Chapter 9 Patient Assessment Flashcards
What does S.A.M.P.L.E. stand for?
S: signs/symptoms A: allergies M: medications P: pertinent past medical history L: last oral intake E: events leading up to "key events leading up to this" "what were you doing when illness started or injury occurred"
What is the normal pulse rate for an adult?
60-100 bpm
What is the normal pulse rate for preschool and school ages (2-10 years)?
60-140 bpm
What is the normal pulse rate for infants and toddlers (3 months-2 years)?
100-190 bpm
What is the normal pulse rate for infants (new born-3 months)?
85-205 bpm
What is the normal respiration rate for adults?
12-20/min
What is the normal respiration rate for a child?
18-30/min
What is the normal respiration rate for an infant?
30-60/min
A noninvasive method to quickly and efficiently provide information on a patient’s ventilatory status, circulation, and metabolism; effectively measures the concentration of carbon dioxide in expired air over time.
capnography
component of air and typically makes up 0.3% of air at sea level; also a waste products exhaled during expiration by the respiratory system.
carbon dioxide
The reason a patient called for help; also, the patient’s response to questions such as “whats wrong?” or “what happened?”
chief complaint
To form a clot to plug and opening in an injured blood vessel and stop bleeding.
coagulate
The delicate membrane that lines the eyelids and covers the exposed surface of the eye.
conjunctiva
A crackling, rattling breath sound that signals fluid in the air spaces of the lungs.
crackles
A grating or grinding sensation caused by fractured bone ends or joints rubbing together; also air bubbles under the skin that produce a crackling sound or crinkly feeling.
crepitus
A blue-gray skin color that is caused by a reduced level of oxygen in the blood.
cyanosis
a mnemonic for assessment in which each area of the body is evaluated for Deformities, Contusions, Abrasions, Punctures/penetrations, Burns, Tenderness, Lacerations, and Swelling.
DCAP-BTLS
Characterized by light or profuse sweating.
diaphoretic
The pressure that remains in the arteries during the relaxing phase of the heart’s cycle (diastole) when the left ventricle is at rest.
diastolic pressure
Any injury that prevents the patient from noticing other injuries he or she may have, even severe injuries; for example, a painful femur or tibia fracture that prevents the patient from noticing back pain associated with a spinal fracture.
distracting injury
A type of physical assessment typically performed on patients who have sustained nonsignificant mechanisms of injury or on responsive medical patients. This type of examination is based on the chief complaint and focuses on one body system or part.
focused assessment
Damage to tissues as the result of exposure to cold; frozen or partially frozen body parts
frostbite
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
The time from injury to definitive care, during which treatment of shock and traumatic injuries should occur because survival potential is best; also called the Golden Period.
Golden Hour
Involuntary muscle contractions of the abdominal wall to minimize the pain of abdominal movement; a sign of peritonitis
guarding
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
Blood pressure that is lower that the normal range.
hypotension
Blood pressure that is higher that the normal range.
hypertensions
A condition in which the internal body temperature falls below 95 degrees fahrenheit (35 degrees celsius( after exposure to a cold environment.
hypothermia
A system implemented to manage disasters and mass and multiple casualty incidents in which section chiefs, including finance, logistics, operations, and planning, report to the incident commander. Also referred to as the incident management system.
incident command system
Yellow skin or sclera that is caused by liver disease or dysfunction.
jaundice
Breathing that requires greater than normal effort; may be slower or faster than normal and characterized by grunting, stridor, and use of accessory muscles.
labored breathing
The forces, or energy transmission, applied to the body that cause injury.
mechanism of injury (MOI)
The biochemical processes that result in production of energy from nutrients within the cells.
metabolism
Widening of the nostrils, indicating that there is an airway obstruction.
nasal flaring
The general type of illness a patient is experiencing.
nature of illness (NOI)
OPQRST
A mnemonic used in evaluating a patient's pain: O: onset P: provocation/palliation Q: quality R: region/radiation S: severity T: timing
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
To examine by touch.
palpate
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.
paradoxical motion
The flow of blood through body tissues and vessels.
perfusion
Protective equipment that blocks exposure to a pathogen or a hazardous material.
personal protective equipment (PPE)
Negative findings that warrant no care or intervention.
pertinent negatives
A painful, tender, persistent erection of the penis; can result from spinal cord injury, erectile dysfunction drugs, or sickle cell disease.
priapism
A step within the patient assessment process that identifies and initiates treatment of immediate and potential life threats.
primary assessment
The pressure wave that occurs as each heartbeat causes a surge in the blood circulating through the arteries.
pulse
An assessment tool that measures oxygen saturation of hemoglobin in the capillary beds.
pulse oximetry
A step within the patient assessment process performed at regular intervals during the assessment process 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.
reassessment
The way in which a patient responds to external stimuli, including verbal stimuli (sound), tactile stimuli (touch), and painful stimuli.
responsiveness
Movements in which the skill pulls in around the ribs during respiration.
retractions
Coarse, low-pitched breath sounds heard in patients with chronic mucus in the upper airways.
rhonchi
A brief history of a patient’s condition to determine signs and symptoms, allergies, medications, pertinent past history, last oral intake, and events leading to the injury or illness.
SAMPLE history
A step within the patient assessment process that involves a quick assessment of the scene and the surrounding to provide information about the scene safety and the mechanism of injury or nature of illness before you enter and begin patient care.
scene size-up
The tough, fibrous, white portion of the eye that protects the more delicate inner structures.
sclera
A step within the patient assessment process in which a systematic physical examination of the patient is performed. The examination may be a systematic exam or an assessment that focuses on a certain area or region of the body, often determined through the chief complaint.
secondary assessment
Respirations characterized by little movement of the chest wall (reduced tidal volume) or poor chest excursion.
shallow respirations
Objective findings that can be seen, heard, felt, smelled, or measured.
sign
Knowledge and understanding of your surroundings and situation and the risk they potentially pose to your safety or the safety of the EMS team.
situational awareness
An upright position in which the patient’s head and chin are thrust slightly forward to keep the airway open.
sniffing position
Breathing that occurs without assistance.
spontaneous respirations
Protective measures that have traditionally been developed by the Centers for Disease Control and Prevention (CDC) for use in dealing with objects, blood, body fluids, and other potential exposure risks of communicable disease.
standard precautions
A harsh, high-pitched, breath sound, generally heard during inspiration, that is caused by partial blockage or narrowing of the upper airway; may be audible without the stethoscope.
stridor
A characteristic crackling sensation felt on the palpation of the skin, caused by the presence of air in soft tissues.
subcutaneous emphysema
Subjective findings that the patient feels but that can be identified only by the patient.
symptom
The increased pressure in an artery with each contraction of the ventricles (systole)
systolic pressure
A rapid heart rate, more than 100 beats/min.
tachycardia
The amount of air (in milliliters) that is moved in or out of the lungs during one breath.
tidal volume
The process of establishing treatment and transportation priorities according to severity of injury and medical need.
triage
An upright position in which the patient leans forward onto two arms stretched forward and thrusts the head and chin forward.
tripod position
A severe breathing problem in which a patient can only speak two or three words at a time without pausing to take a breath.
two- to three-word dyspnea
Narrowing of a blood vessel.
vasoconstriction
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
A high-pitched, whistling breath sound that is most prominent on expiration, and which suggests an obstruction or narrowing of the lower airways; occurs in asthma and bronchiolitis.
wheezing
