Chapter 9 Patient Assessment Flashcards

1
Q

Symptom

A

Subjective findings that the patient feels but that can be identified only by the patient

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2
Q

Sign

A

Objective findings that can be seen, heard, felt, smelled, or measured

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3
Q

Scene size up

A

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.

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4
Q

Situational awareness

A

Knowledge and understanding of your surroundings and situation and the risk they potentially pose to your safety or the safety of the EMS team

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5
Q

Mechanism of injury (MOI)

A

The forces, or energy transmission, applies to the body that causes injury

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6
Q

Nature of illness (NOI)

A

The general type of illness a patient is experiencing

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7
Q

Personal protective equipment (PPE)

A

Protective equipment that blocks exposure to a pathogen or a hazardous material

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8
Q

Standard precautions

A

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.

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9
Q

Incident command system

A

A system implemented to manage disasters and mass- and multiple casualty incidents in which section chiefs, includ ing finance, logistics, operations, and planning report to the incident commander. Also referred to as the incident management system.

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10
Q

Triage

A

The process of establishing treatment and transportation priorities according to severity of injury and medical need

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11
Q

Primary assessment

A

A step within the patient assessment process that identifies and initiated treatment of immediate and potential life threats

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12
Q

Vital signs

A

The key signs that are used to evaluate the patients overall condition, including respirations, pulse, blood pressure, level of consciousness, and skin characteristics

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13
Q

General impression

A

The overall initial impression that determines the priority for patient care; based in the patients surroundings, the mechanism of injury, signs and symptoms, and the chief complaint

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14
Q

Perfusion

A

The flow of blood through body tissues and vessels

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15
Q

AVPU scale

A

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

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16
Q

Responsiveness

A

The way in which a patient responds to external stimuli, including verbal stimuli (sound), tactile stimuli (touch), and painful stimuli

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17
Q

Orientation

A

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)

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18
Q

Altered mental status

A

Any deviation from alert and oriented to person, place, time, and event, or any deviation from a patients normal baseline mental status

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19
Q

Priapism

A

A painful, tender, persistent erection of the penis; can result from spinal cord injury, erectile dysfunction drugs, or sickle cell disease

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20
Q

Distracting injury

A

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

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21
Q

Spontaneous respirations

A

Breathing that occurs without assistance

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22
Q

Shallow respirations

A

Respirations characterized by little movement of the chest wall (reduced tidal volume) or poor chest excursion

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23
Q

Retractions

A

Movements in which the skin pulls in around the ribs during inspiration

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24
Q

Accessory muscles

A

The secondary muscles of respiration. They include the neck muscles (sternocleidomastoids), the chest pectoralis major muscles, and the abdominal muscles

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25
Nasal flaring
Widening of the nostrils, indicating that there is an airway obstruction
26
Two to three word dyspnea
27
Tripod position
An upright position in which the patient leans forward onto two arms stretched forward and thrusts the head and chin forward
28
Sniffing position
An upright position in which the patients head and chin are thrust slightly forward to keep the airway open
29
Labored breathing
Breathing that requires greater than normal effort; may be slower or faster than normal and characterized by grunting, stridor, and use of accessory muscles
30
Pulse
The pressure wave that occurs as each heartbeat causes a surge in the blood circulating through the arteries
31
Palpate
To examine by touch
32
Conjunctiva
The delicate membrane that lines the eyelids and covers the exposed surface of the eye
33
Cyanosis
A blue-gray skin color that is caused by a reduced level of oxygen in the blood
34
Jaundice
Yellowing skin or sclera that is caused by liver disease or dysfunction
35
Sclera
The tough, fibrous, white portion of the eye that protects the more delicate inner structures
36
Diaphoretic
Characterized by light or profuse sweating
37
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 rerun after releasing the pressure
38
Hypothermia
A condition in which the internal body temperature falls below 95F (35C) after exposure to a cold environment
39
Frostbite
Damage to tissues as the result of exposure to cold; frozen or partially frozen body are frostbitten
40
Vasoconstriction
Narrowing of a blood vessel
41
Coagulate
To form a clot to plug an opening in an injured blood vessel and stop bleeding
42
DCAP-BTLS
A mnemonic for assessment in which each area of the body is evaluated for deformities, contusions, abrasions, punctures/penetration, burns, tenderness, lacerations, and swelling
43
Crepitus
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
44
Golden Hour
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
45
History taking
A step within the patient assessment process that provides detail about the patients chief complaint and an account of the patients signs and symptoms
46
OPQRST
A mnemonic used in evaluating a patients pain: onset, provocation/palliation, quality, region/radiation, severity, and timing
47
Pertinent negatives
Negative findings that warrant no cause or intervention
48
SAMPLE history
A brief history of a patients condition to determine signs and symptoms, allergies, medication, pertinent past history, last oral intake, and events leading to the injury or illness
49
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 exam or an assessment that focuses in a certain area or region of the body, often determined through the chief complaint
50
Auscultate
To listen to sounds within an organ with a stethoscope
51
Focused assessment
A type of physical assessment typically performed on patients who have sustained no significant mechanisms of injury or on responsive medical patients. This type of examination is based in the chief complaint and focuses on one body system or part
52
Stridor
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 a stethoscope
53
Breath sounds
An indication of air movement in the lungs, usually assessed with a stethoscope
54
Tidal volume
The amount of air (in milliliters) that is moved in or out of the lungs during one breath
55
Wheezing
A high pitched, whistling breath sound that is most prominent on expiration, and which suggests an obstruction or narrowing if the lower airways; occurs in asthma and bronchiolitis
56
Crackles
A crackling, rattling breath sound that signals fluid in the air spaces of the lungs
57
Rhonchi
Coarse, low pitched breath sounds heard in patients with chronic mucus in the upper airways
58
Tachycardia
A rapid heart rate, more than 100 beats/min
59
Bradycardia
A slow heart rate, less than 60 beats/min
60
Blood pressure
The pressure that the blood exerts against the walls of the arteries as it passes through them
61
Systolic pressure
The increased pressure in an artery with each contraction of the ventricles (systole)
62
Diastolic pressure
The pressure that remains in the arteries during the relaxing phase of the hearts cycle (diastole) when the left ventricle is at rest
63
Hypotension
Blood pressure that is lower than the normal range
64
Hypertension
Blood pressure that is higher than the normal range
65
Subcutaneous emphysema
A characteristic cracking sensation felt on palpation of the skin, caused by the presence of air in soft tissue
66
Paradoxical motion
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
67
Guarding
Involuntary muscle contractions of the abdominal wall to minimize the pain of abdominal movement; a sign of peritonitis
68
Metabolism
The biochemical processes that result in production of energy from nutrients within the cells
69
Carbon dioxide
Carbon dioxide is a component of air and typically makes up .3% of air at sea level; also a waste product exhaled during expiration by the respiratory system
70
Capnography
A noninvasive method to quickly and efficiently provide information on a patients ventilatory status, circulation, and metabolism; effectively measures the concentration of carbon dioxide in expired air over time