Chapter 9 Patient Assessment Flashcards
Accessory muscles
The secondary muscles of respiration. They include the neck muscles (sternocleidomastoid’s), the chest pectoralis major muscles, and the abdominal muscles
Altered mental status
Any deviation from alert and oriented to person, place, time, and event, or any deviation from a patient’s normal baseline mental status
Auscultate
To listen to sounds within an organ with a stethoscope
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
Blood pressure
The pressure that the blood exerts against the walls of the arteries as it passes through them
Bradycardia
A slow heart rate, less than 60 beats per minute
Breath sounds
And indication of air movement in the Lungs, usually assessed with a stethoscope
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
Capnography
A noninvasive method to quickly and efficiently provide information on any patients ventilatory status, circulation, and metabolism; effectively measures the concentration of carbon dioxide in expired air overtime
Carbon dioxide
Carbon dioxide is a component of air and typically makes up a 0.3% of air at sea level; also a waste product exhaled during expiration by the respiratory system
Chief complaint
The reason a patient called for help; also, the patient’s response to questions such as what’s wrong or what happened
Coagulate
To form a clot to plug an opening in an injured blood vessel and stop bleeding
Conjunctiva
The delicate membrane that lines the eyelids and covers the exposed surface of the eye
Crackles
A crackling, rattling breath sound that signals fluid in the air spaces of the Lungs
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
Cyanosis
A blue gray skin color that is caused by a reduced level of oxygen in the blood
DCAP-BTLS
A pneumonic for assessment in which each area of the body is evaluated for deformities, contusions, abrasions, punctures//penetrations, burns, tenderness, lacerations, and swelling
Diaphoretic
Characterized by light or perfuse sweating
Diastolic pressure
The pressure that remains in the arteries doing the relaxing phase of the heart cycle (diastole) when the left ventricle is at rest
Distracting injury
Any injury that prevents the patient from noticing other injuries he or she may have, even severe injuries; for example, a painful femur or to be a fracture that prevents the patient from noticing back pain associated with a spinal fracture
Focused assessment
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
Frostbite
Damage to tissues as the result of exposure to cold; frozen or partially frozen body parts are frostbitten
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
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
Guarding
Involuntary muscle contractions of the abdominal wall to minimize the pain of abdominal movement; A sign of peritonitis
History taking
A step with in the patient assessment process that provides detail about the patient’s chief complaint and an account of the patients signs and symptoms
Hypertension
Blood pressure that is higher than the normal range
Hypotension
Blood pressure that is lower than the normal range
Hypothermia
A condition in which the internal body temperature falls below 95°F (35°C) after exposure to a cold environment
Incident command system
Hey system implemented to manage disasters and mass and multiple casualty incident in which section chiefs, including finance, logistics, operations, and planning, reports to the incident commander. Also referred to as the incident management system
Jaundice
Yellow skin or sclera that is caused by a liver disease or dysfunction
Labored breathing
Breathing that requires greater than normal effort; maybe slower or faster than normal and characterized by grunting, Strider, and use of accessory muscles
Mechanism of injury (MOI)
The forces, or energy transmission, applied to the body that causes injury
Metabolism
The bio chemical process that results in production of energy from nutrients within the cells
Nasal flaring
Widening of the nostrils, indicating that there is an airway obstruction
Nature of illness (NOI)
The general type of illness a patient is experiencing
0PQRST
A pneumonic used in evaluating a patient’s pain: answered, provocation/palliation, quality, region/radiation, severity, and timing
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).
Palpate
To examine by touch
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
Perfusion
The flow of blood through the body tissues and vessels
Personal protective equipment (PPE)
Protective equipment that blocks exposure to a pathogen or a hazardous material
Pertinent negatives
Negative findings that warrant no care or intervention
Priapism
A painful, tender, persistent erection of the penis; can results from the spinal cord injury, erectile dysfunction drugs, or sickle cell disease
Primary assessment
A step within the patient assessment process that identifies and initiates treatment of immediate and potential Life threats
Pulse
The pressure wave that occurs as each heartbeat causes a surge in the blood circulating through the arteries
Pulse oximetry
An assessment tool that measures oxygen saturation of hemoglobin in the capillary beds
Reassessment
Eastep within the patients 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 five minutes, where as a patient in stable condition should be reassessed every 15 minutes
Responsiveness
The way in which a patient response to an external stimuli, including verbal stimuli (sound), tactile stimuli (touch), and painful stimuli
Retractions
Movements in which the skin pulls in around the ribs during inspiration
Rhonchi
Course, low pitched breath sounds heard in patients with chronic mucus in the upper airways
SAMPLE history
A brief history of the patient’s condition to determine signs and symptoms, allergies, medications, pertinent past history, last oral intake, and events leading to the injury or illness
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
Sclera
The tough, fibers, white portion of the eye that protects the more delicate inner structures
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 on a certain area or region of the body, often determined through the chief complaint
Shallow respirations
Respirations characterized by little movement of the chest wall (reduced tidal volume) or poor chest excursion
Sign
Objective findings that can be seen, heard, felt, smelled, or measured
Situational awareness
Knowledge and understanding of your surroundings and situation and the risk they potentially pose to your safety or the safety of the EMS team
Sniffing position
And upright position in which the patient’s head and Chin are thrust slightly forward to keep the airway open
Spontaneous respirations
Breathing that occurs without assistance
Standard precautions
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
Stridor
A harsh, high-pitched, breath sounds, generally heard during inspiration, that is caused by partial blockage or narrowing of the upper airway; maybe audible without a stethoscope
Subcutaneous emphysema
A characteristic crackling sensation felt on palpation of the skin, caused by the presence of air in soft tissues
Symptom
Subjective findings that the patient feels but that can be identified only by the patient
Systolic pressure
The increased pressure in an artery with each contraction of the ventricles (systole)
Tachycardia
A rapid heart rate more than 100 bpm
Tidal volume
The amount of air (in milliliters) that is moved in or out of the lungs during one breath
Triage
The process of establishing treatment and transportation priorities according to severity of injury and medical need
Tripod position
And upright position in which the patient leans forward onto arms stretched forward and thrusts the head and chin forward
2 to 3 word dyspnea
A severe breathing problems in which a patient can speak only 2 to 3 words at a time without pausing to take a breath
Vasoconstriction
Narrowing of a blood vessel
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
Wheezing
A high pitched, whistling sound that is most prominent on expiration, and which suggests an obstruction or narrowing of the lower airway is; occurs in asthma and bronchiolitis
