Chapter 8 Patient Assessment Flashcards
A high pitched noise heard primarily on inspiration.
stridor
Coarse, low-pitched breath sounds heard in patients with chronic mucus in the upper airways.
rhonchi
A rapid heart rate, more than 100 beats/min.
tachycardia
A condition in which the internal body temperature falls below 95° F (35° C), usually as a result of prolonged exposure to cool or freezing temperatures.
hypothermia
A sever breathing problem in which a patient can speak only two or three words at a time without pausing to take a breath.
two-to-three word dyspnea
An assessment tool that measures oxygen saturation of hemoglobin in the capillary beds.
pulse oximetry
To examine by touch.
palpate
Protective measures that have traditionally been developed by the Centers for Disease Control and Prevention for use in dealing with objects, blood, bodily fluids, and other potential exposure risks of communicable disease.
standard precautions
A step within the patient assessment process that is performed at regular intervals to identify and treat changes in a patient’s condition.
reassessment
An upright position in which the patient leans forward onto two arms stretched forward and thrusts the head and chin forward.
tripod position
Circulation of blood within an organ or tissue in adequate amounts to meet the current needs of the cells.
perfusion
The pressure wave that occurs as each heartbeat causes a surge in the blood circulating through the arteries.
pulse
Narrowing of a blood vessel, such as with hypofusion or cold extremities.
vasoconstriction
The delicate membrane that lines the eyelids and covers the exposed surface of the eye.
conjunctiva
An indication of air movement in the lungs, usually assessed with a stethoscope.
breath sounds
The process of sorting patients based on the severity of injury and medical need to establish treatment and transportation priorities.
triage
A test that evaluates distal circulatory system function by squeezing (blanching) blood from an area such as a nail bed and watching the speed of its return after releasing the pressure.
capillary refill
A method of assessing the level of consciousness by determining whether the patient is awake and alert, responsive to verbal stimuli or pain, or unresponsive; used principally early in the assessment process.
AVPU scale
Blood pressure that is lower than the normal range.
hypotension
A step within the patient assessment process that provides detail about the patient’s chief complaint and an account of the patient’s signs and symptoms.
history taking
Involuntary muscle contractions (spasms) of the abdominal wall in an effort to protect an inflamed abdomen; a sign of peritonitis.
guarding
The pressure that remains in the arteries during the relaxing phase of the heart’s cycle when the left ventricle is at rest.
diastolic presssure
A grating or grinding sensation caused by fractured bond ends or joints rubbing together; also air bubbles under the skin that produce a crackling sound or crinkly feeling.
crepitus
The way in which a patient responds to external stimuli, including verbal stimuli (sound), tactile stimuli (touch), and painful stimuli.
responsiveness
A slow heart rate, less than 60 beats/min.
bradycardia
Blood pressure that is higher than the normal range.
hypertension
A systematic head-to-toe examination that is performed during the secondary assessment on a patient who has sustained a significant mechanism of injury, is unconscious, or is in critical condition.
full-body scan
Movements in which the skin pulls in around the ribs during inspiration.
retractions
The time from injury to definitive care, during which treatment of shock and traumatic injuries should occur because survival potential is best.
Golden period
The tough fibrous, white portion of the eye that protects the more delicate inner structures.
sclera
Damage to tissues as the result of exposure to cold; frozen or partially frozen body parts.
frostbite
The pressure of circulating blood against the walls of the arteries.
blood pressure
A bluish gray skin color that is caused by a reduced level of oxygen in the blood.
cyanosis
The secondary muscles of respiration. They include the neck muscles (sternocleidomastoids), the chest pectoralis major muscles, and the abdominal muscles.
accessory muscles
Characterized by profuse sweating.
diaphoretic
The increased pressure in an artery with each contraction of the ventricles.
systolic pressure
To listen to sounds within an organ with a stethoscope.
auscultate
The key signs that are used to evaluate the patient’s overall condition, including respirations, pulse, blood pressure, level of consciousness, and skin characteristics.
vital signs
The mental status of a patient as measured by memory of person (name), place (current location), time (current year, month, and approximate date), and event (what happened).
orientation
An upright position in which the patient’s head and chin are thrust slightly forward to keep the airway open.
sniffing position
The amount of air (in milliliters) that is moved in or out of the lungs during one breath.
tidal volume
The overall initial impression that determines the priority for patient care; based on the patient’s surroundings, the mechanism of injury, signs and symptoms, and the chief complaint.
general impression
Respirations that are characterized by little movement of the chest wall (reduced tidal volume) or poor chest excursion.
shallow respirations
Subjective findings that the patient feels but that can be identified only by the patient.
symptom
Breathing that occurs with no assistance.
spontaneous respirations
The motion of the portion of the chest wall that is detached in a flail chest; the motion (in during inhalation, out during exhalation) is exactly the opposite of normal chest wall motion during breathing. (2 words)
paradoxical motion
Clothing or specialized equipment that provides protection to the wearer.
personal protective equipment (PPE)
Capnometer or end-tidal carbon dioxide detectors are devices that use a chemical reaction to detect the amount of carbon dioxide present in expired gases by changing colors (qualitative measurement rather than quantitative measurement).
colorimetric devices
Objective findings that can be seen, heard, felt, smelled, or measured.
signs
A crackling, rattling breath sound that signals fluid in the air spaces of the lungs; also called crackles.
rales
A step within the patient assessment process that identifies and initiates treatment of immediate and potential life threats.
primary assessment
Negative findings that warrant no care or intervention.
pertinent negatives
GCS
Glasgow Coma Scale score: An evaluation tool used to determine level of consciousness, which evaluates and assigns point values (scores) for eye opening, verbal response, and motor response, which are then totaled; effective in helping predict patient outcomes.
SAMPLE history
A brief history of a patient’s condition to determine:
S.igns and symptoms and social behavior A.llergies M.edications P.ertinent past history L.ast oral intake E.vents leading to the injury or illnesses
OPQRSTU
An abbreviation for key terms used in evaluating a patient’s pain:
O.nset P.rovocation or Palliation Q.uality R.egion/Radiation S.everity T.iming of pain U.nderstanding (has this ever happened to you before? Do you understand what's happening to you?)
DCAP-BTLS
A mnemonic for assessment in which each area of the body is evaluated for:
D.eformities C.ontusions A.brasions P.unctures/penetrations B.urns T.enderness L.acerations S.welling
PEARRL
P.upils E.qual A.nd R.ound R.egular in size L.ight (reactive to)
Eye Opening: GCS score assignment for spontaneous eye opening
4
Eye Opening: GCS score assignment for eye opening in response to speech
3
Eye Opening: GCS score assignment for eye opening in response to pain
2
Eye Opening: GCS score assignment for failure to open eyes in response to stimuli
1
Best verbal response: GCS score assignment for oriented conversation
5
Best verbal response: GCS score assignment for confused conversation
4
Best verbal response: GCS score assignment for inappropriate words
3
Best verbal response: GCS score assignment for incomprehensible sounds
2
Best verbal response: GCS score assignment for no verbal response
1
Best Motor Response: GCS score assignment for ability to obey commands
6
Best Motor Response: GCS score assignment for “localizes pain”
5
Best Motor Response: GCS score assignment for “withdraws to pain”
4
Best Motor Response: GCS score assignment for “abnormal flexion”
3
Best Motor Response: GCS score assignment for “abnormal extension”
2
Best Motor Response: GCS score assignment for no motor response
1
Define: accessory muscles
The secondary muscles of respiration. They include the neck muscles (sternocleidomastoids), the chest pectoralis major muscles, and the abdominal muscles.
Define: auscultate
To listen to sounds within an organ with a stethoscope.
Define: AVPU scale
A method of assessing the level of consciousness by determining whether the patient is awake and alert, responsive to verbal stimuli or pain, or unresponsive; used principally early in the assessment process.
Define: blood pressure
The pressure of circulating blood against the walls of the arteries.
Define: bradycardia
A slow heart rate, less than 60 beats/min.
Define: breath sounds
An indication of air movement in the lungs, usually assessed with a stethoscope.
Define: capillary refill
A test that evaluates distal circulatory system function by squeezing (blanching) blood from an area such as a nail bed and watching the speed of its return after releasing the pressure.
Define: capnography
A noninvasive method that can quickly and efficiently provide information on a patient’s ventilatory status, circulation, and metabolism.
Define: capnometry
The use of a capnometer, a device that measures the amount of expired carbon dioxide.
Define: carbon dioxide
Carbon dioxide is a component of air and typically makes up 0.3% of air at sea level. It is also a waste product exhaled during expiration by the respiratory system.
Define: chief complaint
The reason a patient called for help; also, the patient’s response to questions such as “What’s wrong?” or “What happened?”
Define: coagulate
To form a clot to plug an opening in an injured blood vessel and stop bleeding.
Define: colorimetric devices
Capnometer or end-tidal carbon dioxide detectors are devices that use a chemical reaction to detect the amount of carbon dioxide present in expired gases by changing colors (qualitative measurements rather than quantitative.)
Define: conjunctiva
The delicate membrane that lines the eyelids and covers the exposed surface of the eye.
Define: crepitus
A grating or grinding sensation caused by fractured bond ends or joints rubbing together; also air bubbles under the skin that produce a crackling sound or crinkly feeling.
Define: cyanosis
A bluish gray skin color that is caused by a reduced level of oxygen in the blood.
Define: diaphoretic
Characterized by profuse sweating.
Define: diastolic pressure
The pressure that remains in the arteries during the relaxing phase of the heart’s cycle (diastole) when the left ventricle is at rest.
Define: end tidal CO2
The amount of carbon dioxide present in exhaled breath.
Define: focused assessment
A type of physical assessment that is typically performed on patients who have sustained non-significant MOIs or on responsive medical patients. This type of examination is based on the chief complaint and focuses on one body system or part.
Define: frostbite
Damage to tissues as the result of exposure to cold; frozen or partially frozen body parts are frostbitten.
Define: full-body scan
A systematic head-to-toe examination that is performed during the secondary assessment on a patient who has sustained a significant MOI, is unconscious, or is in critical condition.
Define: general impression
The overall initial impression that determines the priority for patient care; based on the patient’s surroundings, the mechanism of injury, signs and symptoms, and the chief complaint.
Define: Golden Period
The time from injury to definitive care during which treatment of shock and traumatic injuries should occur because survival potential is best.
Define: guarding
Involuntary muscle contractions (spasms) of the abdominal wall in an effort to protect an inflamed abdomen; a sign of peritonitis.
Define: history taking
A step within the patient assessment process that provides detail about the patient’s chief complaint and an account of the patient’s signs and symptoms.
Define: hypertension
Blood pressure that is higher than the normal range.
Define: hypotension
Blood pressure that is lower than the normal range.
Define: hypothermia
A condition in which the internal body temperature falls below 95°F (35°C) after exposure to a cold environment.
Define: Incident Command System
A system implemented to manage disasters and mass- and multi-casualty incidents in which section chiefs, including finance, logistic, operations, and planning, report to the incident commander. Also, referred to as the incident management systems.
Define: jaundice
Yellow skin or sclera that is caused by liver disease or dysfunction.
Define: labored breathing
Breathing that requires visibly increased effort; characterized by grunting, stridor, and use of accessory muscles.
Define: mechanism of injury (MOI)
The way in which traumatic injuries occur; the forces that act on the body to cause damage.
Define: nasal flaring
Flaring out of the nostrils, indicating that there is an airway obstruction.
Define: nature of illness (NOI)
The general type of illness a patient is experiencing
Define: orientation
The mental status of a patient as measured by memory of person (name), place (current location), time (current year, month, and approximate date), and event (what happened).
Define: palpate
To examine by touch
Define: paradoxical motion
The motion of the chest wall section that is detached in a flail chest; the motion is exactly the opposite of normal motion during breathing (ie, in during inhalation, out during exhalation).
Define: perfusion
Circulation of blood within an organ or tissue
Define: personal protective equipment (PPE)
Clothing or specialized equipment that provides protection to the wearer.
Define: pertinent negatives
Negative findings that warrant no care or intervention.
Define: primary assessment
A step within the patient assessment process that identifies and initiates treatment of immediate and potential life threats.
Define: pulse
The pressure wave that occurs as each heartbeat causes a surge in the blood circulating through the arteries.
Define: pulse oximetry
An assessment tool that measures oxygen saturation of hemoglobin in the capillary beds.
Define: rales
A crackling, rattling breath sounds that signals fluid in the air spaces of the lungs; also called crackles.
Define: reassessment
A step within the patent assessment process that is performed at regular intervals during the assessment process. Its purpose is to identify and treat changes in a patient’s condition. A patient in unstable condition should be reassessed every 5 minutes, whereas a patient in stable condition should be reassessed every 15 minutes..
Define: responsiveness
The way in which a patient responds to external stimuli, including verbal stimuli (sound), tactile stimuli (touch), and painful stimuli.
Define: retractions
Movements in which the skin pulls in around the ribs during inspiration.
Define: rhonchi
Coarse, low-pitched breath sounds heard in patients with chronic mucus in the upper airways.
Define: scene size-up
A step within the patient assessment process that involves a quick assessment of the scene and the surroundings to provide information about scene safety and the mechanism of injury or nature of illness before you enter and begin patient care.
Define: sclera
The white portion of the eye; the tough outer coat that gives protection to the delicate, light-sensitive inner layer.
Define: secondary assessment
A step within the patient assessment process in which a systematic physical examination of the patient is performed. The examination may be a systematic full-body scan or a systematic assessment that focuses on a certain area or region of the body, often determined through the chief complaint.
Define: shallow respirations
Respirations that are characterized by little movement of the chest wall (reduced tidal volume) or poor chest excursion.
Define: sign
Objective finding that can be seen, heard, felt, smelled, or measured.
Define: sniffing position
An upright position in which the patient’s head and chin are thrust slightly forward to keep the airway open.
Define: spontaneous respirations
Breathing that occurs with no assistance
Define: standard precautions
Protective measures that have traditionally been developed by the Centers for Disease Control and Prevention for use in dealing objects blood, body fluids, and other potential exposure risks of communicable disease.
Define: stridor
A harsh, high-pitched crowing inspiratory sound, such as the sound often heard in acute laryngeal (upper airway) obstruction; may sound like crowing and be audible without a stethoscope.
Define: subcutaneous emphysema
The presence of air in soft tissues, causing a characteristic crackling sensation on palpation.
Define: symptom
Subjective findings that the patient feels but that can be identified only by the patient.
Define: systolic pressure
The increased pressure in an artery with each contraction of the ventricles (systole).
Define: tachycardia
A rapid heart rate, more than 100 beats/min.
Define: tidal volume
The amount of air (in milliliters) that is moved in or out of the lungs during one breath.
Define: triage
The process of establishing treatment and transportation priorities according to severity of injury and medical need.
Define: tripod position
An upright position in which the patient leans forward onto two arms stretched forward and thrusts the head and chin forward.
Define: two-to-three-word dyspnea
A severe breathing problem in which a patient can speak only two to three words at a time without pausing to take a breath.
Define: vasoconstriction
Narrowing of a blood vessel.
Define: vital signs
The key signs that are used to evaluate the patient’s overall condition, including respirations, pulse, blood pressure, level of consciousness, and skin characteristics.
5 elements of scene size-up
- Ensure scene safety
- Determine MOI/NOI
- Take standard precautions
- Determine number of patients
- Consider additional/specialized resources
7 elements of the 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 patient care and transport
2 elements of history taking
- Investigate the chief complaint (history of present illness)
- Obtain SAMPLE history
2 elements of secondary assessment (for both medical & trauma)
- Assess vital signs using the appropriate monitoring device
- Systematically assess the patient using a full body scan and/or a focused assessment.
6 elements of reassessment
- Repeat the primary assessment
- Reassess vital signs
- Reassess the chief complaint
- Recheck interventions
- Identify and treat changes in the patient’s condition
- Reassess an unstable patient every 5 minutes and a stable patient every 15 minutes.
