Chapter 4 Highlights Flashcards
It is advised in most situations to assess one system ___ and ___the area of complaint
above and below
Based on the regional-interdependence model of musculoskeletal impairments
ABCDE method of quick assessement
(airway, breathing, circulation, disability, exposure)
A common strategy for history taking in the trauma unit
AMPLE: • Allergies • Medications • Past medical history • Last meal • Events of injury
Parts of the assessment of mental status:
3 things
o Level of consciousness
o Orientation
o Ability to communicate
Delirium due to hospitalization=
iatrogenic delirium
the likelihood of delirium associated with hospitalization is much higher with hip fractures and hip and knee joint replacements
Confusion assessment method (CAM)
- Assess hospitalized individuals for delirium
* Just identifies the presence of delirium, not the severity
Is confusion a normal part of the aging process?
- Confusion is not a normal change with aging and must be reported and documented
fruity breath odor→
diabetic ketoacidosis
Paradoxic pulse=
Pulse amplitude that fades with inspiration and strengthens with expiration
Resting pulse pressure consistently greater than 60-80 mmHg is a yellow flag→ risk factor for ________
arterial fibrillation
Excessive morning BP increase is a predictor of stroke in older adults with known hypertension→
red flag sign
most common visceral system causing pruritis.
Hepatic system
ABCDEs to assess a skin lesion for cancer:
A – Asymmetry B – Border (uneven, not round) C – Color (multiple colors) D – Diameter (>1/4 in, pencil eraser) E – Evolving
May be the sign of a silent MI, or may have a known history of MI; common in cardiac care
Splinter hemorrhages
enlargement of one of the supraclavicular lymph nodes in the presence of primary carcinoma of thoracic or abdominal organs→more common on left side
Virchow’s node
Reflexes: DTRs grading system which is similar to pulse grading system
- 0=absent; no response
- 1+=low normal; decreased; slight muscle contraction
- 2+=normal; visible muscle twitch producing movement of arm/leg
- 3+=more brisk than normal, increased or exaggerated; may not indicate disease
- 4+=hyperactive; very brisk; clonus; spinal cord disorder suspected
normal ABI values
(normal=.91-1.3)
Autar scale scoring:
less than 6=no risk, 7-10= low risk (less than 10%), 11-14= moderate risk (11-40%), greater than 15=high risk.
Wells’ scoring(clinical decision rule for DVT): -
-2-0: low probability(3%), 1-2: moderate probability(17%), 3+ high probability(75%)
push on LLQ to stretch peritoneal lining and + if pain felt on RLQ.
Rovsing sign (appendicitis)
