Chapter 13 - Patient Assessment Flashcards
Components of primary assessment
Form general impression of pt Assess level of consciousness Assess the airway Assess breathing Assess oxygenation Assess circulation Establish patient priorities
The main purpose of the primary assessment is to:
Identify and manage immediately life threatening conditions to the airway, breathing, oxygenation, or circulation.
Chief complaint
What the patient tells you is wrong with him
Forming general impression:
Estimate pt age Note pt sex Determine trauma/medical Chief complaint Identify and manage immediate life threats
There are two types of trauma:
Blunt and penetrating
Type of force that pierces the skin and body tissues.
Penetrating
Steps of scene size-up:
Standard precautions Scene hazards/scene safety Moi Noi # of patients Need for additional resources
Bringing the patients head into a neutral in-line position and holding it there.
In-line stabilization
In-line stabilization procedure:
Place one hand on each side of the patient’s head.
Gently bring the head into a position in which the nose is in line with the patient’s navel.
Position the head neutrally so the head is not extended (tipped backward) or flexed (tipped forward).
AVPU
Alert
Voice
Pain
Unresponsive
Central painful stimulus:
Trapezius pinch Supraorbital pressure Sternal rub Earlobe pinch Armpit pinch
Peripheral painful stimuli:
Nail bed pressure
Pinch to the web between thumb and index finger
Pinch to the finger, toe, hand or foot
Purposeful movements
Attempts made by the patient to remove the painful stimulus or avoid the pain. Documented as “withdraws the stimulus” or “withdraws from pain”
Nonpurposeful movements:
Flexion posturing and extension posturing. Both signs of a serious head injury.
Flexion posturing
(Decorticate posturing) The patient arches the back and flexes the arms inward toward the chest.
Extension posturing
(Decerebrate posturing) Patient arches back and extends the arms straight out parallel to the body.
Occluded
Closed or blocked
Patent
Open
Sounds that may indicate partial airway obstruction:
Snoring-a rough, snoring-type sound on inspiration and/or exhalation
Gurgling-a sound similar to air rushing through water on inspiration and/or exhalation
Crowing-a sound like a cawing crow on inspiration
Stridor-harsh, high pitched sound on inspiration
Airway sound heard that is an indication that the tongue and likely the epiglottis are partially blocking the airway.
Snoring
Airway sound that is an indication that a liquid substance is in the airway.
Gurgling
High-pitched sounds produced on inspiration. Commonly associated with the swelling or muscle spasms that can result from conditions such as airway infections, allergic reactions, or burns to the upper airway.
Crowing/Stridor
Breathing assessment:
Determine if breathing is adequate or inadequate
Determine the need for early oxygen therapy if breathing is adequate
Provide positive pressure ventilation with supplemental oxygen for inadequate breathing
Amount of air breathed in and out.
Tidal volume