9. Patient Assessment Flashcards
Name the components of Scene Size-Up
- Scene Safe
- BSI
- MOI/NOI
- Number of patients
- Additional Resources
- C-Spine stabilization
Name the components of Initial Assessment
- Level of consciousness, LOC
- Mental Status, LOC
- Chief Complaint/Life Threats
- Airway
- Breathing
- Circulation
- Priority transport decision (rapid or focuses)
Define DCAPBTLS
Deformity Contusion Abrasion Puncture Burn Tenderness Laceration Swelling
What to look for in the Head
DECAPBTLS, crepitus
What to look for in the Neck
DECAPBTLS, crepitus, JVD, Trachea is midline
What to look for in the Chest
DECAPBTLS, crepitus, lung sounds=rise and fall
What to look for in the Abdomen
DECAPBTLS, rigidity
What to look for in the Pelvis
DECAPBTLS, crepitus, incontinence, priapism
What to look for in the Lower Extremities
DECAPBTLS, PMS
What to look for in the Upper Extremities
DECAPBTLS, PMS
What to look for in the Posterior
DECAPBTLS, crepitus
What is crepitus?
Bone ends grating together
What is priapism?
Make erection due to spinal injury
What is incontinence?
Nerve stimulates release of urine and bowel
Define the steps in ongoing assessment
- reassessment of vital signs
- reassess initial/primary assessment
- reassess secondary assessment
- reassess treatment or interventions
Time durations in reassessing stable patients?
15 min
Time durations in reassessing unstable patients?
5 min
The secondary muscles of respirations. They include the neck muscles (sternocleidomastoids), the chest pectoralis major muscles, and the abdominal muscles.
accessory muscles
The deviation from alert and oriented to person, place, time, and event, or any deviation from a patient’s normal baseline mental status.
altered mental status
To listen to sounds within an organ with a stethoscope.
auscultate
A method of assessing the level of consciousness by determining whether the patient is awake and alert, responsive to verbal stimuli or pain, or unresponsive; used principally early in the assessment process.
AVPU Scale
The process that the blood exerts against the walls of the arteries as it passes through them.
blood pressure
A slow heart rate, less than 60 beats/min.
bradycardia
An indication of air movement in the lungs, usually assessed with a stethoscope.
breath sounds
A test that evaluates distal circulatory system function by squeezing (blanching) blood from an area such as a nail bed and watching the speed of its return after releasing the pressure.
capillary refill
A noninvasive method to quickly and efficiently provide information on a patient’s ventilatory status, circulation, and metabolism; effectively measures the concentration of carbon dioxide in expired air over time.
capnography
This is a component of air and typically makes up 0.3% of air at sea level; also a waste product exhaled during expiration by the respiratory system.
carbon dioxide
The reason a patient called for help; also the patient’s response to such questions as what’s wrong? or what happened?
chief complaint
To form a clot to plug an opening in an injured blood vessel and stop bleeding?
coagulate
The delicate membrane that lines the eyelids and covers the exposed surface of the eye.
conjunctiva
A crackling, rattling breath sound that signals fluid in the air space of the lungs.
crackles
A grating or grinding sensation caused by fracture bone ends or joints rubbing together; also air bubbles under the skin that produce a crackling sound or cranky feeling.
crepitus
A blue-gray skin color that is caused by a reduced level of oxygen in the blood.
cyanosis
Used for assessment of the body deformity contusion abrasion puncture burn tenderness laceration swelling
DCAP-BTLS
Characterized by light or profuse sweating.
diaphoretic
The pressure that remains in the arteries during the relaxing phase of the heart’s cycle (diastole) when the left ventricle is at rest.
diastolic pressure
Any injury that prevents the patient from noticing other injuries he may have.
distracting injury
A type of physical assessment typically performed on patients who have sustained nonsignificant MOI or on responsive medical patients. Based on chief complaints and focuses on one body system or part.
focused assessment
Damage to tissue as a result of exposure to cold.
frostbite
The overall impression that determines the priority for patient care; based on the patient’s surroundings, the mechanism of injury, signs and symptoms, and the chief complaint.
general impression
The time from injury to definitive care, during which treatment of shock and traumatic injuries should occur because survival potential is best.
Golden Hour
Involuntary muscle contractions of the abdominal wall to minimize the pain of abdominal movement; a sign of peritonitis.
guarding
A step within the patient assessment process that provides detail about the patient’s chief complaint and an account of the patient’s signs and symptoms.
history taking
Blood pressure that is higher than the normal range.
hypertension
Blood pressure that is lower than the normal range.
hypotension
A condition in which the internal body temperature falls below 95 F (35 C) after exposure to a cold environment.
hypothermia
A system implemented to manage disasters and mass- and multiple-casualty incidents in which section chiefs, including finance, logistics, operations, and planning,
report to the incident commander. Also referred to as the incident management system.
incident command system
Yellow skin usually indicative of liver disease or failure.
jaundice
Breathing that requires greater than normal effort; may be slower or faster than normal and characterized by grunting, stridor, and use of accessory muscles.
labored breathing
The forces, or energy transmission, applied to the body that cause injury.
mechanism of injury (MOI)
The biochemical processes that result in production of energy from nutrients within the cells.
metabolism
Widening of the nostrils, indicating there is an airway obstruction.
nasal flaring
The general type of illness a patient is experiencing.
nature of illness (NOI)
Used in evaluating the patient. Onset Provocation Quality Region/radiation Severity Timing
OPQRST
The mental status of a patient as measured by memory of person, place, time, and event.
orientation
To examine by touch.
palpate
The motion of the portion of the chest wall that is detached in a flail chest; the motion- in during inhalation, out during exhalation- is exactly the opposite of normal chest wall motion during breathing.
paradoxical motion
The flow of blood through body tissues and vessels.
perfusion
Protective equipment that blocks exposure to a pathogen or a hazardous material.
personal protective equipment (PPE)
Negatives findings that warrant no care or intervention.
pertinent negatives
A painful erection of the penis resulting from a spinal cord injury.
priapism
A step within the patient assessment process that identifies and initiates treatment of immediate and potential life threats.
primary assessment
The pressure wave that occurs as each heartbeat causes a surge in the blood circulating through the arteries.
pulse
An assessment tool that measures oxygen saturation of hemoglobin in the capillary beds.
pulse oximetry
A step within the patient assessment process performed at regular intervals during the assessment process to identify and treat changes in a patient’s condition.
A patient in unstable conditions should be reassessed every 5 minutes, whereas a patient in stable condition should be reassessed every 15 minutes.
reassessment
The way in which a patient responds to external stimuli, including verbal stimuli (sound), tactile stimuli (touch), and painful stimuli.
responsiveness
Movements in which the skin pulls in around the ribs during inspiration.
retractions
Coarse, low pitched breath sounds heard in patients with chronic mucus in the upper airways.
rhonchi
A brief history of a patient's condition to determine Signs/symptoms Allergies Medications Pertinent past history Last oral intake Event leading to the injury
SAMPLE History
A step within the patient assessment process that involves a quick assessment of the scene and the surroundings to provide information about scene safety and the MOI before beginning patient care.
scene size-up
The tough, fibrous, white portion of the eye that protects the more delicate inner structures.
sclera
A step within the patient assessment process in which a systematic physical examination of the patient is performed. The examination may be a systematic exam or an assessment that focuses on a certain area or region of the body; often determined through the chief complaint.
secondary assessment
Respirations characterized by little movement of the chest wall (reduced tidal volume) or poor chest excursion.
shallow respirations
Objective findings that can be seen, heard, felt, smelled, or measured.
sign
Knowledge and understanding of your surroundings and situation and the risk they potentially pose to safety or the safety to the EMS team.
situational awareness
An upright position in which the patient’s head and chin are thrust slightly forward to keep the airway open.
sniffing positions
Breathing that occurs without assistance.
spontaneous respirations
Protective measures that have traditionally been developed by the CDC for use in dealing with objects, blood, body fluids, and other potential exposure risks of communicable diseases.
standard precautions
A harsh, high-pitched, breath sound, generally heard during inspiration that is caused by partial blockage or narrowing of the upper airway; maybe audible without a stethoscope.
stridor
A characteristic cracking sensation felt on palpation of the skin, caused by the presence of air in soft tissue.
subcutaneous emphysema
Subjective findings that the patient feels but that can be identified only by the patient.
symptom
The increased pressure in an artery with each contraction of the ventricles (systole).
systolic pressure
A rapid heart rate, more than 100 beats/min
tachycardia
The amount of air in milliliters that is moved in or out of the lungs during one breath.
tidal volume
An upright position in which the patient leans forward onto two arms stretched forward and thrusts the head and chin forward.
triage tripod position
A severe breathing problem in which a patient can speak only two to three words at a time without pausing to take a breath.
two-to-three word dyspnea
Narrowing of a blood vessel.
vasoconstriction
The key signs that are used to evaluate the patient’s overall condition, including respirations, level of consciousness, and skin characteristics.
vital signs
A high pitched, whistling, breath sound that is more prominent on expiration and which suggests an obstruction or narrowing of the lower airways; occurs in asthma and bronchitis.
wheezing
