Ch. 10 Patient Assessment - Vocabulary Flashcards
Accessory muscles
The secondary muscles of respiration. They include neck (sternocleidomastoids) muscles, the chest (pectoralis major) muscles, and the abdominal muscles.
Altered mental status
A change in the way a person thinks and behaves that may signal disease in the central nervous system or elsewhere in the body.
Auscultate
To listen to sounds within an organ with a stethoscope.
AVPU scale
A method of assessing the level of consciousness by determining whether the patient awake and alert, responsive to verbal or painful stimuli, or unresponsive; used principally early in the assessment process.
A - alert
V - verbal
P - painful
U - unresponsive
Blood pressure
The pressure that the blood exerts against the walls of the arteries as it passes through them.
Bradycardia
A slow heart rate, less than 60 beats/min in an adult.
Breath sounds
An indication of air movement in the lungs, usually assessed with a stethoscope.
Capillary refill
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.
Capnography
A non invasive 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.
Carbon dioxide
A component of air that typically makes up 0.03% of air at sea level; also a waste product exhaled during expiration by the respiratory system.
Chief complaint
The reason a patient called for help; also, the patient’s response to questions such as “What’s wrong?” or “What happened?”
Conjunctiva
The delicate membrane that lines the eyelids and covers the exposed surface of the eye.
Crackles
A crackling, rattling breath sound that signals fluid in the air spaces of the lungs.
Crepitus
A grating or grinding sensation caused by fractured bone ends or joints rubbing together.
Cyanosis
A blue skin discoloration that is caused by a reduced level of oxygen in the blood.
DCAP-BTLS
A mnemonic for assessment in which each area of the body is evaluated for:
Deformities Contusions Abrasions Punctures/Penetrations Burns Tenderness Lacerations Swelling
Diaphoretic
Characterized by light or profuse sweating.
Diastolic pressure
The pressure that remains in the arteries during the relaxing phase of the heart’s cycle (diastole) when the left ventricle is at rest.
Distracting injury
Any injury that prevents the patient from noticing other injuries he or she may have, even severe injuries; for example, a painful femur or tibia fracture that prevents the patient from noticing back pain associated with a spinal fracture.
Field impression
The conclusion about the cause of the patient’s condition after considering the situation, history, and examination findings.
Focused assessment
A type of physical assessment typically performed on patients who have sustained non significant mechanisms of injury or on responsive medical patients. This type of examination is based on the chief complaint and focuses on one body system or part.
Frostbite
Damage to tissues as the result of exposure to cold; frozen or partially frozen body parts are frostbitten.
General impression
The overall initial impression that determines the priority for patient care; based on the patients surroundings, the mechanism of injury, signs and symptoms, and the chief complaint.
Golden Hour
The time from injury to definitive care, during which treatmnt of shock and traumatic injuriesshould occur because survival potential is best; also called the Golden Period
Guarding
Involuntary muscle contractions (spasm) of the abdominal wall; an effort to protect the inflamed abdomen.
History taking
A step within the patient assessment process that provides detial about the patient’s chief complaintand an account of the patieent’s signs and symptoms.
Hypertension
Blood pressure that is higher than the normal range.
Hypotension
Blood pressure that is lower than the normal range.
Hypothermia
A condition in which the internal body temperature falls below 95°F (35°C).
Incident Command System (ICS)
A system implememted to manage disasters and mass-and-multiple-casualty incidents in shich section chiefs, including finance, logistics, operations, and planning report to the incident commander.
Jaundice
Yellow skin or sclera that is caused by liver disease or dysfunction.
Labored breathing
Breathing that requires greater than normal effort; may be slower or faster than normal and charatcterized by grunting, stridor, and/or use of accessory muscles.
Mean arterial pressure (MAP)
The average pressure in the circulatory system during one cardiac cycle.
Mechanism of Injury (MOI)
The forces, or energy transmission, applied to the body that cause injury.
Metabolism
The biochemical processes that result in production of entergy from nutrients within the cells.
Nasal flaring
Widening of the nostrils, indicating that there is an airway obstruction.
Nature of illness (NOI)
The general type of illness a patient is experiencing.
OPQRST
A mneumonic used in evaluating a patient’s pain:
Onset Provocation/Palliation Quality Region/Radiation Severity Timing
Orientation
The mental status of a patientas measured by memory of person (name), place (current location), time (current year, month, and approximate date), and event (what happened).
Palpation
To examine by touch
Paradoxical movement
The motion of the portion of the chest wall that is detatched in a flail chest; the motion - in during inhalation, out during exhalation - is exactly the oppositeof normal chest wall motion during breathing.
PASTE
A mneumonic used in evaluating a patient’s difficulty breathing:
Progression Associated chest pain Sputum Talking tiredness Exercise tolerance
Perfusion
The flow of blood through the body tissues and vessels.
Personal protective equipment (PPE)
Protective equipment tht blocks exposure to a pathogen or a hazardous material.
Pertinent negatives
Negative findings that warrant no care or intervention.
Primary assessment
A step within the patient assessment process that identifies and initiates treatment of immediate and potential life threats.
Pulse
The wave of pressure created as the heart contracts and forces blood out of the left ventricle and into the major arteries.
Pulse oxymetry
An assessment tool that measures oxygen saturation of hemoglobin in the capillary beds.
Reassessment
A step within the patient assessment process perfomred at regular intervals during the assessment process to identify and treat changes in a patient’s condition. A patient in unstable condition should be reassessed every 5 minutes, whereas a patient in stable condition should be reassessed every 15 minutes.
Responsiveness
The way in which a patiennt responds to external stimuli, including verbal stimuli (sound), tactile stimuli (touch), and painful stimuli.
Retractions
Movements in which the skin pulls in around the ribs during inspiration.
Ronchi
Coarse, low-pitched breath sounds heard in patients with chronic mucus in the upper airways.
SAMPLE history
A brief history of a patient’s condition to determine:
Signs and Symptoms Allergies Medications Pertinent Past history Last oral intake Events leading up to the injury or illness
Scene size-up
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 mechanism of injury or nature of illness before you enter and begin patient care.
Sclera
The tough, fibrous, white portion of the eye that protects the more delicate inner structures.
Secondary assessment
A step within the patient assessment process in which a systematic physical examination of the patint 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 chief complaint.
Shallow respirations
Respirations characterized by little movement of the chest wall (reduced tidal volume) or poor chest excursion.
Sign
Objective finding that can be seen, heard, felt, smelled, or measured.
Situational awareness
Knowledge and understanding of one’s surroundings and the abiligy to recognize potential risks to the safety of the patient or EMS team.
Sniffing position
An upright position in which the patient’s head and chin are thrust slightly forward to keep the airway open.
Spontaneous respirations
Breathing that occurs without assistance.
Standard precautions
Protecctive measures that have traditionally been developed by the Centers for Disease Control and Prevention (CDC) for use in dealing with objects, blood, body fluids, and other potential exposure risks of communicable disease.
Stridor
A harsh, high-pitched, respiratory sound, generally heard during inspiration, that is caused by partial blockage or narrowing of the upper airway; may be audible without a stethoscope.
Subcutaneous emphysema
A characteristic crackling sensation felt on palpation of the skin, caused by the presence of air in soft tissues.
Symptom
Subjective findings that the patient feel sbut can be identified only by the patient.
Systolic pressure
The increased pressure in an artery with each contraction of the ventricles (systole).
Tachycardia
A rapid heart rate, more than 100 beats/min in an adult.
Tidal volume
The amount of air (in milliliters) that is moved into or out of the lungs during one breath.
Triage
The process of establishing treatment and transportation priorities accordign to severity of injury and medical need.
Tripod position
An upright position in shich the patient leans forward onto two arms stretched forward and thrusts the head and chin forward.
Two-to-three-word dyspnea
A severe breathign problem in which a patient can speak only two to three words at a time without pausing to take a breath.
Vasoconstriction
Narrowing of blood vessels.
Vital signs
The key signs that are used to evaluatethe patient’s overall condition, including respirations, pulse, blood pressure, level of consciousness, and skin characteristics.
Wheezing
A high-pitched, whistling breath sound that is most prominent on expiration, and which suggests and obstruction or narrowing of the lower airways; occuurs in asthma and bronchiolitis.
