chapter 10 - pt assessment Flashcards
The mental status of a patient as measured by memory of person, place, time, and event
Orientation
The process of establishing treatment and transportation priorities according to severity of injury and medical need
triage
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
stridor
An assessment tool that measures oxygen saturation of hemoglobin in the capillary beds
pulse oximetry
The wave of pressure created as the heart contracts and forces blood out of the left ventricle and into the major arteries
pulse
A mnemonic used in evaluating a patients pain: Onset, Provocation/palliation, quality, region/radiation, severity and timing
OPQRST
To listen to sounds within an organ with a stethoscope
Auscultate
The tough, fibrous, white portion of the eye that protects the more delicate inner structures
Sclera
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 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
A grating or grinding sensation or sound caused by fractured bone ends or joints rubbing together
Crepitus
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
The motion of the portion of the chest wall that is detached in a flail chest
paradoxical motion
Respirations characterized by little movement of the chest wall (reduced tidal volume) or poor chest excursion
shallow respirations
An upright position in which the patient leans forward onto two arms stretched forward and thrusts the head and chin forward
tripod position
The average pressure in the circulatory system during one cardiac cycle
mean arterial pressure
Negative findings that warrant no care or intervention
pertinent negatives
Objective finding that can be seen, heard, felt, smelled or measured
sign
A high-pitched, whistling breath sound that is most prominent on expiration, and which suggests an obstruction or narrowing of the lower airways
wheezing
The time from injury to definitive care, during which treatment of shock and traumatic injuries should occur because survival potential is best
Golden Hour
Subjective findings that the patient feels but that can be identified only by the patient
symptom
The amount of air (in milliliters) that is moved into or out of the lungs during one breath
tidal volume
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
A step within the patient assessment process that involves a quick assessment of the scene and the surroundings to provide info about scene safety and the MOI / NOI before you enter and begin patient care
scene size-up
The flow of blood through body tissues and vessels
perfusion
Yellow skin or sclera that is caused by liver disease or dysfunction
jaundice
The reason a patient called for help
chief complaint
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 disease
standard precautions
A noninvasive method to quickly and efficiently provide info on a patient’s ventilatory status, circulation, and metabolism
capnography
The biochemical processes that result in production of energy from nutrients within the cells; also called cellular respiration
metabolism
Damage to tissues as the result of exposure to cold
frostbite
Blood pressure that is higher than the normal range
hypertension
Widening of the nostrils, indicating there is an airway obstruction
nasal flaring
A test that evaluates distal circulatory system function by squeezing blood from an area such as a nail bed and watching the speed of its return after releasing the pressure
capillary refill
The secondary muscles of respiration
accessory muscles
Involuntary muscle contractions of the abdominal wall to minimize the pain of abdominal movement
guarding
A step within the patient assessment process in which a systematic physical examination of the patient is performed
secondary assessment
Narrowing of a blood vessel
vasoconstriction
A slow heart rate, less than 60 bpm
bradycardia
To examine by touch
palpate
An upright position in which the patient’s head and chin are thrust slightly forward to keep the airway open
sniffing position
A blue skin discoloration that is caused by a reduced level of oxygen in the blood
cyanosis
A type of physical assessment typically performed on patients who have sustained nonsignificant mechanisms of injury or on responsive medical patients
focused assessment
Characterized by light or profuse sweating
diaphoretic
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 patient’s overall condition, including respirations, pulse, blood pressure, level of consciousness, and skin characteristics
vital signs
The way in which a patient responds to external stimuli, including verbal stimuli (sound), tactile stimuli (touch) and painful stimuli
responsiveness
A condition in which the internal body temperature falls below 95 degrees F
hypothermia
A step within the patient assessment process that identifies and initiates treatment of immediate and potential life threats
primary assessment
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
A characteristic crackling sensation felt on palpation of the skin, caused by the presence of air in soft tissues
subcutaneous emphysema
A mnemonic for assessment in which each area of the body is evaluated for Deformities, Contusions, Abrasions, Punctures/penetrations, Burns, Tenderness, Lacerations, and Swelling
DCAP-BTLS
The increased pressure in an artery with each contraction of the ventricles (systole)
Systolic pressure
A system implemented to manage disasters and mass-casualty incidents in which section chiefs, including finance/adminstration, logistics, operations, and planning, report to the incident commander
incident command system
Blood pressure that is lower than the normal range
hypotension
The pressure that the blood exerts against the walls of the arteries as it passes through them
blood pressure
The conclusion about the cause of the patient’s condition after considering the situation, history, and examination findings
field impression
Breathing that occurs without assistance
Spontaneous respirations
The general type of illness a patient is experiencing
nature of illness
Crackling, rattling breath sounds that signal fluid in the air spaces of the lungs
crackles
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
The forces, or energy transmission, applied to the body that causes injury
mechanism of injury
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
An indication of air movement in the lungs, usually assessed with a stethoscope
breath sounds
Protective equipment that blocks exposure to a pathogen or a hazardous material
personal protective equipment
An injury that prevents the patient from noticing other injuries he or she may have, even severe injuries
distracting injury
The overall initial impression that determines the priority for patient care
general impression
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 level
carbon dioxide
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 method of assessing the level of consciousness by determining whether the patient is awake and alert, responsive to verbal stimuli or pain, or unresponsive
AVPU scale
A rapid heart rate, more than 100bpm
tachycardia
Movements in which the skin pulls in around the ribs during inspiration
retractions
