Primary Assessment Study Guide for the EMT Test

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General Information

A primary assessment is your first impression of the patient’s condition. It is done to obtain basic information about the patient and to aid in planning transport. It’s during your primary assessment that you determine if any life-threatening symptoms require immediate interventions. You will also identify the chief complaint and gain a general impression of the patient’s condition. Visual clues to look for during a primary assessment include bleeding, trouble breathing, and an altered level of consciousness. Any threats to life must be dealt with before moving on to the secondary assessment.

The bulk of the questions on the EMT exam, between 39% and 43%, concern the primary assessment, so you should be very well versed in all of the procedures and concepts covered here.

Here are some concepts to know:

  • perfusion—delivery of oxygen and nutrients to the body’s tissues through the blood

  • AVPU scale—determines the patient’s level of responsiveness:

    • A = alert—The patient is awake and responsive.
    • V = verbal—The patient responds to your voice.
    • P = pain—The patient responds only to painful stimuli.
    • U = unresponsive—The patient does not respond.

  • retractions— visible pulling of the skin/muscle around the ribs or neck; indicates trouble breathing

  • **accessory muscles—extra muscles used to help with breathing when someone is having trouble

  • dyspnea—difficulty breathing

  • pulse—beating of an artery as blood is pumped through it by the heart

  • palpate—to feel with your hands (feeling for a pulse, checking for injuries)

  • cyanosis—bluish coloring of the skin, lips, or nail beds, caused by low oxygen in the blood

  • sclera—the white part of the eye

  • diaphoretic—sweaty

  • capillary refill—It’s a quick test to check blood flow to the extremities, done by depressing the fingernail or toenail to see how fast the color returns. (Normal refill time is typically less than two seconds.)

  • coagulate—the clotting of blood

  • DCAP-BTLS—mnemonic used to remember what to look for during a trauma assessment:

    • D—deformities (abnormal bumps or broken bones)
    • C—contusions (bruises)
    • A—abrasions (scrapes)
    • P—penetrations/punctures (holes)
    • B—burns
    • T—tenderness (pain when touched)
    • L—lacerations (cuts)
    • S—swelling

  • crepitus—bones rubbing together

  • Golden Hour—the first 60 minutes after a traumatic injury; considered the most critical time to get a patient to definitive care

Communication

During the primary assessment, communication is vital, and varying emergency circumstances require specific communication skills. Establishing a rapport with patients and bystanders allows for a level of trust to be built, which enables more efficient patient care and facilitates the collection of necessary information. This can be achieved in a multitude of ways; however, proper introductions, a pleasant demeanor, and being forthcoming with information are all key considerations for implementation.

Therapeutic Communication with Patients

Communication with a patient is both verbal and nonverbal. Providers need to establish a rapport with patients and adjust their communications for cultural, age, and language abilities of the patient. Oral reports to other healthcare providers are used to transfer responsibility of care.

Here are some concepts to know:

  • therapeutic communication—use of words, tone, and body language to help patients feel comfortable and understood

  • cultural imposition—forcing one’s own cultural values or beliefs onto someone else

  • open-ended questions—cannot be answered with “yes” or “no”; require further explanation

  • closed-ended questions—can be answered with “yes” or “no”

  • rapport—establishing a trusting and respectful relationship as a provider with patients

Communication in Special Circumstances

The age of the patient or patients may necessitate special approaches and considerations, such as those noted here.

Children

When treating a pediatric patient, you often also deal with caregivers or parents. It’s important to be respectful and inform parents of what you are doing and what is happening. Parents will likely feel helpless and scared and will require emotional support.

Geriatric Patients

Although not all geriatric patients may face the same issues, engaging with older adults can present some challenges. Some adults may have trouble hearing or have memory issues. It is helpful to use clear communication and make eye contact. Speak slowly and allow time for your patient to answer questions. As with any patient, be respectful and explain procedures clearly before performing them.

Communicating with the Family

A basic way to support families during an emergency is to establish and maintain communication about the patient with appropriate persons. Provide factual, clear, and concise information. Provide a designated, consistent emergency team member to help build rapport and trust through ongoing, routine updates on the patient. Involve an appropriate family member to assist with providing information and helping with upset family members. In the event of death at the scene, especially when the patient is not removed, private and direct communication will prove helpful to the family.

Here are some concepts to know:

  • psychological and medical impacts during an emergency—During an emergency, family members can be affected both psychologically and medically. Psychological impacts may include anxiety, fear, shock, anger, disbelief, and grief. Medically/physically, they may experience increased heart rate, nausea, difficulty speaking or processing, or exacerbation of preexisting medical conditions such as asthma, anxiety, or heart disease. It is essential to monitor for these signs and symptoms and provide support as necessary.

General Impression

This is the first part of the patient’s primary assessment. It will help in determining the priority of care. The first steps are visual, as you note the following characteristics of the patient:

  • age, sex, race
  • level of discomfort
  • overall appearance
  • whether they are moving or still
  • their position

Then, referring to the patient by name, introduce yourself and confirm their chief complaint. Try to avoid standing over the patient. As you converse, you will note their:

  • level of consciousness
  • basic respiratory ability
  • obvious circulatory status

Your general impression of the patient will help determine, almost immediately, whether the patient is “sick” or “not sick”. Based on the above three findings, level of consciousness, breathing, and skin color, as well as the patient’s overall appearance, help the provider understand how quickly the patient will require treatment and transport.

Here are some concepts to know:

  • symptom—something the patient feels or reports (pain, dizziness, nausea)

  • sign—something the EMT can see, hear, feel, or measure (bleeding, swelling, wheezing)

  • responsiveness—the degree to which the patient is alert and aware of their surroundings

  • orientation—refers to a patient’s awareness of who they are, where they are, what time it is, and the events occurring

  • altered mental status—any abnormality in a patient’s awareness, they do not know who/where they are, or what events are taking place

  • spontaneous respirations—breathing that happens on its own with no assistance

  • shallow respirations—breaths that are weak or decreased, minimal chest rise and fall, minimal air movement

  • distracting injuries—injuries that cause so much pain or concern that the patient may be unaware of other, possibly more serious injuries

  • nasal flaring—widening of the nostrils while breathing, usually indicating difficulty

  • tripod position—when a patient leans forward in an effort to make breathing easier

  • sniffing position—when a patient’s head is tilted back and their chin is lifted, often used to open the airway

  • labored breathing—any breathing that requires extra effort

  • jaundice—yellowing of the skin, eyes, or mucus membranes; often an indication of liver disease

  • hypothermia—dangerously low body temperature (below 95 degrees), including signs such as shivering, cold/bluish skin, slow/ weak pulse

  • frostbite—injury caused by freezing of the skin and underlying tissue

  • vasoconstriction—narrowing of blood vessels, which reduces blood flow

Level of Consciousness

A patient’s level of consciousness is often one of the first things EMTs assess. Assessing a patient’s level of consciousness is important for several reasons, primarily to determine the severity immediately and whether the patient will require prompt intervention. The level of consciousness should be continuously monitored for changes throughout the duration of patient contact.

The AVPU Scale

The AVPU scale is a tool used by EMTs to help determine a patient’s level of consciousness. It is described in detail in a previous section of this study guide.

Orientation

After determining if the patient is responsive, the EMT must then determine if the patient is oriented. Orientation refers to the patient’s awareness and helps to assess their mental status as well as their neurological function. To assess a patient’s orientation status, the EMT should ask the patient the following questions:

  • What is your name?
  • Do you know where you are?
  • What day is it today?

If the patient can properly answer each of these questions, they are considered to be oriented. If the patient fails to answer even one question, they are either disoriented or only oriented multiplied by the number of questions they can answer. For example, “alert and oriented x 2 (A&Ox2)” would mean the patient answered two of the three questions appropriately. Orientation should be continually reassessed throughout patient contact, as it can be dynamic. Patients may become more or less oriented during assessment and transport.

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