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Emergency Care 13th Edition > Chapter 14: The Secondary Assessment > Flashcards

Chapter 14: The Secondary Assessment Flashcards

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1
Q

Secondary Assessment

A
  • where you find out what is wrong with the pt
  • a series of examinations, both hands on and through pt history
  • performed after the scene size-up and the primary assessment
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2
Q

Medical pt

A

a pt w/ one or more medical diseases or conditions

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3
Q

Trauma pt

A

a pt suffering from one or more physical injuries

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4
Q

Components of the secondary assessment

A

physical examination, patient history, vital signs

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5
Q

Physical examination of the S.A.

A
  • use your sense to exam the pt

- you may feel for injuries, listen for abnormal breathing sounds, and look for swelling

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6
Q

Patient history of the S.A.

A
  • obtained by asking important questions that will provide you with vital info about your pt’s current condition or complaint
  • you find out history of the present illness (HPI) and the past medical history (PMH)
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7
Q

History of the Present Illness (HPI)

A

info gathered regarding the symptoms and nature of the pt’s current concern

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8
Q

Past Medical History (PMH)

A

info. gathered regarding the pt’s health problems in the past

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9
Q

Vital signs of the S.A.

A
  • you will take vital signs such as pulse, respirations, blood pressure, and pulse ox.
  • assess the skin and pupils
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10
Q

When to perform components of the S.A. in medical pts

A
  • history first b/c history provides the most relevant info.

- then perform physical exam based on what you find in the history

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11
Q

When to perform components of the S.A. in trauma pts

A
  • perform the hands on exam first–it provides the most info (you can ask initially if the pt hurts anywhere)
  • in some pts you will do a head to toe exam, in others with minor injuries, you might just palpate one area
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12
Q

When to perform components of the S.A. in unresponsive pts

A
  • get info from family and bystanders when you can

- physical exam will also be a primary source of info

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13
Q

sign

A

something regarding the pt’s conditions that YOU can see

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14
Q

symptom

A

something regarding the pt’s condition that the PT tells you

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15
Q

When to perform components of the S.A. in seriously ill or injured pts

A
  • a serious trauma pt will get a primary assessment and a very quick secondary assessment to check for major injuries before transport.
  • same goes for medical pts; they must be transport promptly to the hospital for lifesaving interventions
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16
Q

Reassessment

A
  • a procedure for detecting changes in a pt’s condition
  • involves 4 steps:
    1. repeating the primary assessment
    2. repeating and recording vital signs
    3. repeating the physical exa,
    4. checking interventions
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17
Q

Open-ended question

A

a question requiring more than just a yes or no

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18
Q

closed-ended question

A

a question requiring only a yes or no answer

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19
Q

SAMPLE

A
  • a memory aid in which the letters stand for elements of the past medical history
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20
Q

S in SAMPLE

A
  • S = signs and symptoms

- What is wrong?

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21
Q

A in SAMPLE

A
  • A = allergies

- Are you allergic to medications or foods, or do you have environmental allergies?

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22
Q

M in SAMPLE

A
  • M = medications

- What meds are you currently taking or are you supposed to be taking?

23
Q

P in SAMPLE

A

P = pertinent past history
Have you been having any medical problems?
Have you had any recent surgeries or injuries?
Have you been seeing a doctor?

24
Q

L in SAMPLE

A

L = last oral intake
When did you last eat or drink?
What did you eat or drink?

25
Q

E in SAMPLE

A

E = events leading to the injury or illness

what sequence of events led up to today’s problem?

26
Q

OPQRST

A

a memory aid in which the letters stand for questions asked to get a description of the present illness

27
Q

O in OPQRST

A

Onset

What were you doing when the pain began?

28
Q

P in OPQRST

A

Provocation

Does anything seem to trigger the pain? Does anything make it feel better?

29
Q

Q in OPQRST

A

Quality

Can you describe the pain?

30
Q

R in OPQRST

A

Region, relief

Where is the pain? Will you please point toward it? Does it seem to shoot or spread anywhere?

31
Q

S in OPQRST

A

Severity

How bad is the pain on a scale of 1-10 with 10 being the worst pain you’ve ever felt.

32
Q

T in OPQRST

A

Time

When did the pain start? Has it changed at all since it started?

33
Q

Physical Exam Techniques

A

Observe, auscultate, palpate

34
Q

Observation

A

looking at the pt for an overall sense of his condition as well as evaluating their chief complaint

35
Q

Auscultation

A

listening for abnormal signs of an abnormal condition; mostly done with a stethoscope

36
Q

Body systems exam: respiratory

A
  • work of breathing and position
  • pedal and sacral edema
  • lung sounds
  • pulse ox
  • respiratory specific history
  • dyspnea on exertion
  • orthopnea
  • weight gain
37
Q

Body systems exam: cardiovascular

A
  • check pulse (presence/rate/regularity)
  • skin color/temp/condition
  • blood pressure
  • orthostatic blood pressure changes
  • JVD
  • many components of the respiratory exam also applies to the cardiovascular exam
38
Q

Body systems exam: neurologic

A
  • cincinnati prehospital scale (or other approved scale)
  • pupils (equality, size, reactivity)
  • monitoring mental status changes over time
39
Q

Body systems exam: endocrine

A
  • blood glucose monitoring
  • skin (color/temp/condition)
  • breath odors
  • excessive hunger, thirst, or urination
  • pupils
  • monitoring mental status changes over time
  • diabetic specific history
  • oral intake
  • medication history/use
  • recent illness
40
Q

Body systems exam: GI/GU

A
  • palpation of abdominal quadrants
  • GI/GU specific history
    • input/output amount and frequency
  • question or observe for bright red or digested blood in vomit, stool, or urine
  • menstrual history and pregnancy where appropriate
41
Q

Jugular vein distention (JVD)

A

bulging of the neck veins

42
Q

crepitation

A

the grating sound or feeling of broken bones rubbing together

43
Q

rapid trauma assessment

A

a rapid assessment of the head, neck, chest, abdomen, pelvis, extremities, and posterior of the body to detect signs and symptoms of injury

44
Q

stoma

A

a permanent surgical opening in the neck through which the pt breathes

45
Q

tracheostomy

A

a surgical incision help open by a metal or plastic tibe

46
Q

paradoxical

A

movement of a part of the chest in the opposite direction to the rest of the chest during respiration

47
Q

distention

A

a condition of being stretched, inflated, or larger than normal

48
Q

priapism

A

persistent erection of the penis that may result from spinal injury and some medical problems

49
Q

detailed physical exam

A
  • an assessment of the head, neck, chest, abdomen, pelvis, extremities, and posterior of the body to detect signs and symptoms of injury
  • it differs from the rapid trauma assessment only in that it also includes examination of the face, ears, eyes, nose, and mouth during the examination of the head
50
Q

trending

A

changes in a pt’s condition over time, such as slowing respirations or rising pulse rate, that may show improvement

51
Q

diagnosis

A

a description or label for a pt’s condition that assists a clinician in further evaluation and treatment

52
Q

differential diagnosis

A

a list of potential diagnoses compiled early in the assessment of the pt

53
Q

How an EMT can learn to think like an experienced physician

A
  • learn to love ambiguity
  • understand the limitations of technology and people
  • realize that no one strategy works for everything
  • form a strong foundation of knowledge
  • organize the date in your head
  • change the way you think
  • learn from others
  • reflect on what you have learned

Emergency Care 13th Edition (27 decks)

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