Assessent Flashcards
Chief Complaint
Primary complaint
General Impressions
Observations
Interventions
Actions taken to correct a problem
Primary Assessment
General Impressions, Mental Status, Airway, Breathing, Circulation, Priority
auscultation
listening
Bradycardia
Pulse below 60
SpO2
Oxygen saturation
Pulse oxymeter
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.
tachycardic
Pulse rate greater than 100
Requires O2 by non-rebreather
Exposure to carbon monoxide
moderate or severe hypoxia
Severe respiratory distress regardless of SpO2 reading
Poor peripheral profusion inhibiting a good reading
nasal Canula administration
Mild (91 to 95) hypoxia or mild respiratory distress
Glucose levels
Normal - at least 60 to 80 and no more than 120 to 140
So 60 to 140
Normal temp
100-96
BP ranges for an adult
Normal Adult - Systolic 90 to 139, Diastolic To 89.
Hypertensive Adult - Systolic >140, Diastolic > 90
Hypotensive Adult - Systolic
BP Ranges for Children
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
Skin color
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
Capillary refill checked
Under 6 years of age
respiratory rates
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
Respiratory sounds
Snoring: airway blocked
Wheezing: asthma
Gurgling: fluids in airway
Crowing (harsh sounds when inhaling): medical
Respiratory quality
Normal
Shallow
Labored
Noisy
respiratory rhythm
Regular
Irregular
Skin temp/ moisture
Cold / clammy - shock Cold / moist - loosing heat Cold / dry - exposure to cold Hot / dry - high fever, heat exposure Hot / moist - high fever, heat exposure
Pupils
Equal / unequał (stroke, head injury, eye injury, eye drops)
Reactive / unreactive
dilated ( blood loss) / constricted (narcotics,eye drops )/ size
Pulse rate / rhythm / quality
Quality - strong, thready
Rhythm -
Rate - normal, bradycardia ( 100)
JVD
Jugular vein Distention -
Peridoxical motion
M
Breath sounds
M
Head assessment
Wounds, Tenderness, Deformities, and …
Crepitation
Neck Assessment -
Wounds, Tenderness, Deformities, and …
Jugular Vein Distention and Crepitation
Chest assessment -
Wounds, Tenderness, Deformities, and …
Paradoxical motion, Crepitation, breath sounds (present, absent, equal)
Abdomen assessment -
Wounds, Tenderness, Deformities, and …
Firmness, Softness, Distention
Pelvis Assessment -
Wounds, Tenderness, Deformities, and …
Pain, tenderness, motion
Extremities assessment -
Wounds, Tenderness, Deformities, and …
Distal circulation, sensation, motor function
Posterior -
Wounds, Tenderness, Deformities, and …
That’s all
Differential Diagnosis
List of potential diagnosis
Distention
Stretched, inflated, or larger than normal
HPI
History of the present illness
Periodical Motion
Movement in the opposite direction of the rest of the body
Priapism
Persistent erection from spinal injury or medications
Rapid trauma assessment
Evaluation of body due to traumatic injury
Reassessment
Repeat of initial assessment/vitals to determine change
Sign
Something about the patient you can see (measurable)
Symptom
Something about the patient’s condition they tell you about
Tracheostomy
A surgical incision held open by a metal or plastic device/tube
Stoma
A hole in the patient’s neck thru which they breath
Drop Report/Transfer Report
Written or computerized report provided to the hospital
AVPU
Level of Conciousness assessment
Alert, responsive to verbal, responsive to pain, unresponsive
