Chapter 10: Patient Assessment Flashcards

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1
Q

Scene Size Up

A

-Ensure safety
-Detemine MOI/NOI
-Take precautions
-# of pts
-Consider additional resources

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2
Q

Primary Assessment

A

-General impressions
-LOC
-Chief complaint (if able)
-ABC
-Primary assessment
-Determine priority

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3
Q

History Taking

A

SAMPLE

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4
Q

Secondary Assessment

A

Focused
-Inspect
-Palpate
-Auscultate

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5
Q

Reassessment

A

-Repeat primary
-Vitals
-Chief complaint
-Recheck interventions
-Identify and treat changes
-Reassess: Stable/ Unstable

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6
Q

Assessment process

A

-Scene size up
-Primary assessment
-History taking
-Secondary assesment
-Reassess

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7
Q

Incident Command System

A

-Multiple pts
-Est command
-Identify # of pts
-Begin triage

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8
Q

General Impression

A

Rapid identifiction of potentially life threatining problems

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9
Q

Assess LOC

A

-AVPU
-GSC

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10
Q

Signs of Respiratory Distress and Failure

A

Distress
-agitation
-stridor
-accessory muscles
-tachypnea
-mild tachicardia
-nasal flaring
Failure
-lethargy
-tachypnea
-inadequate chest rise/fall
-inadequate RR
-bradychardia
-diminshed muscle tone

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11
Q

History Taking Acronyms

A

SAMPLE
OPQRST
-pertinent negatives (reason for not doing something)

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12
Q

Trauma Acronyms

A

DCAP-BTLS

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13
Q

Respiratory Ranges

A

RRQ-Rate rhythm quality
Infant 30-60
Toddler 24-40
Preschoolers 22-34
School aged 18-30
Adolescants 12-16
Adults 12-20

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14
Q

Breath Sounds

A

-Normal
-Snoring: Upper airway obstruction
-Stridor: Neck or upper chest obstruction
-Wheezing: Narrowing in left fields
*wheezing: high pitched
*crackles: wet, crackling (fluid)
*rhonchi: mucus or fluid, experation

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15
Q

Respirations Charactersitics

A

-Normal
-Shallow
-Labored
-Noisy

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16
Q

Pulse Rates

A

Infants (birth-3months) 85-205
Infants and toddlers (3 months-2 years) 100-190
Preschoolers and school aged (2 years-10 years) 60-140
Adults and children (10+) 60-100

17
Q

PPV

A

<8 breaths
>28 breaths

18
Q

Normal BP Ranges

A

Neonate (96 hours) 67-84
Infant (1-12 months) 72-104
Child (2 years) 86-106
Child (7 years) 97-115
Adolescant (15 years) 110-131
Adult 90-120

19
Q

Skin Assessment

A

Normal: Pink, warm, dry
Abnormal: Pale, cool, clammy

20
Q

GSC: Eyes

A

Resonse to:
Spontaneous 4
Sounds 3
Pressure 2
None 1

21
Q

GSC: Verbal

A

Oriented conversation 5
Confused conversation 4
Innapropriate words 3
Incomrehensible sounds 2
None 1

22
Q

GSC: Motor

A

Obeys commands 6
Localizes 5
Withdraws 4
Abnormal flexion 3
Abnormal extension 2
None 0

23
Q

Pupil assessment

A

PEARRL mneumonic

24
Q

Neurovascular Assessment

A

-Pulse
-Cap refill
-Sensation
-Motor function

25
Q

High Priority

A

-Unresponsive
-Altered LOC
-Chest pain
-Pale skin and poor perfusion
-Complicated birth

26
Q

Golden Hour

A

Time from injury to definitive care

27
Q

Platinum 10

A

Initial assessment and intervention

28
Q

Abdominal Assessment

A

TRD-P
-Tenderness
-Rigid
-Distention
-Pulsations

29
Q

Lung sounds

A

Crackl­es/­Rales
-high pitched popping
-low bubbling
-alveoli collapsed or PE
Wheezes
-high pitched sounds (narrowed passageways)
-asthma or COPD
Rhonchi
-low pitched
-continous gurgling
-increased secretions in large airways
Stridor
-intense, high pitched, continous
-airway obstruction