIEMSS.
Assess Circulation (10 of 11)

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 Assess and control external bleeding in trauma patients.
 Should occur before addressing airway or breathing concerns.
 Bleeding from a large vein is characterized by a steady flow of blood.
 Bleeding from an artery is characterized by a spurting flow of blood.
Assess Circulation (11 of 11)

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 Controlling external bleeding can be simple.
 Apply direct pressure.
 Apply a tourniquet if:
 Direct pressure is not quickly successful.
 Obvious arterial hemorrhage of an extremity
Perform a Rapid Exam

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 Identify injuries that must be managed or protected before the patient is
transported.
 Take 60 to 90 seconds to perform.
 Not a systematic or focused physical examination
Determine Priority of Patient Care and Transport (1 of 5)

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 Primary assessment assists in determining transport priority.
 High-priority patients include those with any of the following conditions:
 Unresponsive
 Difficulty breathing
 Uncontrolled bleeding
Determine Priority of Patient Care and Transport (2 of 5)

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 High-priority patients (cont’d):
 Altered level of consciousness
 Severe chest pain
 Pale skin or other signs of poor perfusion
 Complicated childbirth
 Severe pain in any area of the body
Determine Priority of Patient Care and Transport (3 of 5)

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 The Golden Hour (Golden Period) is the time from injury to definitive care.
 Treatment of shock and traumatic injuries must occur.
 Immediate transport is one of the keys to survival of patients who need immediate
care that the EMT cannot provide.
Determine Priority of Patient Care and Transport (4 of 5)

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FIGURE 10-16 The Golden Hour, also called the Golden Period, is
the time during which treatment of shock or traumatic injuries is
most critical and the potential for survival is best.
© Jones & Bartlett Learning.
Determine Priority of Patient Care and Transport (5 of 5)

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 Transport decisions should be made at this point, based on:
 Patient’s condition
 Availability of advanced care
 Distance of transport
 Local protocols
History Taking (1 of 4)

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 Provides detail about the chief complaint and the patient’s signs and symptoms
 Includes demographic information:
 Date of the incident
 Patient’s age, gender, race, past medical history, and current health status
History Taking (2 of 4)

 Investigate the chief complaint.

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 Make introductions, make the patient feel comfortable, and obtain
permission to treat.
 Ask a few simple and direct questions.
 Ask the patient how they would like to be addressed
 Ask open-ended questions.
History Taking (3 of 4)

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 If the patient is unresponsive, patient information and clues about the incident
may be obtained from:
 Family members present
 A person who may have witnessed the situation
 Bystanders
 Medical alert jewelry
 Other patient medical history documentation
History Taking (4 of 4)

 Use the OPQRST mnemonic to assess symptoms.

 Onset

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 Provocation or palliation
 Quality
 Region/radiation
 Severity
 Timing
 Identify pertinent negatives.
Obtain a SAMPLE History

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 Use the mnemonic SAMPLE to obtain the following information:
 Signs and symptoms
 Allergies
 Medications
 Pertinent past medical history
 Last oral intake
 Events leading up to the injury/illness
Critical Thinking in Assessment

 Gathering
 Seeking facts

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 Evaluating
 Considering what the information means

 Synthesizing
 Putting the information together to plan scene management and patient care
Taking History on Sensitive Topics (1 of 3)

 Alcohol and drugs

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 Signs may be confusing, hidden, or disguised.
 Patient may deny having any problems.
 History gathered may be unreliable.
 Do not judge the patient.
 Be professional in your approach.
Taking History on Sensitive Topics (2 of 3)

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 Physical abuse or violence
 Report all physical abuse or domestic violence to the appropriate authorities.
 Follow local protocols.
 Do not accuse; instead, immediately involve law enforcement.
Taking History on Sensitive Topics (3 of 3)

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 Sexual history
 Consider all patients with a uterus of childbearing age who report lower abdominal
pain to be pregnant.
 Ask about the patient’s last menstrual period.
 Inquire about urinary symptoms with male patients.
 When appropriate, ask all patients about the potential for sexually transmitted
diseases.
Special Challenges in Obtaining Patient History (1 of 14)

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 Silence
 Patience is extremely important.
 Use a closed-ended question that requires a simple yes or no answer.
 Consider whether the silence is a clue to the patient’s chief complaint.
Special Challenges in Obtaining Patient History (2 of 14)

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 Overly talkative
 Reasons why a patient may be overly talkative:
 Excessive caffeine consumption
 Nervousness
 Ingestion of cocaine, crack, or methamphetamines
 Underlying psychological issue
Special Challenges in Obtaining Patient History (3 of 14)

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 Multiple symptoms
 Prioritize the patient’s complaints as you would in triage.
 Start with the most serious and end with the least serious.
Special Challenges in Obtaining Patient History (4 of 14)

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 Anxiety
 Some anxious patients show signs of psychological shock:
 Pallor
 Diaphoresis
 Shortness of breath
 Numbness in the hands and feet
 Dizziness or light-headedness
 Loss of consciousness
Special Challenges in Obtaining Patient History (5 of 14)

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 Anger and hostility
 Friends, family, or bystanders may direct their anger and rage toward you.
 Remain calm, reassuring, and gentle.
 If the scene is not safe or secured, get it secured.
Special Challenges in Obtaining Patient History (6 of 14)

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 Intoxication
 Do not put an intoxicated patient in a position where they feel threatened.
 Potential for violence and a physical confrontation is high.
 Alcohol dulls a patient’s senses.
Special Challenges in Obtaining Patient History (7 of 14)

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 Crying
 A patient who cries may be sad, in pain, or emotionally overwhelmed.
 Remain calm.
 Be patient, reassuring, and confident.
 Maintain a soft voice.
Special Challenges in Obtaining Patient History (8 of 14)

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 Depression
 Among the leading causes of disability worldwide
 Symptoms include sadness, hopelessness, restlessness, irritability, sleeping and
eating disorders, and a decreased energy level.
 Be a good listener.
Special Challenges in Obtaining Patient History (9 of 14)

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 Confusing behavior or history
 Conditions such as hypoxia, stroke, diabetes, trauma, medications, and other drugs
could alter a patient’s explanation of events.
 Older patients could have dementia, delirium, or Alzheimer disease.
Special Challenges in Obtaining Patient History (10 of 14)

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 Limited cognitive abilities
 Keep your questions simple and limit the use of medical terms.
 Be alert for partial answers and keep asking questions.
 Rely on the presence of family, caregivers, and friends to supply answers.
Special Challenges in Obtaining Patient History (11 of 14)

 Cultural challenges

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 Do not use medical language.
 Patients may prefer to speak with health care providers of the same gender.
 Gain the assistance of the patient’s friends or family members.
 Enlist the help of health care providers of the same culture or background, if
possible.
Special Challenges in Obtaining Patient History (12 of 14)

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 Language barriers
 Find an interpreter, if possible.
 If not, determine if the patient understands who you are.
 Keep questions straightforward and brief.
 Use hand gestures.
 Be aware of the language diversity in your community.
Special Challenges in Obtaining Patient History (13 of 14)

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 Hearing problems
 Ask questions slowly and clearly.
 Use a stethoscope to function as a hearing aid.
 Learn simple sign language to help with communication.
 Use a pencil and paper.
Special Challenges in Obtaining Patient History (14 of 14)

 Visual impairments

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 Identify yourself verbally when you enter the scene.
 Return any items that have been moved to their previous positions.
 Explain to the patient what is happening in each step of the assessment of
vital signs.
Secondary Assessment (1 of 4)

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 May be performed on-scene, in the back of the ambulance en route to the
hospital, or not at all
 Purpose is to perform a systematic physical examination of the patient.
 May be a systematic head-to-toe secondary assessment or an assessment that
focuses on a certain area or system of the body
Secondary Assessment (2 of 4)

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 How and what to assess:
 Inspection—Look at the patient for abnormalities.
 Palpation—Touch or feel the patient for abnormalities.
 Auscultation—Listen to the sounds a body makes by using a stethoscope.
Secondary Assessment (3 of 4)

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 Use the mnemonic DCAP-BTLS.
 Compare findings on one side of the body with the other side when possible.
Secondary Assessment (4 of 4)

 Systematically assess the patient—secondary assessment

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 Goal is to identify hidden injuries or identify causes missed during 60- to 90-second
exam during primary assessment.
Focused Assessment

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 Performed on patients who have sustained nonsignificant MOIs or on
responsive medical patients
 Typically based on the chief complaint
 Goal is to focus your attention on the body part or systems affected by the
priority problems.
Respiratory System (1 of 7)

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 Expose the patient’s chest.
 Look for signs of airway obstruction.
 Inspect for symmetry.
 Listen to breath sounds.
 Measure the respiratory rate.
 Look for retractions and increased work of breathing.
Respiratory System (2 of 7)

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 Respiratory rate
 A normal rate in adults ranges from 12 to 20 breaths/min.
 Children breathe at even faster rates.
 Count the number of breaths in a 30-second period and multiply by two.
Respiratory System (3 of 7)

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 Respiratory rhythm
 Regular
 The time from one peak chest rise to the next is consistent.
 Irregular
 The respirations vary or the rate changes frequently.
Respiratory System (4 of 7)

 Quality of breathing

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 Normal breathing is silent.
 Breathing accompanied by other sounds may indicate a significant
respiratory problem.
Respiratory System (5 of 7)

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 Depth of breathing
 Amount of air the patient exchanges depends on the rate and tidal volume.

 Breath sounds
 You can almost always hear breath sounds better from the patient’s back.
Respiratory System (6 of 7)

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FIGURE 10-23 Locations for auscultating breath sounds: both sides of the chest in multiple
lung fields, as shown. A. Stethoscope position for auscultating the front of the chest. B.
Stethoscope position for auscultating the back.
© Jones & Bartlett Learning.
Respiratory System (7 of 7)

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 What are you listening for?
 Normal breath sounds
 Snoring breath sounds
 Wheezing breath sounds
 Crackles
 Rhonchi
 Stridor
Cardiovascular System (1 of 10)

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 Look for trauma to the chest and listen for breath sounds.
 Consider the pulse, respiratory rate, and blood pressure.
 Pay attention to rate, quality, and rhythm.
Cardiovascular System (2 of 10)

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 Consider your findings when assessing the skin.
 Check and compare distal pulses.
 Consider auscultation for abnormal heart sounds.
Cardiovascular System (3 of 10)

 Pulse rate
 Normal resting pulse for an adult

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is between 60 and 100 beats/min.
 The younger the patient, the
faster the pulse.
Cardiovascular System (4 of 10)

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 Pulse quality
 Describe a stronger than normal pulse as “bounding.”
 A pulse that is weak and difficult to feel is described as “weak” or “thready.”
Cardiovascular System (5 of 10)

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 Pulse rhythm
 Regular
 The interval between each contraction should be the same.
 The pulse should occur at a constant, regular rhythm.
 Irregular
 If the heart periodically has an early or late beat.
 If a pulse beat is missed.
Cardiovascular System (6 of 10)

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 Blood pressure
 Pressure of circulating blood against the walls of the arteries
 A drop in blood pressure may indicate:
 A loss of blood or fluid components
 A loss of vascular tone and sufficient arterial constriction
 A cardiac pumping problem
Cardiovascular System (7 of 10)

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 Blood pressure (cont’d)
 Decreased blood pressure is a late sign of shock.
 Abnormally high blood pressure may result in a rupture or other critical damage in
the arterial system.
Cardiovascular System (8 of 10)

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 A blood pressure cuff with gauge contains the following components:
 A wide outer cuff
 An inflatable wide bladder
 A ball-pump with a one-way valve
 A pressure gauge
 Cardiovascular System (9 of 10)

 Auscultation is the most common

means of measuring blood pressure.

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 Palpation method does not depend
on the ability to hear sounds.

Follow standard precautions. Check for a dialysis

fistula, central line, previous mastectomy, and
injury to the arm. If any are present, use the
brachial artery on the other arm. Apply the cuff
snugly. The lower border of the cuff should be
about 1 inch (2.5 cm) above the antecubital space.
Cardiovascular System (10 of 10)

 Normal blood pressure

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 Hypotension: Blood pressure is
lower than normal.
 Hypertension: Blood pressure is
higher than normal.
Neurologic System (1 of 2)

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 Neurologic assessment
 Should be performed with any patient who has:
 Changes in mental status
 A possible head injury
 Stupor
 Dizziness/drowsiness
 Syncope
Neurologic System (2 of 2)

 Neurologic assessment (cont’d)

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 Evaluate the level of consciousness and orientation.
 Use the AVPU scale if appropriate.
 The Glasgow Coma Scale (GCS) score can be helpful in providing
additional information.
Pupils (1 of 4)

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 The pupil is the black center portion of the eye.
 Normally round and of approximately equal size
 In the absence of any light, the pupils will become fully relaxed and dilated.
Pupils (2 of 4)

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FIGURE 10-26 A. Constricted pupils.
B. Dilated pupils. C. Unequal pupils.
A., B., C: © American Academy of Orthopaedic Surgeons.
Pupils (3 of 4)

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 A small number of the population exhibit unequal pupils (anisocoria).
 Causes of depressed brain function:
 Injury of the brain or brainstem
 Trauma or stroke
 Brain tumor
 Inadequate oxygenation or perfusion
 Drugs or toxins
Pupils (4 of 4)

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 PEARRL is a useful assessment guide:
 Pupils
 Equal
 And
 Round
 Regular in size
 React to Light
Neurovascular Status

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 Check for bilateral muscle strength and weakness.
 Complete a thorough sensory assessment.
 Test for pain, sensations, and position.
 Compare distal and proximal sensory and motor responses and one side with
the other.
Anatomic Regions (1 of 6)

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 Head, neck, and cervical spine
 Palpate the scalp and skull.
 Check the patient’s eyes.
 Check the color of the sclera.
 Assess the patient’s cheekbones.
 Check the patient’s ears and nose for fluid.
Anatomic Regions (2 of 6)

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 Head, neck, and cervical spine (cont’d)
 Check the upper (maxillae) and lower (mandible) jaw.
 Open the patient’s mouth and look for any broken or missing teeth.
 Note any unusual odors in the mouth.
Anatomic Regions (3 of 6)

 Chest
 Inspect, visualize, and palpate.

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 Watch for both sides of the chest to rise and fall together with normal breathing.
 Observe for abnormal breathing signs.
Anatomic Regions (4 of 6)

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 Abdomen
 Palpate for tenderness, rigidity, and patient guarding.
 Four quadrants:
 Left upper quadrant (LUQ)
 Left lower quadrant (LLQ)
 Right upper quadrant (RUQ)
 Right lower quadrant (RLQ)
Anatomic Regions (5 of 6)

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 Pelvis
 Inspect for symmetry and any obvious signs of injury, bleeding, and deformity.
 Extremities
 Inspect for symmetry, cuts, bruises, swelling, obvious injuries, and bleeding.
 Palpate for deformities.
 Check for pulses and motor and sensory functions.
Anatomic Regions (6 of 6)

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 Posterior body
 Inspect the back for DCAP-BTLS, symmetry, and open wounds.
 Palpate the spine from the neck to the pelvis for tenderness and deformity.
 Assess Vital Signs (1 of 4)

 Use appropriate monitoring devices.

 Should never replace your comprehensive

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assessment of the patient
 Pulse oximetry
 Used to evaluate oxygenation’s
effectiveness

FIGURE 10-36 The pulse oximeter is a

device that measures the saturation of
oxygen in the blood as a percentage.
© juanrvelasco/iStock.
Assess Vital Signs (2 of 4)

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 Pulse oximetry (cont’d)
 Measures the oxygen saturation of hemoglobin in the capillary beds
 Patients with difficulty breathing should receive oxygen regardless of their pulse
oximetry value.
Assess Vital Signs (3 of 4)

 Capnography

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 Can quickly provide information on a patient’s ventilation, circulation, and
metabolism
 Blood glucometry
 Measures the level of glucose in the bloodstream
Assess Vital Signs (4 of 4)

 Noninvasive blood pressure

measurement

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FIGURE 10-24 A sphygmomanometer.
© WizData, Inc./Shutterstock.
Reassessment (1 of 4)

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 Perform at regular intervals during the assessment process.
 Repeat the primary assessment.
 Reassess vital signs.
 Compare with the baseline vital signs obtained during the primary assessment.
 Look for trends.
Reassessment (2 of 4)

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 Reassess the chief complaint.
 Ask and answer the following questions:
 Is the current treatment improving the patient’s condition?
 Has an already identified problem gotten better?
 Has an already identified problem gotten worse?
 What is the nature of any newly identified problems?
Reassessment (3 of 4)

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 Recheck interventions.
 Check all interventions.
 Most important are the patient’s ABCs.
 Ensure management of bleeding.
 Ensure adequacy of other interventions, and consider the need for new
interventions.
Reassessment (4 of 4)

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 Identify and treat changes in the patient’s condition.
 Document any changes, whether positive or negative.
 Reassess the patient.
 Unstable patients: approximately every 5 minutes
 Stable patients: approximately every 15 minutes
Review

1. During the scene size-up, you should routinely determine all of the
following, EXCEPT:

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A. the mechanism of injury or nature of illness.
B. the ratio of pediatric patients to adult patients.
C. whether or not additional resources are needed.
D. if there are any hazards that will jeopardize safety.
Review

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Answer: B
Rationale: Components of the scene size-up—after taking standard precautions
—include determining if the scene is safe for entry, determining the mechanism of
injury or nature of illness, determining the number of patients, and determining if
additional resources are needed at the scene.
Review

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1. During the scene size-up, you should routinely determine all of the following,
EXCEPT:
A. the mechanism of injury or nature of illness.
Rationale: This is part of the scene size-up.
B. the ratio of pediatric patients to adult patients.
Rationale: Correct answer
C. whether or not additional resources are needed.
Rationale: This is part of the scene size-up.
D. if there are any hazards that will jeopardize safety.
Rationale: This is part of the scene size-up.
Review

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2. You arrive at the scene of an “injured person.” As you exit the ambulance, you
see a man lying on the front porch of his house. He appears to have been
shot in the head and is lying in a pool of blood. You should:
A. immediately assess the patient.
B. proceed to the patient with caution.
C. quickly assess the scene for a gun.
D. retreat to a safe place and wait for law enforcement to arrive.
Review

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Answer: D
Rationale: Your primary responsibility as an EMT is to protect yourself. Prior to
entering any scene, you must assess for potential dangers. In cases where
violence has occurred, you must retreat to a safe place and wait for law
enforcement personnel to arrive.
Review

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2. You arrive at the scene of an “injured person.” As you exit the ambulance, you
see a man lying on the front porch of his house. He appears to have been
shot in the head and is lying in a pool of blood. You should:
A. immediately assess the patient.
Rationale: You must wait until the scene is safe.
B. proceed to the patient with caution.
Rationale: You must wait until the scene is safe.
C. quickly assess the scene for a gun.
Rationale: This is the responsibility of law enforcement.
D. retreat to a safe place and wait for law enforcement to arrive.
Rationale: Correct answer
Review

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3. Findings such as inadequate breathing or an altered level of consciousness
should be identified in the:
A. primary assessment.
B. focused assessment.
C. secondary assessment.
D. reassessment.
Review

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Answer: A
Rationale: The purpose of the primary assessment is to identify and manage any
life threats to the patient, such as inadequate breathing, an altered level of
consciousness, or severe hemorrhage.
Review

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3. Findings such as inadequate breathing or an altered level of consciousness
should be identified in the:
A. primary assessment.
Rationale: Correct answer
B. focused assessment.
Rationale: The focused assessment takes place during the secondary
assessment, if appropriate.
C. secondary assessment.
Rationale: The purpose of the secondary assessment is to perform a systematic
physical examination of the patient after the primary assessment.
D. reassessment.
Rationale: Reassessment is performed to identify and treat changes in a
patient’s condition after the primary assessment.
Review

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4. Which of the following would you NOT detect while determining your initial
general impression of a patient?
A. Cyanosis
B. Gurgling respirations
C. Severe bleeding
D. Rapid heart rate
Review

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Answer: D
Rationale: The initial general impression is what you first notice as you approach
the patient, but before physical contact with the patient is made. It is what you
see, hear, or smell. A rapid heart rate (tachycardia) would not be detected until
you actually perform the entire primary assessment; you cannot see, hear, or
smell tachycardia.
Review

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4. Which of the following would you NOT detect while determining your initial
general impression of a patient?
A. Cyanosis
Rationale: You can see cyanosis while determining your initial general
impression.
B. Gurgling respirations
Rationale: You can hear gurgling while determining your initial general
impression.
C. Severe bleeding
Rationale: You can see bleeding while determining your initial general
impression.
D. Rapid heart rate
Rationale: Correct answer
Review

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5. Your primary assessment of an elderly woman who fell reveals an altered
level of consciousness and a large hematoma to her forehead. After
protecting her spine and administering oxygen, you should:
A. reassess your interventions.
B. perform a rapid exam.
C. transport the patient immediately.
D. perform a focused assessment of her head.
Review

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Answer: B
Rationale: If any life-threatening problems are discovered in the primary
assessment, they should be addressed immediately. The EMT should then
perform a rapid exam to look for other potentially life-threatening injuries or
conditions.
Review

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5. Your primary assessment of an elderly woman who fell reveals an altered
level of consciousness and a large hematoma to her forehead. After
protecting her spine and administering oxygen, you should:
A. reassess your interventions.
Rationale: This is the last step of the patient assessment process.
B. perform a rapid exam.
Rationale: Correct answer
C. transport the patient immediately.
Rationale: This is determined after the completion of a rapid exam.
D. perform a focused assessment of her head.
Rationale: This performed during the secondary assessment.
Review

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6. A semiconscious patient pushes your hand away when you pinch his earlobe.
You should describe his level of consciousness as:
A. alert.
B. unresponsive.
C. responsive to painful stimuli.
D. responsive to verbal stimuli.
Review

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Answer: C
Rationale: Semiconscious patients are not alert, nor are they unresponsive. The
fact that the patient pushes your hand away when you pinch his earlobe indicates
that he is responsive to painful stimuli. If he opens his eyes or responds when
you speak to him, he would be described as being responsive to verbal stimuli.
Review

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6. A semiconscious patient pushes your hand away when you pinch his earlobe.
You should describe his level of consciousness as:
A. alert.
Rationale: This is when the patient’s eyes open spontaneously as you
approach.
B. unresponsive.
Rationale: This is when the patient does not respond to any stimulus.
C. responsive to painful stimuli.
Rationale: Correct answer
D. responsive to verbal stimuli.
Rationale: This is when the patient’s eyes open with verbal stimuli and he or
she tries to respond.
Review

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7. Assessment of an unconscious patient’s breathing begins by:
A. inserting an oral airway.
B. manually positioning the head.
C. assessing respiratory rate and depth.
D. clearing the mouth with suction as needed.
Review

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Answer: B
Rationale: You cannot assess or treat an unconscious patient’s breathing until
the airway is patent—that is, open and free of obstructions. Manually open the
patient’s airway (eg, head tilt–chin lift, jaw-thrust), use suction as needed to clear
the airway of blood or other liquids, insert an airway adjunct to assist in
maintaining airway patency, and then assess the patient’s respiratory effort.
Review

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7. Assessment of an unconscious patient’s breathing begins by:
A. inserting an oral airway.
Rationale: You insert an airway adjunct to assist in maintaining airway patency
after the head tilt–chin lift.
B. manually positioning the head.
Rationale: Correct answer
C. assessing respiratory rate and depth.
Rationale: After the airway is opened and suctioned, then determine the
patient’s respiratory effort by assessing the respiratory rate and depth.
D. clearing the mouth with suction as needed.
Rationale: This is done after attempting to open the airway with proper
positioning.
Review

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8. Your 12-year-old patient can speak only two or three words without pausing to
take a breath. He has a serious breathing problem known as:
A. nasal flaring.
B. two- to three-word dyspnea.
C. labored breathing.
D. shallow respirations.
Review

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Answer: B
Rationale: Two- to three-word dyspnea is a severe breathing problem in which a
patient can speak only two to three words at a time without pausing to take a
breath.
Review

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8. Your 12-year-old patient can speak only two or three words without pausing to
take a breath. He has a serious breathing problem known as:
A. nasal flaring.
Rationale: Nasal flaring is the flaring out of the nostrils.
B. two- to three-word dyspnea.
Rationale: Correct answer
C. labored breathing.
Rationale: Labored breathing requires increased effort and is characterized by
increased effort and depth of each respiration.
D. shallow respirations.
Rationale: Shallow respirations are characterized by little movement of the
chest wall or poor chest excursion.
Review

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9. How should you determine the pulse in an unresponsive 8-year-old patient?
A. Palpate the radial pulse at the wrist.
B. Palpate the brachial pulse inside the upper arm.
C. Palpate the radial pulse with your thumb.
D. Palpate the carotid pulse in the neck.
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Answer: D
Rationale: In unresponsive patients older than 1 year, you should palpate the
carotid pulse in the neck. If you cannot palpate a pulse in an unresponsive
patient, begin CPR.
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9. How should you determine the pulse in an unresponsive 8-year-old patient?
A. Palpate the radial pulse at the wrist.
Rationale: Only palpate here in responsive patients who are older than 1 year.
B. Palpate the brachial pulse inside the upper arm.
Rationale: Only palpate here in children younger than 1 year because the radial
and carotid pulses are difficult to locate.
C. Palpate the radial pulse with your thumb.
Rationale: Do not palpate a pulse with your thumb. You may mistake the strong
pulsing circulation in your thumb for the patient’s pulse.
D. Palpate the carotid pulse in the neck.
Rationale: Correct answer
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10. When assessing your patient’s pain, he says it started in his chest but has
spread to his legs. This is an example of what part of the OPQRST
mnemonic?
A. Onset
B. Quality
C. Region/radiation
D. Severity
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Answer: C
Rationale: The region/radiation section of the OPQRST mnemonic assesses a
patient’s pain—where it hurts and where the pain has spread. Because the
patient informed you that his pain spread from his chest to his legs, this would be
an example of radiation.
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10. When assessing your patient’s pain, he says it started in his chest but has
spread to his legs. This is an example of what part of the OPQRST
mnemonic?
A. Onset
Rationale: This assesses the cause of the pain and when it began.
B. Quality
Rationale: This assesses the patient’s description of the pain.
C. Region/radiation
Rationale: Correct answer
D. Severity
Rationale: This assesses the severity of the patient’s pain.