Chapter 10: Patient Assessment Flashcards
What are the indications for spinal immobilization?
What are signs of respiratory distress? Respiratory failure?
table 10-2
What is the DCAP-BTLS mnemonic?
When is it used?
table 10-3
What types of conditions are examples of high-priority pts that should be transported immediately?
Define: accessory muscles
the secondary muscles of respiration. They include the neck muscles (sternocleidomastoids), the chest pectoralis major muscles, and the abdominal muscles
Define: altered mental status
a change in the way a person thinks and behaves that may signal disease in the CNS or elsewhere in the body
Define: auscultate
to listen to sounds within an organ with a stethoscope
Define: AVPU scale
a method of assessing the level of consciousness by determining whether the pt is awake and alert, responsive to verbal stimuli or pain, or unresponsive; used principally in the early assessment process
Define: blood pressure
the pressure that blood exerts against the walls of the arteries as it passes through them
Define: bradycardia
a slow HR, less than 60 beats/min
Define: breath sounds
an indication of air movement in the lungs, usually assessed w a stethoscope
Define: capillary refill
a test that evaluates distal circulatory syste function by squeezing (blanching) blood from an area such as a nail bed and watching the speed of its return after releasing pressure
Define: capnography
a noninvasive method to quickly and efficiently provide information on a pt’s ventilatory status, circulation, and metabolism; effectively measures the concentration of carbon dioxide in expired air over tine
Define: chief complaint
the reason a pt called for help; also, the patient’s response to questions such as “what’s wrong?” or “Whats happened?”
Define: conjunctiva
the delicate membrane that lines the eyelids and covers the exposed surface of the eye
Define: crackles
a crackling, rattling breath sound that signals fluid in the air spaces of the lungs
Define: crepitus
a grating or grinding sensation caused by fractured bone ends or joints rubbing together
Define: cyanosis
a blue skin discoloration that is caused by a reduced level of O2 in the blood
Define: DCAP-BTLS
mnemonic for assessment in which each area of the body is evaluated for:
Deformities
Contusions
Abrasions
Punctures/penetrations
Burns
Tenderness
Lacerations
Swelling
Define: diaphoretic
characterized by light or profuse sweating
Define: diastolic pressure
the pressure that remains in the arteries during the relaxing phase of the heart’s cycle (diastole) when the left ventricle is at rest
Define: distracting injury
any injury that prevents the pt from noticing other injuries he or she may have, even severe injuries; for example, a painful femur or tibia fracture that prevents the pt from noticing back pain associated w a spinal fracture
Define: field impression
the conclusion abt the cause of the pt’s condition after considering the situation, history, and examination findings
Define: focused assessment
a type of physical assessment typically performed on pts who have sustained nonsignificant MOIs or on responsive medical pts. This type of examination is based on the chief complaint and focuses on 1 body system or part
Define: frosbite
damage to tissues that occurs as the result of exposure to cold; frozen or partially frozen body parts are frostbitten
Define: general impression
the overall initial impression that determines the priority for pt care; based on the pt’s surroundings, the MOI, signs and symptoms, and the chief complaint
Define: Golden hour
the time from injury to definitive care, during which treatment of shock and traumatic injuries should occur because survival potential is best; also called the golden period
Define: guarding
involuntary muscle contractions (spasm) of the abdominal wall; an effort to protect the inflamed abdomen
Define: history taking
a step within the pt assessment process that provides detail abt the pt’s chief complain and an account of the pt’s signs and symptoms
Define: hypertension
BP higher than the normal range
Define: hypotensions
BP lower than the normal range
Define: hypothermia
a condition in which the internal body temp falls below 95F (35C)
Define: incident command system
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
Define: jaundice
yellow skin or sclera that is caused by liver disease or dysfunction
Define: labored breathing
breathing that requires greater than normal effort; may be slower or faster than normal and characterized by grunting, stridor, and use of accessory muscles
Define: mean arterial pressure (MAP)
the avg pressure in the circulatory system during one cardiac cycle
Define: mechanism of injury (MOI)
the forces, or energy transmission, applied to the body that cause injury
Define: metabolism
the biochemical processes that result in the production of energy from nutrients within the cells
Define: nasal flaring
widening of the nostrils, indicating that there is an airway obstruction
Define: nature of illness (NOI)
the general type of illness a pt is experiencing
Define: OPQRST
a mnemonic used in evaluating a pt’s pain: Onset, provocation/palliation, quality, region/radiation, severity, and timing
Define: orientation
the mental status of a pt as measured by memory of person (name), place (current location), time (current year, month, and appx date), and event (what happened)
PPTE
The 4 Whats
Define: palpate
to examine by touch
Define: paradoxical motion
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
Define: perfusion
the flow of blood through body tissues and vessels
Define: PPE
protective equipment that blocks exposure to a pathogen or a hazardous material
Define: pertinent negatives
negative findings that warrant no care or intervention
Define: primary assessment
a step within pt assessment that identifies and initiates treatment of immediate and potential life threats
Define: pulse
the wave of pressure created as the heart contracts and forces blood out the left ventricle and into the major arteries
Define: pulse oximetry
an assessment tool that measures oxygen saturation of hemoglobin in the capillary beds
wanna be around 94%
Define: reassessment
a step within the pt assessment process performed at regular intervals durin gthe assessment process to identify and treat changes in a pts condition. A pt in unstable condition should be reassessed every 5 min, whereas a pt in stable condition should be reassessed every 15min
Define: responsiveness
the way in which a pt reacts to external stimuli, including verbal stimula (sound), tactile stimnuli (touch), and painful stimuli
Define: retractions
movements in which the skin pulls in around the ribs during inspiration
Define: rhonchi
coarse, low-pitched breath sounds heard in pts w chronic mucus in the upper airways
Define: SAMPLE history
a brief history of a pts condition to determine:
signs & symptoms
allergies
medications
past pertinent medical history
last oral intake
events leading up to incident
Define: scene sizeup
a step within the pt assessment process that involves a quick assessment of the scene and the surroundings to provide info abt scene safety and the mechanism of injuury or nature of illness before you enter and begin pt care
Define: sclera
the tough, fibrous, white portion of the eye that protects the more delicate inner structures
Define: secondary assessment
a step within pt assessment process in which a systematic physical examination of the pt 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
Define: shallow respirations
respirations characterized by little movement of the chest wall (reduced tidal volume) or poor chest excursion
Define: sign
objective finding that can be seen, heard, felt, smelled, or measured
Define: situational awareness
knowledge and understanding of one’s surroundings and the ability to recognize potential risks to the safety of the pt or EMS team
Define: sniffing positions
an upright position in which the pt’s head and chin are thrust slightly forward to keep the airway open
Define: spontaneous respirations
breathing that occurs without assistance
Define: standard precautions
protective measures that have traditionally been developed by the CDC for use in dealing w objects, blood, bodily fluids, and other potential exposure risks of communicable disease
Define: stridor
a harsh, high-pitched, respiratory sound, generally heard during inspiration, that is caused by partial blockage or narrowing of the upper airway, may be audible without a stethoscope
Define: subcutaneous emphysema
a characteristic crackling sensation felt on palpatation of the skin, caused by presence of air in soft tissues
Define: symptom
subjective findings that the pt feels but that can be identified only by the pt
Define: systolic pressure
the increased pressure in an artery with each contraction of the ventricles (systole)
Define: tachcardia
a rapid HR, more than 100 beats/min
Define: tidal volume
the amount of air (in mL) that is moved into or out of lungs during one breath
Define: triage
the process of establishing treatment and transportation priorities according to severity of injury and medical need
Define: tripod position
an upright position in which the pt leans forward onto 2 arms stretched forward and thrusts the head and chin forward
Define: 2 to 3 word dyspnea
a severe breathing problem in which a pt can speak only 2-3 words at a time without pausing to take a breath
Define: vasoconstriction
narrowing of a blood vessel
Define: vital signs
the key signs used to evaluate the pt’s overall condition, including respirations, pulse, BP, LOC, and skin characteristics
Define: wheezing
a high-pitched, whistling breath sound that is most prominent on expiration, and which suggest an obstruction or narrowing of the lower airways; occurs in asthma and brochiolitis
What does the assessment process begin with?
Scene size up!
