EMT-Basic Exam: The Basics of Patient Assessment - Initial Assessment

Once the scene is declared safe and the patient is protected, you can perform your initial assessment. You should complete this process within a few minutes. The initial assessment includes forming a general impression; assessing mental status, airway, breathing, and circulation; and identifying priority patients. You will undoubtedly encounter questions about this process on the EMT-Basic exam because the initial assessment is an important part of every call.

1. General Impression of Patient
Your general impression is the way you interpret the safety of your surroundings and the patient’s problem. General impressions form within seconds of approaching the patient. By observing the patient’s body position, appearance, and attitude, you can usually determine whether the patient is suffering from a medical condition or an injury. You should also take the patient’s gender, race, and age into consideration when forming your impression as certain conditions may be related to those factors. If the patient has a medical illness, you need to determine the nature of illness (NOI). The NOI is the way in which the patient describes his or her chief complaint, which is the reason why EMS was called. If the patient is injured, you need to determine the MOI. Finally, determine whether the patient’s status is life threatening. If so, address the threat accordingly.

Tip: If a patient’s MOI suggests an injury to the spine, don’t allow the patient to move before stabilizing the spine.

2. Assessing the Patient’s Mental Status
To begin assessing a patient’s mental status, try to start a conversation with the patient. Introduce yourself as an EMT-Basics and verbally walk the patient through the process as you go. The following are four categories of mental statuses. Many EMT-Basics remember these categories using the acronym AVPU, which stands for alert, verbal, painful, and unresponsive.
- Alert—These patients respond to the EMT-Basic’s presence and answer questions with little difficulty. They may or may not be disoriented, however.
- Verbal—These patients respond to the EMT-Basic’s voice, but may not be aware of the EMT-Basic’s presence. Often, you must raise your voice or change your tone to invoke a response from this type of patient.
- Painful—These patients respond to painful stimuli, such as an appropriate stimulus performed by the EMT-Basic to elicit a response. EMT-Basics don’t want to cause the patient pain; they only wish to see a response.
- Unresponsive—These patients do not respond to verbal or painful stimuli. Completely unresponsive patients are rare and always an indication for a priority transport, but EMT-Basics should always be prepared to assess them.

Tip: A patient’s mental status may deteriorate over time, so you need to pay careful attention to the level of responsiveness as you assess the patient for injuries.

3. Assessing the Patient’s Airway Status
The most important part of assessing the patient’s airway status is determining whether the airway is blocked and, if so, clearing the airway to restore the flow of oxygen to the brain. Signs that a patient’s airway may be blocked include coughing, gagging, wheezing, an inability to speak, clutching of the throat, and cyanosis, a condition in which the skin turns blue.
If the patient is alert and isn’t experiencing these symptoms while you form your initial assessment, the airway is open and you can move on to assess the patient’s breathing. If your patient is only responding to verbal or painful stimuli, or he or she is unresponsive, you need to open and assess the airway manually.
When treating a medical condition, perform a head-tilt chin-lift and check the airway. If it is blocked, clear it immediately. If the patient is injured and the MOI is unknown, stabilize the spine and complete a modified jaw thrust. Again, clear the airway and then assess the patient’s breathing.

4. Assessing the Patient’s Breathing
A healthy adult takes 12 to 20 breaths per minute. While performing your initial assessment, evaluate your patient’s breathing rate and monitor breath sounds. If your patient is taking fewer than 12 breaths per minute or more than 20 breaths per minute, ask another crew member to place the patient on high-flow oxygen using a nonrebreather mask.
If the patient’s responsiveness decreases during your evaluation, instruct a crew member to open the patient’s airway and use a nonrebreather mask. If this doesn’t help the patient’s breathing, try using pocket masks, bag-valve masks, and flow-restricted, oxygen-powered ventilation devices. 

5. Assessing the Patient’s Circulation
After assessing the patient’s mental status, airway, and breathing, you have to check the patient’s pulse. The pulse is a representation of the patient’s heartbeat and is measured by pressing an artery against bone. The pulse is a strong indicator of a patient’s overall health.
You must first check the patient’s radial pulse, located at the wrist. If you discover a radial pulse, compare its rate to the pulse of the carotid artery, located in the patient’s neck. If the radial pulse is weaker than the carotid pulse, the patient may be in shock.

Tip: You can feel the pulse in many areas of the body, including the neck (carotid artery), the wrist (radial artery), the inside of the elbow (brachial artery), behind the knee (popliteal artery), and at the ankle joint (posterior tibial artery).
 

The major arteries in the body.

6. Identifying Priority Patients
Your initial assessment should allow you to determine if your patient needs to be transported to a medical facility immediately. The following are common characteristics of priority patients:
- Difficulty breathing
- Severe pain
- Poor general impression
- Chest pain
- Uncontrolled bleeding
- Complicated childbirth
- Exhibiting signs of shock
- Responsive, but cannot follow instructions
- Unresponsive with no cough or gag reflex
The majority of trauma patients are priority patients. Your assessment of the scene and the patient’s MOI will determine whether a patient is listed as trauma or medical. A trauma patient is someone who has suffered a serious or life-threatening injury and who may be at risk of shock, respiratory failure, or death. All unresponsive patients with unknown MOI should be assessed for potentially having both trauma and medical issues.

Related Topics You Should Review:
- Types of life-threatening injuries
- Determining mental status in children
- Further distinctions between mental statuses
- Performing the head-tilt chin-lift and modified jaw thrust
- Clearing an obstructed airway
- Oxygen administration techniques
- Assessing perfusion