Chapter 7 - Patient Assessment Flashcards
Patient Assessment Skills and Knowledge
AVPU
Determines Level of Responsiveness A - Alert V - Verbal P - Pain U - Unresponsive
ABCD
4 Parameters of the Primary Assessment A - Airway B - Breathing C - Circulation D - Disability
Normal pulse for an adult
60-100 bpm
Normal pulse for a child
80 - 100 bpm
Normal pulse for an infant
100 - 120 bpm
Normal adult respirations
12-20
Normal child respirations
15-30
Normal infant respirations
25-50
Normal adult Bp
90-140 / 60-90
Normal Child Bp
80-100 / 60-90
Normal Infant Bp
75-95 / 60-90
Normal Temperature
97.0 F to 100.4 F
What is decorticate posturing and what does it indicate?
Abnormal flexing
Nerve pathway injury between brain and spinal cord.
What is decerebrate posturing and what does it indicate?
Abnormal extension
Injury to the brain at the level of the brainstem.
What is paresthesia?
“pins and needles” feeling
What is paralysis?
Loss or impairment of motor function.
What is hypoxia?
a reduction in O2 supply to a tissue
MOI
Mechanism of Injury
NOI
Nature of Illness
Under normal circumstances how long should capillary refill take?
2 Seconds
When determining LOR what does AAO X 4 mean?
Awake, alert, and oriented to person, place, time and situation.
When determining LOR what 4 questions should be asked?
- Name
- Location
- Time of day
- What happened
What are the three components of the Glasgow Coma Scale?
- Eye response
- Verbal response
- motor response
What is SAMPLE used for and what does it stand for?
Medical History S - Signs and symptoms A - Allergies M - Medications P - Pertinent past medical history L - Last oral intake E - Events leading to incident
What is OPQRST used to assess and what does it stand for?
Pain Assessment O - Onset P - Provocation and palliation Q - Quality R - Radiation S - Severity T - Time
What is a sign?
An objective finding that can be seen, heard, smelled or measured.
What is a symptom?
A subjective finding that the patient tells you.
What is a distracting injury?
Any injury that directs the patient’s attention away from the exam.
What is DCAP-BTLS used to assess and what does it stand for?
Trauma D - Deformity C - Contusions A - Abrasions/avulsions P - Punctures/penetrations B - Burns/bleeding/bruises T - Tenderness L - Lacerations S - Swelling
What is PERRL used to assess and what does it stand for?
Eyes P - Pupils are E - Equal R - Round R - Reactive to L - Light
How should you examine the pelvis?
Gently squeeze the “hip” bones inward, only once.
What does LOR stand for?
Level of Responsiveness
What are the three sections of a Patient Assessment (according to the Skill Guide)
- Scene Size-up
- Primary Assessment
- Secondary Assessment
What are the steps of the Scene Size-up (according to the Skill Guide)?
- Determine scene is safe.
- Introduce yourself and obtain permission to examine and treat.
- Initiate standard precautions.
- Determine MOI and/or NOI and Chief Complaint.
- Identify number of patients and LOR of each.
- Form general impression - evaluate extrication issues - C-spine considerations.
What are the steps of the Primary Assessment (according to the Skill Guide)?
- ABCDs
- Provide Airway/breathing interventions
- Check for and control major breathings
- Confirm and monitor LOR
- Call for transport, equipment, help
What is PERRL used to assess and what does it stand for?
Eyes P - Pupils are E - Equal R - Round R - Reactive to L - Light
How should you examine the pelvis?
Gently squeeze the “hip” bones inward, only once.
What does LOR stand for?
Level of Responsiveness
What are the three sections of a Patient Assessment (according to the Skill Guide)
- Scene Size-up
- Primary Assessment
- Secondary Assessment
What are the steps of the Scene Size-up (according to the Skill Guide)?
- Determine scene is safe.
- Introduce yourself and obtain permission to examine and treat.
- Initiate standard precautions.
- Determine MOI and/or NOI and Chief Complaint.
- Identify number of patients and LOR of each.
- Form general impression - evaluate extrication issues - C-spine considerations.
What are the steps of the Primary Assessment (according to the Skill Guide)?
- ABCDs
- Provide Airway/breathing interventions
- Check for and control major breathings
- Confirm and monitor LOR
- Call for transport, equipment, help
What are the steps of the Secondary Assessment (according to the Skill Guide)?
- Perform head-to-toe assessment DCAP-BTLS
- Obtain SAMPLE history
- Obtain baseline vitals
- Provide interventions
- Treat for Shock
- Maintain spinal immobilization if needed
- Prepare for transport
- Reassess vitals and primary assessment
