Chapter 10: Patient Assessment Flashcards by Beyond Limits Education

What should be observed and noted on the Patient Care Report?

Mental Status

Use descriptive words (i.e. irritable, lethargic, combative, alert)

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The overall impression that determines the priority for patient care; based on the patient’s surroundings, the mechanism of injury, signs and symptoms, and the chief complaint.

General Impression

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This is a component of air and typically makes up 0.3% of air at sea level; also a waste product exhaled during expiration by the respiratory system.

Carbon Dioxide

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What does the acronym mean?

CSM

Circulation

Sensory

Motor

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The process that the blood exerts against the walls of the arteries as it passes through them.

Blood Pressure

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A painful erection of the penis resulting from a spinal cord injury.

Priapism

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What should EMTs look for in the physical exam of the head and neck?

DCARP, BLS, TICS, Medical Alert Tags, JVD, Tracheal Shifting

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What do the acronyms mean?

DCARP BLS TICS

Deformity / Discoloration / Drainage / Distension

Contusion

Abrasion / Avulsion

Rigidity

Puncture / Penetration / Paradoxical Movement

Burn

Laceration

Swelling / Soft / Subcutaneous Emphysema

Tenderness

Instability

Crepitus

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The flow of blood through body tissues and vessels.

Perfusion

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What should be observed and noted on the Patient Care Report?

Temperature

Temperature measured with thermometer (degrees F or degrees C).

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The secondary muscles of respirations. They include the neck muscles (sternocleidomastoids), the chest pectoralis major muscles, and the abdominal muscles.

Accessory Muscles

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Negatives findings that warrant no care or intervention.

Pertinent Negatives

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An assessment tool that measures oxygen saturation of hemoglobin in the capillary beds.

Pulse Oximetry

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Fine Crackles

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What should be observed and noted on the Patient Care Report?

Respirations

Rate - Breaths/min
Rhythm – “Regular”, “Irregular”
Effort – “Unlabored”, “Labored”
Tidal Volume – “Normal”, “Shallow”, “Deep”

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A step within the patient assessment process that provides detail about the patient’s chief complaint and an account of the patient’s signs and symptoms.

History Taking

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A grating or grinding sensation caused by fracture bone ends or joints rubbing together; also air bubbles under the skin that produce a crackling sound or cranky feeling.

Crepitus

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The general type of illness a patient is experiencing.

Nature of Illness (NOI)

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What should an EMT look for during a physical exam?

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What should be observed and noted on the Patient Care Report?

Glasgow Coma Scale (GCS)

Best Eye Response (4)

None
To sound
To pressure
Spontaneous

Best Verbal Response (5)

None
Sounds
Words
Confused
Orientated

Best Motor Response (6)

None
Extension
Abnormal flexion
Normal flexion
Localizing
Obeys commands

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An upright position in which the patient’s head and chin are thrust slightly forward to keep the airway open.

Sniffing Positions

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Subjective findings that the patient feels but that can be identified only by the patient.

Symptom

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A high pitched, whistling, breath sound that is more prominent on expiration and which suggests an obstruction or narrowing of the lower airways; occurs in asthma and bronchitis.

Wheezing

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Yellow skin usually indicative of liver disease or failure.

Jaundice

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# What should be observed and noted on the Patient Care Report? Pupillary Response

“Pupils are Equal, Round, and Reactive to Light and Accommodation” Otherwise, state what is wrong.

# What phrase or word matches this definition? The time from injury to definitive care, during which treatment of shock and traumatic injuries should occur because survival potential is best.

Golden Hour

What should EMTs look for in the physical exam of the abdomen?

DCARP, BLS, TICS

# What phrase or word matches this definition? Coarse, low pitched breath sounds heard in patients with chronic mucus in the upper airways.

Rhonchi

# What phrase or word matches this definition? The increased pressure in an artery with each contraction of the ventricles (systole).

Systolic Pressure

Bronchial Sounds

# What should be observed and noted on the Patient Care Report? Blood Glucose Levels (BGL)

Mg/dL

# What phrase or word matches this definition? The forces, or energy transmission, applied to the body that cause injury.

Mechanism of Injury (MOI)

# What should be observed and noted on the Patient Care Report? Blood Pressure

Auscultate or Palpate Systolic/Diastolic #s (Auscultated) or Systolic #/P (Palpated)

# What phrase or word matches this definition? Characterized by light or profuse sweating.

Diaphoretic

# What phrase or word matches this definition? Breathing that requires greater than normal effort; may be slower or faster than normal and characterized by grunting, stridor, and use of accessory muscles.

Labored Breathing

# What phrase or word matches this definition? A crackling, rattling breath sound that signals fluid in the air space of the lungs.

Crackles

# What phrase or word matches this definition? Movements in which the skin pulls in around the ribs during inspiration.

Retractions

# What phrase or word matches this definition? A slow heart rate, less than 60 beats/min.

Bradycardia

Ronchi Breath Sounds

# What phrase or word matches this definition? Blood pressure that is higher than the normal range.

Hypertension

# What phrase or word matches this definition? Protective equipment that blocks exposure to a pathogen or a hazardous material.

Personal Protective Equipment (PPE)

# What does the acronym mean? ROM

**R**ange **O**f **M**otion

# What phrase or word matches this definition? An indication of air movement in the lungs, usually assessed with a stethoscope.

Breath Sounds

# What phrase or word matches this definition? Narrowing of a blood vessel.

Vasoconstriction

# What phrase or word matches this definition? To examine by touch.

Palpate

# What phrase or word matches this definition? The pressure that remains in the arteries during the relaxing phase of the heart's cycle (diastole) when the left ventricle is at rest.

Diastolic Pressure

# What phrase or word matches this definition? The reason a patient called for help; also the patient's response to such questions such as what's wrong? or what happened?

Chief Complaint

What are the components of Scene Size-Up?

# What does the acronym mean? OPQRST

**O**nset (What Pt. was doing?) **P**rovoked (Makes worse?) / **P**alliate (Feels better?) **Q**uality (Feels like?) **R**egion/Radiation (Where does it hurt?) **S**everity (Pain Scale 1-10; Worst past pain?) **T**rend (How long has problem occurred? 1^st time? Similar to last time? Getting better? Getting worse? Staying same?)

# What phrase or word matches this definition? The pressure wave that occurs as each heartbeat causes a surge in the blood circulating through the arteries.

Pulse

# What phrase or word matches this definition? A system implemented to manage disasters and mass- and multiple-casualty incidents in which section chiefs, including finance, logistics, operations, and planning, report to the incident commander.

Incident Command System

# What phrase or word matches this definition? The biochemical processes that result in production of energy from nutrients within the cells.

Metabolism

Course Crackles

# What phrase or word matches this definition? The delicate membrane that lines the eyelids and covers the exposed surface of the eye.

Conjunctiva

# What phrase or word matches this definition? The motion of the portion of the chest wall that is detached in a flail chest; the motion- in during inhalation, out during exhalation- is exactly the opposite of normal chest wall motion during breathing.

Paradoxical Motion

# What should be observed and noted on the Patient Care Report? Orientation

Person (x1) + Place (x2) + Time (x3) + Event (x4)

# What phrase or word matches this definition? The key signs that are used to evaluate the patient's overall condition, including respirations, level of consciousness, and skin characteristics.

Vital Signs

What does a reassessment entail?

Reassessment of critical systems (primary assessment), vitals, chief complaint, and effectiveness of interventions. Looking for patterns / trends. Updating problem list and treatment plan.

# What phrase or word matches this definition? Widening of the nostrils, indicating there is an airway obstruction.

Nasal Flaring

# What phrase or word matches this definition? Protective measures that have traditionally been developed by the CDC for use in dealing with objects, blood, body fluids, and other potential exposure risks of communicable diseases.

Standard Precautions

# What phrase or word matches this definition? A condition in which the internal body temperature falls below 95° F (35° C) after exposure to a cold environment.

Hypothermia

# What phrase or word matches this definition? A type of physical assessment typically performed on patients who have sustained nonsignificant MOI or on responsive medical patients. Based on chief complaints and focuses on one body system or part.

Focused Assessment

# What phrase or word matches this definition? A characteristic cracking sensation felt on palpation of the skin, caused by the presence of air in soft tissue.

Subcutaneous Emphysema

Vesicular Breath Sounds

# What phrase or word matches this definition? Knowledge and understanding of your surroundings and situation and the risk they potentially pose to safety or the safety to the EMS team.

Situational Awareness

Stridor

What are the components of the primary assessment?

# What phrase or word matches this definition? The way in which a patient responds to external stimuli, including verbal stimuli (sound), tactile stimuli (touch), and painful stimuli.

Responsiveness

# What phrase or word matches this definition? Damage to tissue as a result of exposure to cold.

Frostbite

# What phrase or word matches this definition? An upright position in which the patient leans forward onto two arms stretched forward and thrusts the head and chin forward.

Triage Tripod Position

# What phrase or word matches this definition? Any injury that prevents the patient from noticing other injuries he may have.

Distracting Injury

# What does the acronym mean? AVPU

* *A**wake * *V**erbal (Responds to Verbal Stimuli) * *P**ain (Responds to Painful Stimuli) * *U**nresponsive

What should EMTs look for in the physical exam of the chest?

DCARP, BLS, TICS, Subcutaneous Emphysema

How often should a unstable patient be reassessed?

Every 5 minutes.

# What phrase or word matches this definition? A step within the patient assessment process that identifies and initiates treatment of immediate and potential life threats.

Primary Assessment

# What should be observed and noted on the Patient Care Report? Pulse

Rate - # beats/min Rhythm – “Regular”, “Irregular” Quality – “Strong”, “Weak”, “Absent”

# What phrase or word matches this definition? A blue-gray skin color that is caused by a reduced level of oxygen in the blood.

Cyanosis

# What phrase or word matches this definition? A method of assessing the level of consciousness by determining whether the patient is awake and alert, responsive to verbal stimuli or pain, or unresponsive; used principally early in the assessment process.

AVPU Scale

# What phrase or word matches this definition? A step within the patient assessment process performed at regular intervals during the assessment process to identify and treat changes in a patient's condition.

Reassessment

What should EMTs look for in the physical exam of the pelvis?

DCARP, BLS, TICS, Incontinence, Priapism

# What phrase or word matches this definition? The mental status of a patient as measured by memory of person, place, time, and event.

Orientation

# What does the acronym mean? SAMPLE

**S**ymptoms **A**llergies (medications, food, environment, type of reaction, last reaction) **M**edications (Rx, OTC, Supplements, Recreational Drugs/Alcohol, What for?) **P**ertinent History (anything that may relate to current problem, current medical problems) **L**ast Ins/Outs (Quantity/Quality) **E**vents (relevant events leading up to illness/incident)

# What phrase or word matches this definition? The amount of air in milliliters that is moved in or out of the lungs during one breath.

Tidal Volume

# What should be observed and noted on the Patient Care Report? Skin Signs

Skin Color Temperature – “Cold”, “Warm”, “Hot” Moisture – “Dry”, “Moist”, “Diaphoretic”

Expiratory Wheezing

# What phrase or word matches this definition? An upright position in which the patient leans forward onto two arms stretched forward and thrusts the head and chin forward.

Tripod Position

# What phrase or word matches this definition? Respirations characterized by little movement of the chest wall (reduced tidal volume) or poor chest excursion.

Shallow Respirations

# What phrase or word matches this definition? A step within the patient assessment process that involves a quick assessment of the scene and the surroundings to provide information about scene safety and the MOI before beginning patient care.

Scene Size-Up

# What phrase or word matches this definition? The tough, fibrous, white portion of the eye that protects the more delicate inner structures.

Sclera

What should EMTs look for in the physical exam of the upper and lower extremities?

DCARP, BLS, TICS, ROM, CSM, Medical Alert Tags

What should EMTs look for in the physical exam of the back?

DCARP, BLS, TICS

# What phrase or word matches this definition? The deviation from alert and oriented to person, place, time, and event, or any deviation from a patient's normal baseline mental status.

Altered Mental Status

# What phrase or word matches this definition? A rapid heart rate, more than 100 beats/min

Tachycardia

# What phrase or word matches this definition? To listen to sounds within an organ with a stethoscope.

Auscultate

# What phrase or word matches this definition? Breathing that occurs without assistance.

Spontaneous Respirations

What should EMTs look for in the physical exam of the head?

DCARP BLS TICS, Airway Obstruction

# What phrase or word matches this definition? A test that evaluates distal circulatory system function by squeezing (blanching) blood from an area such as a nail bed and watching the speed of its return after releasing the pressure.

Capillary Refill

# What phrase or word matches this definition? A harsh, high-pitched, breath sound, generally heard during inspiration that is caused by partial blockage or narrowing of the upper airway; maybe audible without a stethoscope.

Stridor

# What should be observed and noted on the Patient Care Report? O₂ Saturation

% Saturation

# What phrase or word matches this definition? Objective findings that can be seen, heard, felt, smelled, or measured.

Sign

# What phrase or word matches this definition? Blood pressure that is lower than the normal range.

Hypotension

# What phrase or word matches this definition? A step within the patient assessment process in which a systematic physical examination of the patient is performed. The examination may be a systematic exam or an assessment that focuses on a certain area or region of the body; often determined through the chief complaint.

Secondary Assessment

# What phrase or word matches this definition? What are the components of the secondary assessment?

# What phrase or word matches this definition? Involuntary muscle contractions of the abdominal wall to minimize the pain of abdominal movement; a sign of peritonitis.

Guarding

# What phrase or word matches this definition? A noninvasive method to quickly and efficiently provide information on a patient's ventilatory status, circulation, and metabolism; effectively measures the concentration of carbon dioxide in expired air over time.

Capnography

How often should a stable patient be reassessed?

Every 15 minutes.