CHAPTER 10 ACRONYMS AND PATIENT ASSESSMENT Flashcards
COMPONENTS OF PATIENT ASSESSMENT
SCENE SIZE UP
PRIMARY ASSESSMENT
HISTORY TAKING
SECONDARY ASSESSMENT MEDICAL/TRAUMA
REASSESSMENT
SCENE SIZE UP
ENSURE SCENE SAFETY
DETERMINE MECHANISM OF INJURY (MOI) OR NATURE OF ILLNESS (NOI)
TAKE STANDARD PRECAUTIONS
DETERMINE # OF PATIENTS
CONSIDER ADDITIONAL RESOURCES
PRIMARY ASSESSMENT
MAKE GENERAL IMPRESSION
ASSESS LEVEL OF CONSCIOUSNESS
ASSESS AIRWAY
ASSESS BREATHING
ASSESS CIRCULATION
PERFORM PRIMARY ASSESSMENT
DETERMINE PRIORITY CARE AND TRANSPORT
HISTORY TAKING
INVESTIGATE THE CHIEF COMPLAINT
OBTAIN SAMPLE HISTORY
SECONDARY ASSESSMENT: MEDICAL/TRAUMA
SYSTEMATICALLY ASSESS THE PATIENT
-SECONDARY ASSESSMENT OR FOCUSED ASSESSMENT
ASSESS VITAL SIGNS USING THE APPROPRIATE DEVICE
REASSESSMENT
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
“O” IN OPQRST AND MEANING?
ONSET-
-WHAT WAS THE PATIENT DOING WHEN SYMPTOMS BEGAN?
“P” IN OPQRST AND MEANING
PROVOCATION-
-IS THEIR ANYTHING THAT MAKES THE SYMPTOMS FEEL BETTER OR WORSE?
-MOST COMFORTABLE?
“Q” IN OPQRST AND MEANING?
QUALITY-
-WHAT DOES THE SYMPTOM FEEL LIKE?
DOES IT COME IN WAVES?
“R” IN OPQRST AND MEANING
REGION/RADIATION-
-WHERE IS THE SYMPTOM LOCATED? DOES IT MOVE AROUND?
“S” IN OPQRST AND MEANING?
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?
“T” IN OPQRST
TIMING-
HOW LONG HAS THE SYMPTOM BEEN PRESENT?
“S” IN SAMPLE AND MEANING?
SIGNS & SYMPTOMS-
-WHAT SIGNS AND SYMPTOMS OCCURRED AT THE ONSET OF THE INCIDENT?
“A” IN SAMPLE AND MEANING?
ALLERGIES-
-DOES THE PATIENT HAVE ANY KNOWN ALLERGIES TO MEDICATION, FOOD, OR OTHER SUBSTANCE?
-WHAT ARE THEIR REACTIONS? IF NO, PUT NKA ON REPORT.
“M” IN SAMPLE AND MEANING
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?
“P” IN SAMPLE AND MEANING?
PAST MEDICAL HISTORY-
-DOES THE PATIENT HAVE ANY HISTORY OF SURGICAL, MEDICAL, OR TRAUMA OCCURRENCES?
-ANY IMPORTANT FAMILY HISTORY?
“L” IN SAMPLE AND MEANING?
LAST ORAL INTAKE-
-WHAT AND WHEN DID THE PATIENT LAST EAT OR DRINK?
-IN WOMEN “L” CAN MEAN LAST MENSTRUAL CYCLE.
“E” IN SAMPLE AND MEANING?
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?
“P” IN PEARRL
PUPILS
“E” IN PEARRL
EQUAL
“A” IN PEARRL
AND
“R” IN PEARRL
ROUND
2ND “R” IN PEARRL
REGULAR IN SIZE
“L” IN PEARRL
REACTIVE TO LIGHT
