CHAPTER 10 ACRONYMS AND PATIENT ASSESSMENT Flashcards

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1
Q

COMPONENTS OF PATIENT ASSESSMENT

A

SCENE SIZE UP
PRIMARY ASSESSMENT
HISTORY TAKING
SECONDARY ASSESSMENT MEDICAL/TRAUMA
REASSESSMENT

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2
Q

SCENE SIZE UP

A

ENSURE SCENE SAFETY
DETERMINE MECHANISM OF INJURY (MOI) OR NATURE OF ILLNESS (NOI)
TAKE STANDARD PRECAUTIONS
DETERMINE # OF PATIENTS
CONSIDER ADDITIONAL RESOURCES

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3
Q

PRIMARY ASSESSMENT

A

MAKE GENERAL IMPRESSION
ASSESS LEVEL OF CONSCIOUSNESS
ASSESS AIRWAY
ASSESS BREATHING
ASSESS CIRCULATION
PERFORM PRIMARY ASSESSMENT
DETERMINE PRIORITY CARE AND TRANSPORT

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4
Q

HISTORY TAKING

A

INVESTIGATE THE CHIEF COMPLAINT
OBTAIN SAMPLE HISTORY

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5
Q

SECONDARY ASSESSMENT: MEDICAL/TRAUMA

A

SYSTEMATICALLY ASSESS THE PATIENT
-SECONDARY ASSESSMENT OR FOCUSED ASSESSMENT
ASSESS VITAL SIGNS USING THE APPROPRIATE DEVICE

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6
Q

REASSESSMENT

A

REPEAT THE PRIMARY ASSESSMENT
REASSESS VITAL SIGNS
REASSESS THE CHIEF COMPLAINT
RECHECK INTERVENTIONS
IDENTIFY AND TREAT CHANGES IN THE PATIENT’S CONDITION
REASSESS THE PATIENT
-IF UNSTABLE EVERY 5 MIN
-IF STABLE EVERY 15 MIN

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7
Q

“O” IN OPQRST AND MEANING?

A

ONSET-
-WHAT WAS THE PATIENT DOING WHEN SYMPTOMS BEGAN?

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8
Q

“P” IN OPQRST AND MEANING

A

PROVOCATION-
-IS THEIR ANYTHING THAT MAKES THE SYMPTOMS FEEL BETTER OR WORSE?
-MOST COMFORTABLE?

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9
Q

“Q” IN OPQRST AND MEANING?

A

QUALITY-
-WHAT DOES THE SYMPTOM FEEL LIKE?
DOES IT COME IN WAVES?

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10
Q

“R” IN OPQRST AND MEANING

A

REGION/RADIATION-
-WHERE IS THE SYMPTOM LOCATED? DOES IT MOVE AROUND?

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11
Q

“S” IN OPQRST AND MEANING?

A

SEVERITY-
-ON A SCALE OF 0-10, 0 BEING “NOTHING AT ALL” AND 10 “BEING THE WORST YOU CAN IMAGINE” HOW WOULD YOU RATE YOUR SYMPTOM?

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12
Q

“T” IN OPQRST

A

TIMING-
HOW LONG HAS THE SYMPTOM BEEN PRESENT?

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13
Q

“S” IN SAMPLE AND MEANING?

A

SIGNS & SYMPTOMS-
-WHAT SIGNS AND SYMPTOMS OCCURRED AT THE ONSET OF THE INCIDENT?

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14
Q

“A” IN SAMPLE AND MEANING?

A

ALLERGIES-
-DOES THE PATIENT HAVE ANY KNOWN ALLERGIES TO MEDICATION, FOOD, OR OTHER SUBSTANCE?
-WHAT ARE THEIR REACTIONS? IF NO, PUT NKA ON REPORT.

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15
Q

“M” IN SAMPLE AND MEANING

A

MEDICATIONS-
-WHAT MEDICATION IS THE PATIENT PRESCRIBED?
-WHAT DOSE? HOW OFTEN?
-WHAT OTHER DRUGS OR MEDICATIONS HAS THE PATIENT TAKEN IN THE LAST 12 HOURS?
-DOES THE PATIENT USE RECREATIONAL DRUGS?

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16
Q

“P” IN SAMPLE AND MEANING?

A

PAST MEDICAL HISTORY-
-DOES THE PATIENT HAVE ANY HISTORY OF SURGICAL, MEDICAL, OR TRAUMA OCCURRENCES?
-ANY IMPORTANT FAMILY HISTORY?

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17
Q

“L” IN SAMPLE AND MEANING?

A

LAST ORAL INTAKE-
-WHAT AND WHEN DID THE PATIENT LAST EAT OR DRINK?
-IN WOMEN “L” CAN MEAN LAST MENSTRUAL CYCLE.

18
Q

“E” IN SAMPLE AND MEANING?

A

EVENTS LEADING UP TO THE INJURY OR ILLNESS-
-WHAT KEY EVENTS LEAD UP TO THE INCIDENT?
-WHAT OCCURRED BETWEEN ONSET AND YOUR ARRIVAL?
-WHAT WAS PATIENT DOING WHEN ILLNESS STARTED?

19
Q

“P” IN PEARRL

A

PUPILS

20
Q

“E” IN PEARRL

A

EQUAL

21
Q

“A” IN PEARRL

A

AND

22
Q

“R” IN PEARRL

A

ROUND

23
Q

2ND “R” IN PEARRL

A

REGULAR IN SIZE

24
Q

“L” IN PEARRL

A

REACTIVE TO LIGHT

25
Q

“D” IN DCAP BTLS

A

DEFORMITY

26
Q

“C” IN DCAP BTLS

A

CONTUSION

27
Q

“A” IN DCAP BTLS

A

ABRASIONS

28
Q

“P” IN DCAP BTLS

A

PUNCTURES

29
Q

“B” IN DCAP BTLS

A

BURNS

30
Q

“T” IN DCAP BTLS

A

TENDERNESS/REBOUND TENDERNESS

31
Q

“L” IN DCAP BTLS

A

LACERATIONS

32
Q

“S” IN DCAP BTLS

A

SWELLING

33
Q

“A&O X4”

A

ALERT AND ORIENTED: NAME? TIME? PLACE? EVENT?

34
Q

A IN “AVPU”

A

AWAKE AND ALERT

35
Q

“V” IN AVPU

A

VERBAL

36
Q

“P” IN AVPU

A

PAIN

37
Q

“U” IN AVPU

A

UNRESPONSIVE

38
Q

GLASGOW COMA SCALE

A

EYE OPENING
VERBAL RESPONSE
BEST MOTOR RESPONSE

39
Q

“EYE OPENING” STAGE OF GLASGOW

A

SPONTANEOUS-4
WITH SOUND-3
WITH PRESSURE-2
NONE-1

40
Q

VERBAL RESPONSE

A

ORIENTED CONVERSATION-5
CONFUSED CONVERSATION-4
INAPPROPRIATE WORDS-3
INCOMPREHENSIBLE SOUNDS-2
NONE-1

41
Q

“BEST MOTOR RESPONSE”

A

OBEYS COMMANDS-6
LOCALIZES TO PRESSURE-5
WITHDRAWS FROM PRESSURE-4
ABNORMAL FLEXION-3
ABNORMAL EXTENSION-2
NONE-1