Chapter 8 - Patient Assessment Flashcards
Elements of Assessment Process (5)
- Scene size-up
- Primary assessment
- History taking
- Secondary assessment
- Reassessment
How a traumatic injury occurred.
Mechanism of Injury (MOI)
Force of injury occurs over a broad area.
Blunt trauma
Skin usually not broken.
Tissues and organs below area of impact may be damaged.
Force of injury occurs at a small point of contact.
Penetrating trauma
Object pierces skin and creates open wound.
High potential for infection.
Severity of injury depends on characteristics of penetrating object, amount of force, part of the body affected.
General type of illness a patient is experiencing.
Nature of illness (NOI)
Chief complaint.
Look for clues.
Talk with patient and others at scene.
When you observe more than one patient at a scene…..
Utilize Incident Command System
Call for additional units.
Perform triage.
Sorting patients on the severity of each patient’s condition.
Triage
Identify and initiate treatment of immediate or potential life threats.
Primary Assessment
Form a general impression.
Assess level of consciousness.
Assess the airway; identify and treat life threats.
Assess breathing; identify and treat life threats.
Assess circulation; identify and treat life threats
Perform rapid scan.
Determine priority of care and transport.
Key signs to identify a patient’s condition.
Vital signs
Level of consciousness.
Airway, breathing, and circulation (ABCs)
Causes of altered level of consciousness in a conscious patient.
Altered LOC caused by: Altered organ perfusion Medications Drugs Alcohol Poison
How to assess responsiveness (consciousness)?
AVPU Patient is Alert Patient responds to Verbal commands Patient responds to Painful stimuli Patient is Unresponsive
How to evaluate mental status in a responsive patient?
Person - patient remembers own name.
Place - patient is able to identify current location.
Time - patient knows current year, month, and approximate day.
Event - patient can describe event (MOI or NOI)
What is Glasgow Coma Scale?
Eye opening (spontaneous 4; speech 3; pain 2; none 1) Verbal response (oriented 5; confused 4; inappropriate 3; incomprehensible 2; none 1) Motor response (obeys 6; localizes pain 5; withdraws to pain 4; abnormal flexion 3; abnormal extension 2; none 1) 13-15 mild dysfunction 9-12 moderate dysfunction 8 or less Severe dysfunction
A useful guide in assessing pupils.
PEARRL P - pupils E - equal A - and R- round R - regular in size L - react to light
Signs of airway obstruction in an unconscious patient?
Obvious trauma, blood or other obstruction.
Noisy breathing; snoring, bubbling, gurgling, crowing.
Extremely shallow breathing.
If any apply, open the airway with appropriate head tilt-chin lift or jaw-thrust maneuver, suction as necessary.
Breathing without assistance?
Spontaneous respirations
Includes inspiration and expiration. 1 to 3 timing ratio.
Watch chest move, feel breath on exhalation, listen to breath sounds.
What information do you need to assess breathing. (4)
Respiratory rate
Rhythm, regular or irregular
Quality/characteristics of breathing
Depth of breathing
Normal respiration rates? (3)
Adults and adolescents - 12 to 20
Children (6 to 12 years) - 15 to 30
Infants - 25 to 50
Auscultation
Hear breath sounds better from back.
Auscultate apices (upper), bases (lower), midclavicular and midaxillary (over major airways).
Lift clothing and place stethoscope firmly.
Breath sounds? (5)
Normal - clear and quiet
Wheezing - high pitched whistling sound; lower obstruction.
Rales - moist crackling sound; cardiac failure.
Rhonchi - congested sound, most prominent on expiration; mucus in the lungs.
Stridor - brassy, crowing sound; neck or upper airway.
Presence of indentations above the clavicle and in spaces between the ribs?
Retractions or use of accessory muscles is a sign of inadequate breathing.
Also nasal flaring.
Two- to three-word dyspnea.
Tripod position and labored breathing.
Secondary muscles of respiration?
Accessory muscles
Neck muscles (sternocleidomastoids)
Chest pectoralis muscles
Abdominal muscles
Test to evaluate distal circulatory system function?
Capillary refill
Squeeze blood from an area (nail bed or skin), evaluate rate of return of color.
2 seconds is normal.
A noninvasive method that can provide information on a patient’s ventilation status, circulation, and metabolism.
Capnography
Measures amount of expired carbon dioxide.
Normal range 35 - 45 mm Hg (5% - 6% CO2)
Secondary tool to determine accurate placement of endotracheal intubation or effectiveness of ongoing CPR.
2% or greater indicates adequate circulation.
What is capnometry?
Use of a capnometer to determine end-tidal carbon dioxide.
A colorimetric device that uses colors to provide qualitative measurements.
What is the membrane that lines the eyelids?
Conjunctiva
A grinding sensation caused by fractured bone ends or joints rubbing together?
Crepitus
Blue or grey skin color caused by reduced oxygen in blood?
Cyanosis
DCAP-BTLS assessments?
Deformities
Contusions
Abrasions
Punctures/Penetrations
Burns
Tenderness
Lacerations
Swelling
Physical assessment performed on patients who have sustained non-significant mechanisms of injury?
Focused assessment
A systematic head to toe examination performed during second assessment?
Full-body scan
Time from injury to definitive care?
Golden Period
60 minutes or less for discovery, activation of EMS, initial assessment/intervention/packaging (Platinum Ten Minutes), EMS transport/initial hospital stabilization.
Involuntary muscle contractions (spasms) of abdominal wall?
Guarding
Effort to protect an inflamed abdomen.
Sign of peritonitis.
Key terms in evaluating a patient’s pain?
OPQRST Onset Provocation/Palliation Quality Region Severity Timing of pain
What is paradoxical motion?
Motion of chest wall section that is detached; in during inhalation and out during exhalation.
Pertinent negatives?
Negative findings that warrant no care or intervention.
Step within patient assessment to identify and initiate treatment of immediate and potential life threats?
Primary assessment
The white portion of the eye?
Sclera
Tough outer coat.
An indication of fracture of middle cranial fossa of the skull, and may suggest underlying brain trauma.
Battle’s sign, also mastoid ecchymosis, is an indication of fracture of middle cranial fossa of the skull, and may suggest underlying brain trauma. Battle’s sign consists of bruising over the mastoid process, as a result of extravasation of blood along the path of the posterior auricular artery.
Another common bruising sign of a skull injury is raccoon eyes, the purplish discoloration around the eyes following fracture of the frontal portion of the skull base.
Battle’s sign may be confused with a spreading hematoma from a fracture of the mandibular condyle, which is a less serious injury.
Associated symptoms.
Patient complaints in addition to the chief complaint.
Pertinent negatives
Signs or symptoms that you expect, but are denied by the patient.
