Ch. 11 Patient Assessment Flashcards
Adventitious breath sounds
Abnormal breath sounds, such as wheezing, rhonchi, crackles, strider, and pleural friction rubs.
Alert and oriented (A X O)
A determination made when assessing mental status by looking at whether the patient is oriented in four areas: person, place, time, and event.
Anisocoria
Unequal pupils with a greater than 1-mm difference
Aphasia
The language impairment that affects the production or understanding of speech and the ability to read or write.
Apparent life-threatening event (ALTE)
An episode characterized by some combination of apnea (central or obstructive), color change (cyanosis, pallid, erythematous, or plethoric) change in muscle tone, and choking or gagging.
Ascites
Abnormal accumulation of fluid in the peritoneal cavity; typicallly signals liver failure.
Aspiration
The entry of fluids or solids into the trachea, bronchi, and lungs; the act of drawing material in or out by suction.
Auscultation
The act of using a stethoscope to listen to sounds within the body
AVPU
Method of assessing mental status by determining whether a patient is Awake and alert, responsive to Verbal stimuli or Pain, or Unresponsive.
Battle signs
Bruising over the mastoid process, which may indicate a basilar skull fracture; also known as a retroauricular ecchymosis or raccoon eyes.
Beck triad
The combination of a narrowed pulse pressure, muffled heart tones, and jugular venous distention associated with cardiac tamponade; usually caused by penetrating chest trauma.
Blood pressure (BP)
Measurement of the force exerted against the walls of the blood vessels as the product of cardiac output and peripheral vascular resistance.
Bronchial sounds
Hollow, tubular, lower-pitched sounds heard over the trachea.
Bronchophony
Test of decreased breath sounds performed by placing the diaphragm of the stethoscope over the area in question while the patient says “ninety-nine” a loud, clear sounds indicates lug consolidation
Bronchovesicular sounds
A combination of the tracheal and vesicular breath sounds; heard where airways and alveoli are found, in the upper part of the sternum and between scapulae.
Bruit
An abnormal whooshing sound of turbulent blood flow moving through a narrowed artery; usually heard in the carotid arteries.
Capnography
The use of noninvasive diagnostic tool that can quickly and efficiently provide information on a patient’s ventilatory and circulatory status with a graphic and digital depiction similar to an electrocardiograph.
Capnometry
The use of a capnometer, which is a monitoring device used to measure the amount of expired carbon dioxide. The reading is usually given as a digital reading.
Cerumen
Ear wax
Chief complaint
The reason the patient is seeking help.
Crackles
Wet rattling, bubbling, or crackling lung sounds indicative of fluid in the small airways; also known as rails
Crepitus
A crackling, grating, or grinding sound often heard when fragments of broken bones rub together.
Current health status
A composite picture of a number of factors in a patient’s life, such as dietary habits, current medications, allergies, exercise, alcohol or tobacco use, recreational drug use, sleep patterns and disorders, and immunizations.
Crushing reflex (triad)
The combination of a slowing pulse, rising blood pressure, and an erratic respiratory pattern; a grave sign for patients with head trauma or cerebrovascular accident.
Cyanosis
A blue-gray skin color that is caused by invadequate levels of oxygen in the blood.
Delirium
An acute confusion also state characterized by global impairment of thinking, perception, judgment, and memory.
Dementia
the gradual and pervasive deterioration or losss of cognitive cortical functions
Diaphoresis
Excessive sweating; it is often associated with shock.
Diastolic pressure
The result of residual pressure In the circulatory system while the left ventricle is relaxing
Differential diagnosis
Process of comparing one disease versus other diseases by comparing clinical findings that could account for a patient’s illness; also refers to the list of possible conditions considered based on the patient’s signs and symptoms.
Diplopia
Doubled vision
Ecchymosis
Localized bruising or collection of blood within or under the skin
Egophony
A test of decreased breath sounds performed by placing the diaphragm of the stethoscope over the area in question while the patient says a drawn out “eye;” an “A” sound indicates lung consolidation.
Field impression
Field conclusion on the patients problem based on the clinical presentation and the exclusion of other possible causes through considering the differential diagnoses.
Focused exam
Type of physical exam that is typically performed on responsive patients who have sustained an isolated injury.
This type of exam is based on the chief complaint and focuses on one body system or part.
Full-body exam
A systematic head-to-toe exam performed during the secondary assessment of a patient who has sustained a significant MOI, is unresponsive, or is in critical condition.
General impression
Overall initial impression that determines the priority of patient care; based on the patient’s surroundings, the mechanism of injury, signs and symptoms, and the chief complaint.
Glasgow Coma Scale (GCS)
An evaluation tool used to determine level of consciousness by evaluating and assigning point values (scores) for eye opening, verbal response, and motor response, which are then totaled; effective in helping predict patient outcomes.
Guarding
Contraction of the abdominal muscles indicating peritoneal irritation
Heave
The perception that the heat is beating very strongly; felt upon palpating of the chest wall, this finding suggests hypertrophy; also called a lift.
History of the present illness
A narrative detail of the symptoms that a patient is experiencing, usually obtained using the OPQRST mnemonic.
Iatrogenic
Related to a side effect or complication of medications or other medical treatment.
Inspection
Looking at the patient, either in general or at a specific area
Jugular vein distention (JVD)
The visible bulging of the jugular veins when a patient is in semi-Fowler or full Fowler position; indicates inadequate blood movement through the heart and/or lungs
Korotkoff sounds
Sounds related to blood pressure measurement that are heard by stethoscope.
Kyphosis
Outward curve of the thoracic spine
Lesions
Localized areas of the skin that do not resemble the area surrounding it.
Lift
A sensation felt upon palpating of the chest wall, in which the heart beats extremely strongly; suggests hypertrophy; also called a heave
Lordosis
Inward curve of the lumbar spine just above the button. An exaggerated form results in the condition known as swayback.
Mechanism of injure (MOI)
The series of events that result in traumatic injuries; the forces that act on the body to cause injury.
Mottling
A blotchy patter on the skin; a typical finding in states of severe protracted hypoperfusion and shock
Murmur
An abnormal whooshing sound heard over the heart that indicates turbulent blood flow around a cardiac valve.
Nature of illness (NOI)
The general type of illness a patient is apparently experiencing.
Ophthalmoscope
An instrument used to examine a patients eyes and view the retina and aqueous fluid; consists of a concave mirror and a battery-powered light that is usually contained in the handle.
Orthostatic vital signs
Multiple sets of vital signs taken from the patient in different positions. (Supine, sitting, standing) to determine the degree of hypovolemia; also called a tilt test.
Otoscope
An instrument used to examine the ears of a patient; consists of a head and handle,, the head contains an electric light source and a low powered magnifying lense
Pallor
Paleness
Palpating
Physical touching for the purpose of obtaining information
Paresthesias
Tingling feeling or sensory change
Past medical history
Information obtained during the history taking process, such as the patient’s general state of health, childhood and adult diseases, surgeries and hospitalizations, psychiatric and mental illness, or traumatic injuries, which may relate to the patient’s current condition.
Pathologic fracture
A fracture that occurs when normal forces are applied to abnormal bone structures
Patient history
Information about the patient’s chief complaint, present symptoms, and previous illnesses.
Percussion
Gently striking the surface of the body, typically overlying various body cavities, to detect changes in the densities of the underlying structures.
Perfusion
The circulation of oxygenated blood through the body tissues and vessels.
Pertinent negatives
The absence of certain signs and symptoms normally expected of specific illnesses or conditions; these findings warrant no medical care or intervention, but demonstrate the thoroughness of the patient exam and history.
Pleural friction rubs
Squeaking or grating sounds that occur when the pleural linings rub together, which may be heard on inspiration, expiration, or both;
Commonly caused by inflammation of the pleura.
Primary survey
The part of the assessment process that focuses on identifying immediate or potential life threatening conditions so you can initiate lifesaving care.
Primitive reflexes
Reflex reactions such as babinski, gasping, and sucking signs normally found in infants
Pronator drifts
Drifting of one arm downward toward a patient’s feet while he or she holds out his or her arms, palm side up, with his or her eyes shut; can be a sign of a stroke.
Proprioception
The perception of the position and movement of the body or limbs
Pulse
The wave of pressure created as the heart contracts and forces blood out of the left ventricle and into the major arteries; palpated at a point where an artery passes close to a bone
Pulse oximitry
An assessment tool used to measure oxygen saturation of hemoglobin in the capillary beds.
Rapid full body scan
A 60 to 90 second non systematic review and palpation of the patients body to identify injuries that must be managed or projected immediately;
Also called the rapid full body sweep
Reassessment
Portion of the assessment process in which a patient’s condition is reevaluated and responses to treatment is assessed.
Reflexes
Involuntary motor responses to specific sensory stimuli, such as a tap on the knee or stroking the eyelash.
Rhonchi
Coarse, low-pitched breath sounds heard in patients with chronic mucus in the upper airways.
Rigidity
A clinically important sign characterized by marked peritoneal irritation and guarding, indicating an injury or illness for which urgent surgical intervention may be required.
Rubor
Redness; one of the classic sgns of inflammation.
Scene size up
A step in the patient assessment process involving a quick assessment of the scene and its surroundings to gather information about the overall safety and stability of the scene and the mechanism of injury or nature of illness
This process is carried out before you enter and begin patient care
Scoliosis
Sideways curvature of the spine
Secondary assessment
The process by which more detailed, quantifiable, objective information is obtained from the patient about his or her overall state of health.
Signs
Objective observations that can be seen, heard, felt, smelled, or measured.
Social history
A subsection of the patient history that provides valuable information regarding the patient’s overall health status ad helps to identify risks factors for various disease processes; included items such as Tabasco use, alcohol and drug use, sexual behavior, diet, travel history, living environment, and occupation.
Sphygmomanometer
A blood pressure cuff
Spitting
In the context of heart sounds, a situation in which events on the right side of heart occur slightly later than those on the left side, and create two discernible sounds rather than one heart sound
Strider
A harsh, high pitched respiratory sound produced as air moves past an obstruction within or immediately above the glottis opening; associated with severe upper airway obstruction.
Symptoms
Subjective information the patient feels, such as pain, discomfort, or other abnormality.
Systolic pressure
Blood pressure created by the left ventricle as it contracts
Tenting
A condition in which the skin slowly retracts after being pinched and pulled away slightly from the body; a sign of dehydration,
Thrill
Humming vibration that can be palpated through the chest wall, suggesting an underlying bruit or murmmur.
Traumatic fracture
A fracture that occurs when abnormal forces are applied to normal bone structures
Turf or
Loss of skin elasticity
Vasoconstriction
Narrowing of the diameter of the blood vessel
Vasodilation
Widening of the diameter of the blood vessel
Vesicular sounds
Normal breath sounds made by air moving in and out of the alveoli
Visual acuity
Determined by the ability or inability to see, and by how far.
Wheezing
High pitched whistling sound that may be heard on inspiration, expiration, or both , indicating air movement through constricted lower airways, as in asthma
Whispered pectoriloquy
A test of decreased breath sounds performed by placing the diaphragm of the stethoscope over the area in question as the patient whispers “ninety nine” a loud, clear sound indicates lung consolidation.
Working diagnosis
The one diagnosis from a differential list used to base a patient’s treatment plan.
