Chapter 9: Patient Assessment Flashcards
The secondary muscles of respiration. They include the neck muscles (sternocleidomastoids), the chest pectoralis major muscles, and the abdominal muscles.
accessory muscles
To listen to the sounds within an organ with a stethoscope
auscultate
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
The pressure of circulating blood against the walls of the arteries
blood pressure
a slow heart rate, less than 60 beats per minute
bradycardia
An indication of air movement in the lungs, usually assessed with a stethoscope
breath sounds
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 noninvasive method that can quickly and efficiently provide information on a patient’s ventilatory status, circulation, and metabolism
capnography
The use of a capnometer, a devices that measures the amount of expired carbon dioxide
capnometry
typically makes up 0.3% of air at sea level, It is also a waste product exhaled during expiration by the respiratory system
carbon dioxide
The reason a patient called for help; the patient’s response to questions such as “what’s wrong?” or “what happened?”
chief complaint
to form a clot to plug an opening in an injured blood vessel and stop bleeding
coagulate
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)
colorimetric devices
The delicate membrane that lines the eyelids and covers the exposed surface of the eye
conjunctiva
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 bluish gray skin color that is caused by a reduced level of oxygen in the blood
cyanosis
A mneumonic for assessment in which each area of the body is evaluated for Deformities, Contusions, Abrasions, Punctures/penitrations, Burns, Tenderness, Lacerations, and Swelling
DCAP-BTLS
Characterized by 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
the amount of carbon dioxide present in exhaled breath
end-tidal CO2
A type of physical assessment that is typically performed on patients who have sustained non-significant 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
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
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
Golden Period
Involuntary muscle contractions (spasms) of the abdominal wall in an effort to protect an inflamed abdomen; 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 higher than the normal range
hypertension
blood pressure that is lower than the normal range
hypotension
A condition in which the internal body temperature falls below 95 degrees Fahrenheit 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.
incident command system
yellow skin or sclera that is caused by liver disease or dysfunction
jaundice
breathing that requires visibly increased effort; characterized by grunting, stridor, and use of accessory muscles
labored breathing
The way in which traumatic injuries occur; the forces that act on the body to cause damage.
Mechanism of Injury (MOI)
flaring out 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)
An abbreviation for key terms used in evaluating a patient’s pain: Onset, Provocation or Pallition, Quality, Region/radiation, Severity, and Timing of pain
OPQRST
The mental status of a patient as measured by memory of the 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 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)
paradoxical motion
circulation of blood within an organ or tissue
perfusion
Clothing or specialized equipment that provides protection to the wearer
personal protective equipment (PPE)
Negative findings that warrant no care or intervention
pertinent negatives
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 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 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
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 skin pulls in around the ribs during inspiration
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 surroundings to provide information about scene safety and the mechanism of injury or nature of illness before you enter and begin patient care
scene size-up
The white portion of the eye; the tough outer coat that gives protection to the delicate, light-sensitive inner layer
sclera
A step within the patient assessment process in which a systematic physical examination of the patient is performed. The examination maybe 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.
secondary assessment
Respirations that are categorized 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
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 with no assistance
spontaneous respirations
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 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
stridor
The presence of air in soft tissues, causing a characteristic crackling sensation on palpation
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 lings 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 speak only two to 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
