Chap 14 Flashcards
3 basic Secondary assessment components
Physical exam Patient history- History of present and past illnesses -OPQRST -SAMPLE Vital signs
OPQRST
O- Onset P- Provocation Q- Quality R- Region, relief S- Severity T- Time
SAMPLE
S- Signs and symptoms A- Allergies M- Medications P- Past pertinent history L- Last oral intake E- Events leading to the injury or illness
Reassessment
a procedure for detecting changes in a patients condition. It involves four steps: repeating the primary assessment, repeating and recording vital signs, repeating the physical exam and checking interventions
building rapport with patient
- Get on same level with patient
- demonstrating empathy for problems an condition
- listen carefully
Open ended questions
a question requiring more than just a yes or no answer
Closed ended questions
a question requiring only a yes or no
Three techniques in physical exam
Observe
Auscultate
Palpate
Respiratory assessment- History
- Dyspnea on exertion
- Difficulty breathing after exerting himself
Weight gain
-Does patient have recent, rapid weight gain or that clothes fit more tightly? This may indicate fluid build up (heart failure)
Orthopnea
-Difficulty breathing laying down? This occurs in several respiratory conditions, including heart failure
Does the patient sleep on pillows? Has the patient required more pillows recently?
Does the patient have a cough? Has the cough been productive? What does the patient cough up?
Has respiratory conditions recently? (Flu, bronchitis, cold
Does the patient have a chronic illness that affects the respiratory system? (Asthma, emphysema (COPD)
Respiratory exam
Mental status
-due to hypoxia to brain
Level of respiratory distress
Observe chest wall motion
Auscultate lung sounds
Use pulse oximeter
Observe edema
- Lungs, feet
- Bedridden patients have edema in abdomen and flanks
Fever
-Infectious process such as pneumonia
Cardiovascular history
History of existing cardiac conditions and medications
Determine if signs and symptoms match previous episode
Obtain description of chest pain
Determine specific characteristics of the pain
Cardiovascular exam
Look for signs that the condition may be severe
- Skin color, temperature and condition
- mental status altered due to poor perfusion to brain
Obtain a pulse
Obtain blood pressure
Note the pulse pressure
Jugular vein distension (JVD)
- Heart failure or obstruction within chest
Palpate the chest
-Trauma
Observe posture and breathing
- Guarding chest?
- Shallow breathing indicate chest trauma
Two main elements to the nervous system exam
Mental status
-Decreased oxygen, low perfusion, stroke, tumors, dementia
Signs of dysfunction
-Facial asymmetry, slurred speech, weakness or inability to move extremities
Neurological history
Patients mental status
-AO x4
Patients normal state of mental functioning
-patients might not have normal functioning to begin with (dementia, Alzheimer’s
History of neurological conditions
- Prior strokes, transient ischemic attacks
- Amyotrophic Lateral Sclerosis (Lou Gehrig’s disease) or Guillain-Barre syndrome
Patients Speech
Neurological exam
Perform a stroke scale
-Cincinnati Prehospital Stroke Scale (CPSS)
Check peripheral sensation and movement
Gently palpate the spine for tenderness or deformity
Check extremity strength
Check the patients pupils for PEARL
Endocrine History
Obtain history of endocrine conditions
-Diabetes mellitus or thyroid disease
Determine medications taking, last taken and is doses have changed
Determine if patient has eaten
Has patient exerted himself at unusual levels
Patient currently sick
Has patient recently taken his blood glucose
Does patient have insulin pump
Endocrine Exam
Evaluate patients mental status
Observe skin
-Cool, moist skin may occur in hypoglycemia
Obtain glucose level
-Normal 70-100
Look for insulin pump
Unusual fruity breath mean hyperglycemic
Gastrointestinal History
Oral intake
Pain
History of gastrointestinal issues
Vomiting
-dark blood, red blood or coffee ground looking
Bowel movements
-Dark, tarry, or bright red blood
Gastrointestinal Exam
Observe the patients position
Assess the abdomen
Inspect gastrointestinal system
Inspect vomitus or feces
Immune History
Allergies and typical reactions
Exposed to something he is allergic to
Feel tightness in the chest or throat, difficulty breathing, or swelling around the face, mouth or tongue
Patient have medications for allergic reactions
Immune system exam
Inspect point of contact with the allergen
Inspect the patients skin for hives
Inspect the face, lips, and mouth for swelling
Listen to the lungs to assure adequate breathing
Musculoskeletal History
Prior injuries
Taking blood-thinning medications or medications that might delay clotting
History to determine if medical problem (loss of consciousness) caused the traumatic injury
Musculoskeletal Exam
Inspect and palpate for DCAP-BTLS
-Deformities, contusions, abrasions, punctures, burn, tenderness, lacerations, swelling
Compare sides of the body and note asymmetry
Be alert for crepitations
Rapid physical exam
Head- Jugular vein distention, medical devices
Neck
Chest presence and equality of breath sounds
abdomen- Distention, firmness, and rigidity
Pelvis- Incontinences of the urine and feces
Extremities- Pulse, motor function, sensation, oxygen saturation, medical devices
Questioning bystanders at scene
What’s the patients name?
What happened?
Did you see anything else?
Did the patient complain of anything before this happened?
Does the patient have any known illnesses or problems?
Is the patient taking any medication?
General combination of factors to determine how serious patient is
Location of the injury
Mental status
Airway
Vital signs
MOI
age or the presence of preexisting conditions
different terms to describe a seriously injured patient
Serious, critical, high priority
Steps for not seriously injured patient
- Determine chief complaint and illicit information about how the patient was injured
- Perform the physical exam based on the chief complaint or MOI
- Assess baseline vital signs
- Obtain a past medical history
Steps for a more seriously injured patient
- Determine the chief complaint, and rapidly elicit information about how the patient was injured
- Continue manual stabilization of the head and neck
- Consider requesting Advanced life support
- Perform rapid trauma assessment
- Assess baseline vital signs
- Obtain a past medical history
HPI
History of present illness
- nature of force
- Direction and strength of force
- Equipment used to protect the patient
- Actions taken to prevent or minimized injury
- Areas of pain and injuries resulting from the incident
Cervical collars
STIFNECK SELECT
WIZLOC
Philadelphia Cervical Collar
NEC-LOC
Rapid trauma assessment
a rapid assessment of the head, neck, chest, abdomen, pelvis, extremities, and posterior of the body to detect signs and symptoms of injury
Field triage: significant MOI
Falls
- Adults greater than 20ft
- Children <15 yrs fall >10 or 2 to 3 times height of child
High-risk auto crash
- Intrusion: >12 inches to the occupant site or > 18 inches to any site
- Ejection (partial or complete) from car
- Death in the same passenger compartment
- Vehicle telemetry data consistent with the high risk of injury
Auto versus pedestrian/ bicyclist thrown, run over, or with significant (>20mph) impact
Motorcycle crash >20mph
CSF
cerebrospinal fluid
Battle signs
a late sign of head injury
- bruise behind the ears
- Blood in anterior chamber of eye
- blood or clear water-like fluid in ear and nose
- Unequal pupils
- Discoloration of soft tissue under eyes
tension pneumothorax
air trapped in chest
Cardiac tamponade
Blood filling the sac around the heart
Flat neck veins in a patient laying down
Might be a sign of blood loss
Paradoxical motion
Movement of a part of the chest in the opposite direction to the rest of the chest during respiration
-Usually occurs when ribs have broken at both ends and are free floating
Subcutaneous emphysema
Crackling or crunching sensation under the skin from air that has escaped from normal passageways
Distention
a condition of being stretched, inflated, or larger than normal
Palpating abdomen
Palpate painful abdomen last
Make sure hands are warm
Depress surface about 1 inch
Firmness of the abdomen can be sign of injury to the organs or internal bleeding
Pulsating mass might be a enlarged aorta
Priapism
Persistent erection of penis resulting from spinal cord injury or certain medical problems
general principles of an exam
Tell patient what you are going to do
Expose any injured area before examining it
Try to maintain eye contact
Apply your spinal protocols
You may stop or alter the assessment process to provide care that is necessary
During the rapid trauma assessment, apply cervical collar if spine injury is suspected
Detailed physical exam
assessment of the head, neck, chest, abdomen, pelvis, extremities, and posterior of the body to detect sign and symptoms of injury
Differs from rapid trauma assessment only in that it also includes examination of the face, ears, eyes, nose, and mouth during the examination of the head
Reassessment
Repeating primary assessment
- Reassess mental status
- Maintain an open airway
- Monitor breathing for rate and quality
- Reassess the pulse for rate and quality
- Monitor skin color and temperature
- Reestablish patient priorities
Repeat pertinent parts of history and physical exam
- see if chief complaint changed
- See if pain changed
Check interventions
Observe trends
Diagnosis
description or label for a patients condition that assists a clinician in further evaluation and treatment
differential diagnosis
a list of potential diagnoses compiled early in the assessment of the patient
Heuristics and their biases- Representativeness
-When you encounter a patients with a certain group of signs and symptoms that resemble a particular condition
Heuristics and their biases- Availability
-urge to think of things because they are more easily recalled, often because of a recent exposure
Heuristics and their biases- Overconfidence
Thinking you know more than you really do
Heuristics and their biases- Confirmation bias
Primarily looks for evidence that supports the diagnosis he already has in mind
Heuristics and their biases- Illusory correlation
Humans are able to draw conclusions about how the world works because they are able to see how one thing causes another
