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Emergency Care 13th Edition > EC Chp 14 Secondary Assessment > Flashcards

EC Chp 14 Secondary Assessment Flashcards

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1
Q

Secondary Assessment is done when?

A

After scene the size up and primary assessment

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2
Q

3 components of secondary assessment

A
  1. Physical examination - feel for injuries, listen breathing, look for swelling
  2. Patient history - past medical history and history of present illness (HPI)
  3. Vital signs - Pulse, respiration’s, blood pressure and pulse Ox, assess skin and pupils also.
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3
Q

A Sign

A

Something you can see regarding the patients condition

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4
Q

Symptom

A

Is something the patient tells you

Ex. Abdominal pain or difficulty breathing

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5
Q

Reassessment means

A

Procedure for detecting changes in patient condition which involves

4 steps:

  • repeat primary assessment
  • repeat and record vital signs
  • physical exam
  • Checking interventions
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6
Q

How to gain a rapport with patient

A
  • get to same level as them
  • demonstrate empathy
  • listen carefully

Ask open ended questions.

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7
Q

S.A.M.P.L.E stand for?

A 
Signs and Symptoms
Allergies
Medications
Pertinent past medical history
Last oral intake
Events
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8
Q

Allergy questions

A

Are you allergic to medications or foods or do have environmental allergies?

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9
Q

Medication questions

A

What are you currently taking? Or should be taking
Are you on birth control?
Do you have a medical tag?
Do you take any herbal supplements or vitamins

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10
Q

O.P.Q.R.ST

A 
Onset:
Provocation: 
Quality:
Region/Relief:
Severity:
Time:
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11
Q

Onset:

A

What were you doing when the pain began

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12
Q

Provocation:

A

Does anything seem to trigger the pain or anything to make it feel better?

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13
Q

Quality:

A

Can you describe the pain for me?

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14
Q

Region/Relief:

A

Where is the pain, will you please point to it? Does it seem to spread or shoot anywhere?

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15
Q

Severity:

A

How bad is the pain? If 0 were no pain and 10 being the worst pain, what number would you say yours is?

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16
Q

Time:

A

When did the pain start? Has it changed at all since it started

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17
Q

Physical Examination Techniques (3)

A

Observe(look): overall sense of his condition as well as evaluating chief complaint

Auscultate(listen): listening for signs of abnormal condition

Palpate (touch): feeling an area for deformities or other abnormal findings

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18
Q

The most important determination you can make when assessing the respiratory system is?

A

Whether the patient is breathing adequately

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19
Q

Orthopnea

A

Does the patient have difficulty. Breathing when lying down?

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20
Q

Respiratory Assessment - Physical Exam what do you do and look for?

A
  • Mental Status
  • Level of respiratory distress
  • Observe Ches wall motion (significant expansion and equally)
  • Auscultate lung sounds
  • use Pulse Ox
  • Observe Edema (in lungs and check ankles
  • Fever does the patient have one
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21
Q

Cardiovascular Assessment - Physical exam, what do you do?

Effects the heart and the blood vessels

A
  • Look for signs that the condition may be severe
  • Obtain Pulse
  • Obtain blood pressure
  • note pulse pressure
  • look for JVD
  • Palpate chest
  • observe posture and breathing
22
Q

Neurological Assessment - Physical exam what do you do?

A
  • Perform Stroke Test ( Speaking, Smile, Raise hands)
  • Check Peripheral sensation (wiggle you fingers for me)
  • Gently palpate spine
  • Check Extremity strength ( can you squeeze your fingers?)
  • Check pupils
23
Q

Most common endocrine emergency?

A

A Diabetic patient

24
Q

Endocrine Assessment - Physical Exam what do you do?

A
  • Evaluate mental status
  • Observe patients skin (cool and moist indication of hypoglycemia)
  • Obtain blood glucose level (if allowed to do so)
  • look for an insulin pump
25
Q

GI Assessment - Physical exam, what do you do?

A
  • Observe patients position (may take fetal or knees to chest for)
  • Assess Abdomen (palpate each quadrant
  • inspect other parts of the GI system as appropriate
  • If there is vomitus or feces available. INSPECT IT. Note volume and color
26
Q

Crepitation is what?

A

The grating sound of feeling of broken bones rubbing together.

27
Q

If you patient were responsive what do you do next for your secondary assessment?

A
  1. Talk with the patient to obtain the history of his present illness OPQRST
  2. Then past history using AMPLE
  3. Followed by physical exam and base line vitals
28
Q

If patient is unconscious you will do what?

A
  1. Do a rapid physical exam
  2. Then complete a set of baseline vitals
  3. Gather relevant info from any relatives or bystanders
29
Q

Most important time to check the pupils is when?

A

When the patients eyes are closed

30
Q

Rapid Physical exam:

A

Check entire body:
Neck - JVD
Chest - presence and quality
Abdomen - Distention, firmness or rigidity
Pelvis - incontinence of urine or feces
Extremities - pulse, motor function, sensation, O2 saturation, medical ID

31
Q

Baseline Vital Signs include what?

A
  • Pulse
  • Respiration rate
  • Skin
  • Pupils
  • blood pressure
  • and note any abnormalities
32
Q

How to determine how serious the patient is include the following:

A 
The location of the injury or injuries
The patients mental status
The patients airway status
Vital signs
Mechanism of injury
Patients age or presence of preexisting conditions.
33
Q

DCAP - BTLS stand for?

And WTD

A

Deformities, Contusions, Abrasions, Punctures

Burns, Tenderness, Lacerations, and Swelling

Wounds, Tenderness, and Deformities

34
Q

Rapid assessment of the head

A

Gently palpate the cranium for wounds, tenderness and deformities

  • run gloved fingers through the patients hair
  • Inspect and palpate face gently
  • inspect and palpate ears for WTD and drainage of blood or other fluids
35
Q

Tension Pneumothorax is?

A

Air trapped in the chest

36
Q

Cardiac Tamponade is?

A

Blood filling with sac around the heart

37
Q

Flat neck veins in a patient lying down may be a sign of what?

A

Blood loss, not enough to fill them

38
Q

When the patient is sitting up and veins are bulging it could be a sign of what?

A

The heart is not pumping blood effectively as the blood is backing up in the veins

39
Q

Priapism

A

Persistent erection of the penis that may result from spinal injury and some medical problems

40
Q

several important principles when examining a patient? (5)

A
  • Tell the patient what you are going to do
  • Expose any injured area before examining it
  • Try to maintain eye contact
  • apply your spinal protocols
  • during physical exam you may stop or alter assessment process to provide care that is necessary for the priority of the patient
41
Q

Trauma patient who is not seriously injured

A

Focus on your assessment on just eh areas the patient tells you, plus those you suspect

This patient received all asserted while at the scene and does not generally need a detailed physical exam.

42
Q

Pediatric Note: Mental status of an unresponsive child or infant can be checked by?

A 
Shouting (verbal stimulus)
Flicking feet (painful stimulus)

Crying would be an expected response from a child with an adequate mental status

43
Q

Differential diagnosis

A

The list of potential diagnoses compiled early in the assessment of the patient

44
Q

Emergency medicine approach to Diagnosis?

A
  1. Ruling out life threatening conditions
  2. Narrowing the range of possible diagnoses
  3. Instituting urgent treatment
45
Q

Representativeness

A

When you encounter a patient with a certain group of signs and symptoms that resemble a particular condition, you assume the patient has that condition.

46
Q

Availability:

A

The urge to think of things because they are more easily recalled often ve cause of a recent exposure

47
Q

Overconfidence

A

Thinking you know more than you really do

48
Q

Confirmation bias

A

When he primarily looks for evidence that supports the diagnosis he already has in mind. But may overlook evidence that refutes or reduce dies the probability of that one

49
Q

Illusory correlation:

A

A one event may appear to cause another when in fact the two events are either coincidental or both caused by the same thing

50
Q

Anchoring and adjustment

A

Considers a particular condition and his later thinking is anchored to that hypothesis

51
Q

Search satisfying

A

Stop searching or assessing a faster you determine what causing the patients problem

52
Q

How an EMT can learn to think like a physician

A
  • learn to love ambiguity
  • understand the limitations of tech and people
  • realize that no one strategy works for everything
  • form a strong foundation of knowledge
  • organza the data in your head
  • change the way you think
  • learn from others
  • reflect on what you’ve learned

Emergency Care 13th Edition (17 decks)

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