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WFR > Ch 1. Patient Assessment System > Flashcards

Ch 1. Patient Assessment System Flashcards

1
Q

What are the 5 steps of Scene Size Up?

A
  1. “I’m number one” Are you safe?
  2. “What happened to you” (Assess Mechanism of Injury MOI)
  3. “Not On Me” (Body Substance Isolation BSI) Put on your gloves/mask
  4. Are there more patients?
  5. Whats the vibe? (Serious or Mild?)
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2
Q

What is purpose of Scene Safety (2)

A

Evaluate and manage hazards.

Make decisions on acceptable risk.

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3
Q

How do you find the Mechanism of Injury (MOI)? (2)

A

Observe the environment,
ask bystanders gather as much information as possible.
First thing to look for is Mechanism for Spine Injury!

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4
Q

Describe Body Substance Isolation (BSI). why it is needed and the steps to take.

A

Treat all patients as if they are infectious, because it is impossible to tell if they aren’t.
Body Substance Isolation is gloves, face and eye coverings, long sleeve shirt and pants.
use BSI when in contact with patient, bandages and bodily fluids.

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5
Q

How do you dispose of soiled bandages and clothing?

A

Place soiled bandages in sealed plastic bags labeled BIOHAZARD.
OR
INCINERATE items in a hot fire.

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6
Q

What conditions constitute protecting the spine?(2)

A

a fall of 5ft+ or landing on the head or buttocks.

Also if patient is unresponsive.

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7
Q

What are the 8 steps in the Patient Assessment Triangle

A
  1. Scene Size up
  2. Initial Assessment
  3. Head to Toe
  4. Vital Signs
  5. History
  6. Problem List and Plan
  7. Interventions/ Treatment
  8. Monitor
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8
Q

What is the purpose of the Initial Assessment?

A

To survey the patient for immediate threats to life

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9
Q

How do you approach a patient after the scene size up (2 Steps)?

A
  1. introduce yourself and your level of training. Ask for consent to help.
  2. establish responsiveness and spine control, protect the spine if there is an MOI for spine
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10
Q

What are the ABCDE of the Initial Assessment?

A 
A = Airway: check their mouth for obstructions 
B = Breathing: Look, listen and feel for breathing. 
C = Circulation: Check for a pulse and signs of circulation. Control live threatening bleeding.
D = Decision about Disability: (Immobilize Spine? ) 
E = Expose: look at and treat life threatening injuries.
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11
Q

What are the 3 steps of the Secondary Exam?

A
  1. Physical Exam
  2. Vital Signs
  3. Patient History
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12
Q

Head-To-Toe Exam

- Describe steps for Checking Head, Face and Neck (6)

A
  • Carefully remove hats/helmets/sunglasses/etc
  • Check scalp for injury
  • Check eyes, nose, mouth
  • Check in, below and behind ears for blood
  • Feel along muscles and bones on neck (tickle the ivories. lol)
  • Check for tracheal alignment
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13
Q

Head-To-Toe Exam

- Describe steps for Checking Shoulders (1)

A

check one shoulder at a time, make a “sandwich” and press the shoulders in with your hands.

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14
Q

Head-To-Toe Exam

- Describe steps for checking the Chest (2)

A
  • Place your hands under patients armpits and have them take 1 deep breath
  • Repeat this on the lower rib cage
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15
Q

Head-To-Toe Exam

- Describe the steps for checking the Abdomen (1)

A
  • stack hands flat and Press with a rolling motion on all four quadrants of abdomen.
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16
Q

Head-To-Toe Exam

- Describe the steps for checking the Pelvis (1)

A
  • press in on both hips (iliac crests) simultaneously
17
Q

Head-To-Toe Exam

- Describe the steps for checking the Groin(1)

A
  • Lick hand shove down pants
18
Q

Head-To-Toe Exam

  • Describe the steps for checking the Lower Extremities. (2)
  • CSMs (Circulation Sensation and Motion) (4)
A
  • one leg at a time
  • in circle leg with hands and press lightly working towards feet.
  • Pull up on hands
  • Push down
  • check for warmth
  • Pinch toes and have them identify
19
Q

Head-To-Toe Exam

  • Describe the steps for checking the Upper Extremities. (2)
  • CSMs (Circulation Sensation and Motion) (4)
A
  • one arm at a time
  • in circle arm start at biceps with hands and press lightly working towards hands.
  • Make a fist
  • Rev the Motorcycle
  • Pinch fingers
  • look at nail beds
20
Q

Head-To-Toe Exam

- Describe the steps for checking the spine and back (3)

A
  • Log roll to side
  • lightly press on each vertebra as you work your way down
  • press lightly above tail bone.
21
Q

Vital Signs
Level of Responsiveness (LOR)

What is each level
A+Ox4
A+Ox3
A+Ox2
A+Ox1
A+Ox0
V
P
U
A

A+Ox4 - Awake and oriented to X person place, time and Events
A+Ox3- Awake and oriented to X person place, and time
A+Ox2- Awake and oriented to X person and place
A+Ox1 Awake and oriented to X person
A+Ox0 Awake and oriented not responding appropriately
V-Verbal
P-Pain
U-No response

22
Q

Vital Signs:

What 3 things are we checking for with Heart Rate (HR)

A
  • Beats per Min(count for 15 seconds and multiply by 4)
  • Regular or irregular
  • Strong, weak or Bounding
23
Q

Vital Signs:

What 3 things are we checking for with Respiratory Rate(RR)

A
  • breaths per Min(count for 15 seconds then Multiply by 4) 12-20
  • Rhythm regular or irregular
  • Effort Easy Shallow labored or deep
24
Q

Vital Signs

What 3 things are we checking for with Skin (SCTM)

A
  • Color Pink, red, pale or ashen
  • Temp: Warm cool hot
  • Moisture: Dry, moist wet
25
Q

Vital Signs

What 2 things are we checking for Blood Pressure(BP)

A
  • Systolic/diastolic (2 numbers Pressure at the beat and constant pressure)
  • Auscultate(using a stethoscope) or palpate (feeling pulse)
26
Q

Vital Signs

What thing are we checking for Pupils (PERRL)

A
  • pupils are equal round and reactive to light
27
Q

Vital Signs

What 2 thing are we checking for Temperature

A
  • measure with thermometer

- Check if warm or cold

28
Q

Vital Signs

Healthy Vital Signs of an Adult:
LOR: 
HR:
RR:
SCTM:
BP:
P:
T:
A 
Healthy Vital Signs of an Adult:
LOR:  A+Ox4
HR: 50-100 Strong and regular
RR: 12-20 regular easy
SCTM: Pink Warm and Dry
BP: less than 120/80 strong radial pulse
P: PERRL (Pupils are equal, round reactive to light)
T: 98.6 Degreef F
29
Q

Patient History

What 6 questions are asked to find Chief complaint (CC)
O,P,Q,R,S,T.

A 
O: Onset Sudden or Gradual
P: Provokes Makes worse or better
Q: Quality Describe (sharp, Dull, Constant vs erratic)
R: Region- does it move
S: Severity Rate 1-10
T: Time and Trend better or worse
30
Q

Patient History

What is S.A.M.P.L.E

A

S: Symptoms Headache, Dizziness, Nausea and stress
A: Allergies Medications, food, pollen, insects. what happens when exposes
M: Medications Prescription, Over the counter, Alcohol or recreational and herbal
P: Pertinent Medical history felt this way before, diabetes
L: Lasts ins and Outs quantity and quality
Food/water
urination and deification
Vomiting
E: Events leading up to injury or illness

WFR (35 decks)

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