Patient Assessment - Medical
I’m going to walk you through the basic patient assessment. I’ve outlined this using the NREMT practical station for Patient Assessment/Management - Medical. This is a guide to help those who are taking their practical exams or who just want to learn a little bit about it!
As an EMT, the most important skill you can have is basic patient assessment. This assessment is broken down into 5 main parts:
Scene size-up
Primary assessment
History taking
Secondary assessment
Reassessment
1. Scene Size-up
The most important thing in EMT is to make sure your scene is safe. If your scene is unsafe, then you cannot perform the needed medical attention. You must assess whether or not your scene is safe. This is done by being aware of your surroundings. Look for things such as: potential threats, unstable footing, weather, time of day, available resources, etc. The list is endless. If the scene is not safe, see what can be done to make it safe or request additional resources.
For example: A crash on the highway. Police should be called in order to redirect traffic to ensure that no oncoming traffic interferes with the medical attention being provided to the potential patients. The ambulance should be parked at a safe distance from the vehicles in case gas is leaking. Additionally, did the accident occur at night? If so, high-visibility vests are needed for everyone so you can be seen and flares can be set up to indicate where the crash occurred.
It is also important to note personal protective equipment (PPE) or body substance isolation (BSI). This ensures that you yourself are protected.
Gloves
Shoe covers
Safety goggles
Surgical mask
Gown
Note: not all of these need to be worn in an EMT setting, typically your uniform is enough. However, gloves should always be considered when contacting a patient.
Determine the mechanism of illness (MOI) or the nature of injury (NOI). This is done by listening to the patient’s chief complaint, or the most serious thing the patient is concerned with. Patient’s can complain of:
Headache
Chest pain
Hip pain
Lower abdominal pain
Dizziness
Loss of hearing
Confusion
Weakness
Etc.
Determine the number of patients. Are there multiple or just the one you have been dispatched for? Sometimes you are dispatched for only one patient, but by the time you arrive at the scene, more people are injured.
Request additional EMS. As a basic EMT, there is a limit to what you can do. For instance, you are not allowed to start an IV line and cannot before invasive procedures. These skills and tasks are typically performed by paramedics or more advanced medical personnel. Requesting these additional services can provide a better standard of care for your patient. It’s always better to ask for help.
Consider C-spine. This assessment that I’m taking you through is purely for medical assessment of a patient, not trauma. The difference being that for trauma (such as falls, car crashes, etc.), you will most likely need to consider c-spine and put on a cervical spine stabilizer. For this post, we’re focusing solely on medical and no c-spine is needed.
2. Primary Assessment
The primary assessment is used to identify and begin treatment of immediate or imminent life threat. This is done by verbalizing the general impression of the patient.
My general impression of this patient is poor because... (reiterating the chief complaint)
Next, the level of consciousness (LOC) must be determined. This is done by seeing whether the patient tracks your movements with their eyes, responds to your voice, responds to pain, or is unresponsive altogether.
The chief complaint must be said. This (at the moment) is based on what the dispatch has told you.
Airway, breathing, circulation, decision for transport (ABCD)
Is it shallow, is the patient gasping for breaths? Hypoxia?
Initiate O2 therapy: 15L/min via non-rebreather at 100% oxygen
3. History Taking
Onset, provocation, quality, radiation, severity, time (OPQRST)
O - How long has this been going on?
P - Does anything you do make it better or worse?
Q - In your own words, can you describe pain/how you feel?
R - Does it stay in one place or does it radiate anywhere else?
S - On a scale of 0 to 10, 0 being no pain and 10 being the worst, how would you say it is?
T - Does it come and go? Has this ever happened before?
It is very important to note that these are basic questions to begin asking the patient, but you should always ask clarifying questions.
For example: “Time”. If the patient answers, “Yes, this chest pain has happened before.” Ask “Does it feel the same? What did you do?” They may respond with “Yes, this feels exactly the same. I was taken to the hospital.”
“What did they do for you?” and so on.
Past Medical History
Inquire about the patient’s medical history. Sometimes, if there is another person in the room, you can ask both people about the situation. If the patient is altered mentally, sometimes you cannot trust that the patient is giving you the correct answers. You can ask
Signs/symptoms, allergies, medication, past pertinent medical history, last oral intake, events (SAMPLE)
Allergies - Do you have any allergies to any medication/food? If so, what are they?
Medications - Are you prescribed or currently taking any medications? Do you take it as directed? What are they for?
Past pertinent medical history - Do you have any medical problems that you are aware of?
Last oral intake - What/when was the last time you ate or drank something?
Events - What were you doing when the symptoms began?
Under the same pretenses as the History Taking, continue to ask clarifying questions. Do not stop asking questions just because your patient has answered them. If you need to investigate a point further, do so.
Sometimes, information may be contradictory. If your patient says that they do not have any food allergies, yet they are having difficulties breathing and maybe having an allergic reaction, finding out the last thing they ate may point you in some direction. If they ate peanut butter, shellfish, etc. start thinking they may be allergic to something they came into contact with.
4. Secondary Assessment
The rule here is rule in/rule out. Only ask questions for the systems that are pertinent to the situation. For example, if your patient is having chest pains, there’s no reason to ask about the reproductive system (except potential medication being taken such as viagra, but this should have already been discovered in the Past Medical Hx). Your systems to ask questions about are:
Cardiovascular
Pulmonary
Neurological
Musculoskeletal
Integumentary
Gastrointestinal/Genital and Urinary
Reproductive
Psychological
You’re going to want to take vitals next.
Blood pressure
Pulse
Respiratory rate/rhythm/quality
By now you should have a general understanding of the patient’s problem. If not, you are at least able to relay to paramedics, nurses, doctors, or anyone who the patient will be handed to, the basics of what has been happening with this patient.
5. Reassessment
The rule is to reassess the patient every 5 minutes for critical situations and every 15 minutes for non-threatening situations. In this case, until it has been ruled that it is not a critical situation, reassessment is needed every 5 minutes.
Next, you must provide an accurate verbal report. This will be you regurgitating everything you have just learned. Starting with when you arrived at the scene and what you saw up to the vital signs.
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This is a LOT of information, I know. There is still a whole lot more to this section than what I’ve laid out for you. These are the skills at a basic level for patient assessment. If you have questions or need something clarified, or if you have any information that is important to add, please let me know!
