EMR - Day #3 Flashcards
What does the secondary survey consist of?
The secondary survey consists of gaining the patients critical history, pain assessment, vital signs, hospital notification, head 2 toe, GCS (Glasgow Coma Scale).
How do you gain the critical history of a patient?
You gain the critical history of a patient by assessing them with SAMPLE.
What is SAMPLE?
S - Signs, Symptoms and Story
A - Allergies
M - Medications
P - Past med hx (history)
L - Last oral intake
E - Events prior
What is the difference between signs and symptoms?
Signs are what you can see and symptoms are what a patient tells you.
How do you assess a patients pain?
OPQRRRST
What does OPQRRST stand for?
O - Onset
P - Provocation
Q - Quality
R - Region
R- Radiation
S - Severity
T - Time
What vital signs must you take in the secondary survey?
BP (blood pressure)
RR (resp. rate and auscultation)
HR (heart)
SpO2 (blood O2 level)
Pain (0-10 scale)
GCS (LOC)
Pupils (light pen)
BGL (blood glucose level, when necessary)
Skin/Temp (fingers to forehead)
What is GSC?
GCS stands for Glasgow Coma Scale, it is a point scale for measuring a patients ongoing LOC during a call. It goes from 1-15
What are the three parts to the GCS?
Eye Movement, verbal response and motor response.
How is eye movement in the GCS scored?
It is scored from 1-4
4 (eyes react spontaneously)
3 (eyes react to voice)
2 (eyes react to pain)
1 (no response)
How is verbal response measured in the GCS?
It is scored from 1-5
5 (pt. is oriented and converses)
4 (pt. is disoriented and converses)
3 (uses the wrong words)
2 (incomprehensible sounds)
1 (no response)
Ex. for 3: using foods for the days of the week
Ex. for 2: moaning and groaning
How is motor response measured in the GCS?
It is scored from 1-6.
6 (obeys commands)
5 (localizes to pain)
4 (withdraws from pain)
3 (decorticate [flexion])
2 (decerebrate [extension])
1 (no response)
What can mess with the reading of a SpO2?
- Nail polish and acrylic nails
- Carbon monoxide poisoning
How many auscultation points are there?
There are 12 total, 6 on the back and 6 on the front.
What are you listening for during auscultation?
You are listening for an abnormal or absent sounds. ex) crackling, wheezing
What is the number one drug allergy?
The number one drug allergy is to non steroidal anti inflammatory drugs (NSAIDs).
What is the number one bug bite allergy?
The number one bug bite allergy is wasps.
What is the normal temperature for humans?
The normal temp. is 36.6C but round to 37C for exams!
What is the bench mark temp. for having a fever?
The benchmark temp. for fevers is 37.8C
Where do you measure for body temp?
You can get a patients body temp. from under their tongue or in their armpits.
What is the WHI acronym?
W - Worse, is this worst then previous occurrences?
H - Hospitalization, have you been to the hospital for this before?
I - Intervention, what has been done before to solve this?
What is ISBAR and when is it used?
ISBAR is used during hospital notifications and patient handoffs.
I - identification/introduction
S - situation
B - background
A - assessment
R - recommendations
What is the head to toe exam?
It is a more in depth examination of the body, following the same order as a RBS.
What are some questions to use when testing if patient is oriented?
What is there name?
Where they are?
What time of day is it (roughly)?
What day is it?
