Chapter 10: Patient Assessment Flashcards
Knowledge and understanding of one’s surroundings and the ability to recognize potential risks to the safety of the patient or EMS team.
situational awareness
The tough, fibrous, white portion of the eye that protects the more delicate inner structures.
sclera
An upright position in which the patient’s head and chin are thrust slightly forward to keep the airway open.
sniffing position
The delicate membrane that lines the eyelids and covers the exposed surface of the eye.
conjunctiva
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.
stridor
Subjective findings that the patient feels but that can be identified only by the patient.
symptom
Blood pressure that is higher than the normal range.
hypertension
A noninvasive method to quickly and efficient provide information on a patient’s ventilatory status, circulation, and metabolism; effectively measures the concentration of carbon dioxide in expired air over time.
capnography
A mnemonic for assessment in which each area of the body is evaluated for Deformities, Contusions, Abrasions, Puntures/penetrations, Burns, Tenderness, Lacerations, and Swelling.
DCAP-BTLS
A component of air that typically makes up 0.03% of air at sea level; also a waste product exhaled during expiration by the respiratory system.
carbon dioxide
Protective measures that have traditionally been developed by the Centers for Disease Control and Prevention (CDC) for use in dealing with objects, blood, body fluids, and other potential exposure risks of communicable disease.
standard precautions
The increased pressure in an artery with each contraction of the ventricles (systole).
systolic pressure
Movements in which the skin pulls in around the ring during inspiration.
retractions
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. A patient in unstable condition should be reassessed every 5 minutes, whereas a patient in stable condition should be reassessed every 15 minutes.
reassessment
The biochemical processes that result in production of energy from nutrients within the cells; also called cellular respiration.
metabolism
Respirations characterized by little movement of the chest wall (reduced tidal volume) or poor chest excursion.
shallow respirations
A mnemonic used in evaluating a patient’s pain: Onset, Provocation/palliation, Quality, Region/radiation, Severity, and Timing.
OPQRST
A step within the patient assessment process in which a systemic physical examination of the patient is performed. The examination may be a systemic exam or an assessment that focuses on a certain area or region of the body, often determined through the chief complaint.
secondary assessment
To examine by touch
palpate
A type of physical assessment typically performed on patients who have sustained no significant mechanisms of injury or on responsive medical patients. This type of examination is based on the chief complaint and focuses on one body system or part.
focused assessment
The mental status of a patient as measured by memory of person (name), place (current location), time (current year, month, and approximate date), and event (what happened).
orientation
Negative findings that warrant no care or intervention.
pertinent negatives
A slow heart rate, less than 60 beats/min.
bradycardia
The amount of air (in milliliters) that is moved into or out of the lungs during one breath.
tidal volume
Breathing that occurs without assistance.
spontaneous respirations
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 mechanism of injury or nature of illness before you enter and begin patient care.
scene size-up
Objective finding that can be seen, heard, felt, smelled, or measured.
sign
An upright position in which the patient leans forward onto two arms stretched forward and thrusts the head and chin forward.
tripod position
A brief history of a patient’s condition to determine signs and symptoms, allergies, medications, pertinent past history, last oral intake, and events leading to the injury or illness.
SAMPLE history
Yellow skin or sclera that is caused by liver disease or dysfunction.
jaundice
A step within the patient assessment process that identifies and initiates treatment of immediate and potential life threats.
primary assessment
Involuntary muscle contractions (spasm) of the abdominal wall to minimize the pain of abdominal movement, a sign of peritonitis.
guarding
The flow of blood through body tissues and vessels.
perfusion
The process of establishing treatment and transportation priorities according to severity of injury and medical need.
triage
crackling, rattling breath sounds that signal fluid in the air spaces of the lungs.
crackles
A change in the way a person thinks and behaves that may signal disease in the central nervous system or elsewhere in the body.
altered mental status
A heating or grinding sensation or sound caused by fractured bone ends or joints rubbing together.
crepitus
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.
Golden Hour
Narrowing of a blood vessel
vasoconstriction
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
An assessment tool that measures oxygen saturation of hemoglobin in the capillary beds.
pulse oximetry
A blue skin discoloration that caused by a reduced level of oxygen in the blood. Although paleness, or a decrease in blood flow, can be difficult to detect in dark-skinned people, it may be observed by examining mucous membranes inside the inner lower eyelid and capillary refill. On general observation, the patient may appear ashen or gray.
cyanosis
The wave of pressure created as the heart contracts and forced blood out the left ventricle and into the major arteries.
pulse
The conclusion about the cause of the patient’s condition after considering the situation, history, and examination findings.
field impression
Coarse, low pitched breath sounds heard in patients with chronic mucus in the upper airways.
rhonchi
The key signs that are used to evaluate the patients overall condition, including respirations, pulse, blood pressure, level of consciousness, and skin characteristics.
vital signs
A condition in which the internal body temperature falls below 95 degrees F (35 degrees C)
hypothermia
The overall initial 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
Characterized by light or profuse sweating.
diaphoretic
A characteristic cracking sensation felt on palpation of the skin, caused by the presence of air in soft tissues.
subcutaneous emphysema
A severe breathing problem in which a patient can speak only two to three words at a time without pausing to take a breath.
two-to three-word dyspnea
Protective equipment that blocks exposure to a pathogen or a hazardous material
personal protective equipment
The reason a patient called for help; also, the patient’s response to questions such as “What’s wrong?” or “What happened?”
chief complaint
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
The way which a patient responds to external stimuli, including verbal stimuli (sound), tactile stimuli (touch), and painful stimuli.
responsiveness
Any injury that prevents the patient from noticing other injuries her or she may have, even severe injuries; for example, a painful femur or tibia fracture that prevents the patient from noticing back pain associated with a spinal fracture.$
distracting injury
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
The general type of illness a patient is experiencing.
nature of illness
An indication of air movement in the lungs, usually assessed with a stethoscope.
breath sounds
Blood pressure that is lower than the normal range.
hypotension
Damage to tissues as the result of exposure to cold; frozen or partially frozen body parts are frostbitten.
frostbite
To listen to sounds within an organ with a stethoscope.
auscultate
The pressure that the blood experts against the walls of the arteries as it passes through them.
blood pressure
A grating or grinding sensation or sound caused by fractured bone ends or joints rubbing together.
crepitus
The average pressure in the circulatory system during one cardiac cycle.
mean arterial pressure
The use of muscles of the chest, back, and abdomen to assist in expanding the chest; occurs when air movement is impaired.
labored breathing
A step within the patient assessment process that provides details about the patient’s chief complaint and an account of the patient’s signs and symptoms.
history taking
Widening of the nostrils, indicating that there is an airway obstruction
nasal flaring
A high-pitched, whistling breath sound that is most prominent on expiration, and which suggests an obstruction or narrowing of the lower airways; occurs is asthma and bronchiolitis
wheezing
The secondary muscles of respiration. They include the neck muscles (sternocleidomastoids), the chest pectoralis major muscles, and the abdominal muscles.
accessory muscles
A rapid heart rate, more than
100 beats/min.
tachycardia
The forces, or energy transmission, applied to the body that cause injury.
mechanism of injury
A system implemented to manage disasters and mass casualty incidents in which section chiefs, including finance/administration, logistics, operations, and planning, report to the incident commander.
incident command system
The motion of the portion 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
