Assessent Flashcards

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1
Q

Chief Complaint

A

Primary complaint

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2
Q

General Impressions

A

Observations

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3
Q

Interventions

A

Actions taken to correct a problem

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4
Q

Primary Assessment

A

General Impressions, Mental Status, Airway, Breathing, Circulation, Priority

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5
Q

auscultation

A

listening

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6
Q

Bradycardia

A

Pulse below 60

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7
Q

SpO2

A

Oxygen saturation

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8
Q

Pulse oxymeter

A

Used to measure bloods O2 level

Normal - 100 to 96
Mild hypoxia - 95 to 91
Moderate hypoxia - 90 to 86
Severe hypoxia - 85 or less

Inaccurate in cases of shock and hypothermia due to restricted blood flow, carbon monoxide poisoning due to binding with the hemoglobin (chronic smokers), excessive movement, finger nail polish, anemia, and hypovolimia.

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9
Q

tachycardic

A

Pulse rate greater than 100

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10
Q

Requires O2 by non-rebreather

A

Exposure to carbon monoxide
moderate or severe hypoxia
Severe respiratory distress regardless of SpO2 reading
Poor peripheral profusion inhibiting a good reading

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11
Q

nasal Canula administration

A

Mild (91 to 95) hypoxia or mild respiratory distress

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12
Q

Glucose levels

A

Normal - at least 60 to 80 and no more than 120 to 140

So 60 to 140

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13
Q

Normal temp

A

100-96

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14
Q

BP ranges for an adult

A

Normal Adult - Systolic 90 to 139, Diastolic To 89.
Hypertensive Adult - Systolic >140, Diastolic > 90
Hypotensive Adult - Systolic

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15
Q

BP Ranges for Children

A

Infants and children Systolic = 80 / 2 x age(yrs) Diastolic = 2/3 of systolic
13 - 18 years = Systolic 88 - 140, Diastolic = avg 76
6 - 12 = Systolic 80 - 122, Diastolic = avg 69
3 - 5 = Systolic 78 - 104, Diastolic = avg 65

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16
Q

Skin color

A

Pink (inner eye lid, lips, nail beds in dark skin)
Pale blood loss, shock, hypotension
Cyanotic (blue-gray) breathing difficulties, heart related
Flushed (red)
Jaundiced (yellow)
Mottled (blotchy) shock

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17
Q

Capillary refill checked

A

Under 6 years of age

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18
Q

respiratory rates

A
Normal adult: 10 to 24
13 - 18:  12 to 20
6 - 12: 15 to 30
6 mos -5:  20 to 30
Newborn: 30 to 50
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19
Q

Respiratory sounds

A

Snoring: airway blocked
Wheezing: asthma
Gurgling: fluids in airway
Crowing (harsh sounds when inhaling): medical

20
Q

Respiratory quality

A

Normal
Shallow
Labored
Noisy

21
Q

respiratory rhythm

A

Regular

Irregular

22
Q

Skin temp/ moisture

A
Cold / clammy - shock
Cold / moist -  loosing heat
Cold / dry - exposure to cold
Hot / dry - high fever, heat exposure
Hot / moist - high fever, heat exposure
23
Q

Pupils

A

Equal / unequał (stroke, head injury, eye injury, eye drops)
Reactive / unreactive
dilated ( blood loss) / constricted (narcotics,eye drops )/ size

24
Q

Pulse rate / rhythm / quality

A

Quality - strong, thready
Rhythm -
Rate - normal, bradycardia ( 100)

25
Q

JVD

A

Jugular vein Distention -

26
Q

Peridoxical motion

A

M

27
Q

Breath sounds

A

M

28
Q

Head assessment

Wounds, Tenderness, Deformities, and …

A

Crepitation

29
Q

Neck Assessment -

Wounds, Tenderness, Deformities, and …

A

Jugular Vein Distention and Crepitation

30
Q

Chest assessment -

Wounds, Tenderness, Deformities, and …

A

Paradoxical motion, Crepitation, breath sounds (present, absent, equal)

31
Q

Abdomen assessment -

Wounds, Tenderness, Deformities, and …

A

Firmness, Softness, Distention

32
Q

Pelvis Assessment -

Wounds, Tenderness, Deformities, and …

A

Pain, tenderness, motion

33
Q

Extremities assessment -

Wounds, Tenderness, Deformities, and …

A

Distal circulation, sensation, motor function

34
Q

Posterior -

Wounds, Tenderness, Deformities, and …

A

That’s all

35
Q

Differential Diagnosis

A

List of potential diagnosis

36
Q

Distention

A

Stretched, inflated, or larger than normal

37
Q

HPI

A

History of the present illness

38
Q

Periodical Motion

A

Movement in the opposite direction of the rest of the body

39
Q

Priapism

A

Persistent erection from spinal injury or medications

40
Q

Rapid trauma assessment

A

Evaluation of body due to traumatic injury

41
Q

Reassessment

A

Repeat of initial assessment/vitals to determine change

42
Q

Sign

A

Something about the patient you can see (measurable)

43
Q

Symptom

A

Something about the patient’s condition they tell you about

44
Q

Tracheostomy

A

A surgical incision held open by a metal or plastic device/tube

45
Q

Stoma

A

A hole in the patient’s neck thru which they breath

46
Q

Drop Report/Transfer Report

A

Written or computerized report provided to the hospital

47
Q

AVPU

A

Level of Conciousness assessment

Alert, responsive to verbal, responsive to pain, unresponsive