Ch7 Key Terms - Patient Assessment Flashcards
An exaggerated immune response to a substance that does not normally cause a reaction.
Allergy
A mnemonic for assessing neurologic function, represents awake and alert, responds to verbal stimuli or pain, or unresponsive.
AVPU scale
The pressure of the blood on the interior walls of the arteries.
Blood pressure
An indication of air movement in the lungs, usually assessed with a stethoscope.
Breath sounds
The symptom or group of symptoms about which the patient is concerned.
Chief complaint
A mnemonic for assessing trauma-related injuries; represents deformity; contusions; abrasions and avulsions; punctures and penetrations; burns, bleeding, and bruises; tenderness; lacerations; and swelling
DCAP-BTLS
Abnormal extension of the arms and legs, downward pointing of the toes, and arching of the head due to an injury to the brain at the level of the brainstem.
Decerebrate posturing
Abnormal flexing of the arms, clenching of the fists, and extending of the legs; due to an injury along the nerve pathway between the brain and spinal cord
Decorticate posturing
Initial findings based on the patient’s chief complaint, the scene size-up, the mechanism of injury or nature of illness, and the patient’s initial appearance.
General impression
The degree of cognitive function and arousal of the brain, ranges from fully alert to unresponsive.
Level of responsiveness
The type of force that acts on the body to cause injury; the method of trauma causing an injury.
Mechanism of injury (MOI)
The type of medical illness present.
Nature of illness (NOI)
A mnemonic that is used in the assessment of a patient’s chief complaint; represents onset, provocation and palliation, quality, radiation, severity, and time.
OPQRST
The act of touching a patient during an examination to feel for any abnormality.
Palpation
A sensation of tingling, pricking, or numbness of the skin, or the feeling of “pins and needles” or a limb being “asleep.”
Paraesthesia
The procedure performed to determine a patient’s condition, especially any immediate life-threatening injuries or conditions; forms the basis for decision about emergency medical care and transport
Patient assessment
A mnemonic for assessing the eyes; represents pupils equal, round, reactive to light.
PERRL
A step within the patient assessment process that identifies and initiates treatment of immediate and potential life threats.
Primary patient assessment
A rhythmic throbbing of the artery caused by the movement of blood.
Pulse
A medical device that measures oxygen saturation level (the oxygen levels in the blood) noninvasively and painlessly.
Pulse oximeter
A mnemonic used to obtain medical history information during the patient assessment process; represents signs/symptoms, allergies, medications, past medical history, last oral intake, and events leading up to the present incident.
SAMPLE
The process of identifying any hazards or possible hazards that could harm you or others and mitigating them prior to attending to the patient.
Scene safety
A general overview of the incident and its surroundings.
Scene size-up
The thorough, systematic physical examination that follows primary patient assessment, any immediate resuscitation, and history taking; includes taking the patient’s vital signs
Secondary patient assessment
Any objective finding that can be seen, heard, smelled, or measured (e.g., a bruise, the patient’s blood pressure); typically discovered during a physical exam
Sign
A subjective finding or a departure from normal function or feeling that is noticed by a patient (e.g., pain, blurred vision), reflecting the presence of a medical problem
Symptom
The key objective findings used to evaluate a patient’s overall condition, includes pulse rate, respiratory rate, blood pressure, temperature, and level of responsiveness.
Vital signs
What does AVPU stand for?
What is it used for?
A - Awake and Alert
V - Responds to Verbal stimuli
P - Responds to Pain Stimuli
U - Unresponsive
Used for assessing neurologic function and patient responsiveness. Used during primary patient assessment.
What does the DCAP-BTLS mnemonic stand for?
What is it used for?
D- Deformity
C- Contusions
A- Abrasions/Avulsions
P- Punctures/Penetrations
B- Bleeding/Bruises
T- Tenderness
L- Lacerations
S- Swelling
Used to assess trauma related injuries and Identify abnormalities, helpful during secondary patient assessment physical exam
What does the OPQRST mnemonic stand for?
What is it used for?
O- Onset (when did symptoms begin)
P- Provocation and palliation (does anything make symptoms better or worse)
Q- Quality (nature of symptom, dull, sharp, throbbing)
R- Radiation (Symptoms can move or only one place)
S- Severity (describe pain 0-10 scale)
T- Time (how long has the patient had the problem)
Used to asses the patients pain and other complaints.
Used in history taking part of patient assessment.
What Does the SAMPLE mnemonic stand for?
What is it used for
S- Signs and Symptoms
A- Allergies
M- Medications
P- Past Medical History (Illness, surgery, other medial issues)
L- Last Oral Intake (last time patient ate or drank)
E- Events leading up to present medical problem
Used in patient history taking after primary assessment.
Used to investigate chief complaint and gather additional information
What does the PERRL mnemonic stand for?
What is it used for?
P- Pupils E- Equal R- Round R- Reactive to... L-...Light
Used to examine pupils and identify abnormalities in the secondary assessment, physical examination.
