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Patient Assessment > General Assessment > Flashcards

General Assessment Flashcards

1
Q

What are the components of a patient assessment?

A 
Scene Assessment/Survey
Primary Assessment/Survey
Baseline Vitals
Identify any Priority Patients
Transport/Treatment Decisions
Detailed Secondary Assessment/Survey
Ongoing Care
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2
Q

When approaching a scene during the scene survey, what should you be looking for?

A 
Preparation
Responding
Hazards
MOI
Patients Involved
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3
Q

The preparation should be done at shift change, what should this include?

A

Vehicle Check
Equipment Check
System Status

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4
Q

When responding, what should you be considering?

A 
Weather
Road Delays: Any construction, what detours do I need to take
Dispatch Info
The ambulance itself
Any extra resources
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5
Q

What are the priorities of scene safety?

A 
You
Your crew
Any other responding personnel
The patient
Bystanders
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6
Q

What should your Personal Protective Equipment (PPE) include?

A 
Gloves
Eyewear
Vests
Helmets
Boots
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7
Q

What should your scene assessment or windshield survey include?

A

HEMP

Hazards
Environment
MOI
Patients Involved (#)

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8
Q

What are some Hazards you should be watching for?

A 
Traffic
Power Poles
Bystanders
Fire
Weapons
Vehicles
Animals
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9
Q

What should be done with unsafe scenes before providing patient care?

A

They should be made safe

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10
Q

What could an unsafe scene be or include?

A 
MVC or rescue scenes
Toxic substances
Crime scenes
Unstable surfaces/structures
Violent/Hostile environment
Farm emergencies
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11
Q

What is a Mechanism of Injury?

A

It is the force applied to (or taken away) from the body and how the body reacts to it

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12
Q

What should you be looking for with regards to an MOI

A

Strength
Direction
Nature of the Forces

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13
Q

What is Newton’s First Law of Motion?

A

An object, whether at rest or in motion, remains in that state unless acted upon by another force

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14
Q

What is the Conservation of Energy?

A

Energy can’t be created or destroyed, it can only change form

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15
Q

What are some significant MOI’s

A 
Ejection from a vehicle
Death in the same passenger compartment
Falls > 6 feet or the pt's height
Rollover
High-speed vehicle collision
Auto-ped collision
Motorcycle crash
Unresponsive or altered mental status
Penetrations of the head, chest, or abdomen
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16
Q

What is the Primary Assessment?

A

It is used to determine the nature of the illness

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17
Q

During the Primary assessment, what are you using to determine the nature of the illness

A

Bystanders, family or the patient
The scene can give you clues
The patients illness may be very different from the chief complaint

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18
Q

What are the overall steps of a primary assessment?

A 
Form a general impression
Stabilize c-spine as needed
Assess baseline level of response
Assess airway
Assess breathing
Assess circulation
Complete an RBS as needed
Assess priority of the patient
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19
Q

What is the General Impression?

A

It is the initial, intuitive evaluation of the patient to determine the general clinical status and priority for transport

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20
Q

What is your assessment of c-spine based on?

A

MOI
History of the event
General Impression

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21
Q

What is a Patient Assessment?

A

It is a problem-oriented evaluation establishing priorities of care
It is based on existing and potential threats

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22
Q

What are some signs to look for when assessing Appearance?

A 
Level of Consciousness
Signs of Distress
Apparent State of Health
Vital statics
Sexual Development
Skin color and obvious lesions
Posture, gait, motor activity
Dress, grooming and personal hygiene
Odours of breath or body
Facial expression
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23
Q

When assessing level of responsiveness, what scale do we use?

A 
AVPU
Alert
Alert to Voice
Alert to Painful stimuli
Unresponsive
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24
Q

When assessing the airway in the primary survey, what are we looking for?

A

To determine if it is patent or obstructed

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25
Q

How do we assess airway patency

A

Determine if the patient can speak
Note any signs of airway obstruction or respiratory insufficiency such as stridor, wheezing, gurgling
Inspect the oral cavity for foreign objects

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26
Q

When assessing breathing, what are we evaluating?

A

Level of Consciousness
Rate (Tachypnea or Bradypnea)
Depth
Symmetry of chest wall movement

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27
Q

When assessing breathing, what are we looking for when we expose the chest

A

Structural integrity
Tenderness
Crepitus
Also observing if any accessory muscle use
Signs of distress
Audible sounds (quick ascultation of bases and apex)
Listen to the patient when they talk

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28
Q

What are we looking for when we assess circulation?

A

Consists of evaluating the pulse and skin and controlling any bleeding if necessary
Rate (Tachycardic or Bradycardic)
Force
Compare Carotid and Radial

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29
Q

If it is required to complete a rapid body survey, what does it consist of?

A

It is a quick head-to-toe and control any of the following if required:

  • signs of severe external bleeding
  • signs of internal hemorrhage
  • fractures

Evaluate the skin color, moisture and temperature

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30
Q

What are some signs of Inadequate Circulation?

A 
Altered or decreased LOC
Distended neck veins
Pale, cool, diaphoretic skin
Restlessness
Thirst
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31
Q

What do baseline vitals include?

A

LOC
Pulse
Respirations
Blood Pressure

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32
Q

What is included in a pulse assessment?

A

Rate:

  • Normal Range: 60-100 bpm
  • Average (adult): 72 bpm
  • Tachycardia > 100 bpm
  • Bradycardia
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33
Q

What are the peripheral pulse sites?

A

Temporal - lateral to the eye orbit
Carotid - medial to and below the angle of the jaw
Brachial - just medial to the biceps tendon
Radial - thumb side of the wrist
Ulnar - little finger side of the wrist
Femoral - Just below the inguinal ligament
Popliteal - just behind the knee
Dorsalis pedis - top of the foot
Posterior tibial - behind medial malleolus

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34
Q

What are we looking for when assessing respirations?

A

Rate:
- Normal range for adults is 12-20 bpm

Rhythm:
- Regular, regular-irregular, irregular-irregular

Volume:
- Deep or shallow

Audible noises

Tachypnea > 20 bpm
Bradypnea

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35
Q

Describe Tachypnea

A

Increased respiratory rate

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36
Q

Describe Bradypnea

A

Decreased respiratory rate

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37
Q

Describe Apnea

A

Absence of breathing

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38
Q

Describe Hyperpnea

A

Normal rate, but deep respirations

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39
Q

Describe Cheyne-Stokes respirations

A

Gradual increases and decreases in respirations with periods of apnea

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40
Q

Describe Biot’s respirations

A

Rapid, deep respirations (gasps) with short pauses between sets

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41
Q

Describe Kussmaul’s Respirations

A

Tachypnea and hyperpnea

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42
Q

Describe Apneustic respirations

A

Prolonged inspiratory phase with shortened expiratory phase

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43
Q

What is Blood Pressure

A

It is the force of blood against the arteries walls as the heart contracts and relaxes
It is measured in mmHg
Expressed as a fraction, Systolic/Diastolic

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44
Q

What is the Systolic portion of blood pressure

A

It is the maximum force of blood against the arteries when the ventricles contract (pumping pressure)

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45
Q

What is the diastolic portion of blood pressure?

A

It is the force of blood against the vessel walls when the ventricles relax
It is the measure of systemic vascular resistance (correlates well to blood vessel size)
It is the resting pressure

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46
Q

What are the ways a blood pressure can be assessed?

A

Auscultation
Palpation
Non-Invasive

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47
Q

What is the normal Systolic range in adults?

A

Adult Male: 100-140 mmHg, up to the age of 50

Adult Female: 90-130mmHg, up to the age of 50

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48
Q

What is the normal diastolic range in adults?

A

Adult Male/Female: 60-96mmHg

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49
Q

What is the 80-70-60 guideline?

A

It gives a rough estimate of the patients systolic blood pressure by palpating pulse sites.
Radial - 80mmHg or higher
Femoral - 70mmHg or higher
Carotid - 60mmHg or higher

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50
Q

Define Pulse Pressure

A

Difference between systolic and diastolic blood pressure

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51
Q

Define Perfusion

A

Passage of blood through and organ or tissue

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52
Q

Define Korotkoff Sounds

A

Sound of blood hitting the arterial walls

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53
Q

What are some major criteria to identify priority patients?

A 
Poor general impression
Unresponsive
Responsive but cannot follow commands
Difficultly breathing
Hypoperfusion
Complicated child birth
Chest pain and BP below 100 systolic
Uncontrolled bleeding
Severe pain
Multiple injuries
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54
Q

What are the four types of patients?

A

Trauma patient with significant MOI
Trauma patient with isolated injury
Responsive medical patient
Unresponsive medical patient

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55
Q

When assessing a Major trauma patient, what are the four components of assessment we are looking for?

A

Primary assessment
Rapid trauma assessment
Packaging
Rapid transport and ongoing assessment

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56
Q

What are predictors of serious internal injury?

A 
Ejection from vehicle
Death in the same passenger compartment
Fall from higher than 6 meters
Rollover of vehicle
High speed MVC
Vehicle-passenger collision
Motorcycle crash
Penetration of the head, chest or abdomen
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57
Q

What should field management be limited to in major trauma patients

A

Airway control, ventilatory support, spinal immobilization, major fracture stabilization

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58
Q

In a major trauma patient, when should the IV be started and administered

A

Perferrably enroute to the hospital

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59
Q

What are the four components of an isolated-injury trauma patients?

A

No significant MOI
Shows no signs of systemic involvement
They do not require an extensive history
They do not require a comprehensive physical exam

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60
Q

What are the differences in a responsive medical patient?

A

The history takes precedence over the physical exam

The physical exam is aimed at identifying medical complications rather than signs of injury

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61
Q

What are the components of an unresponsive medical patient?

A

Initial assessment
Rapid medical assessment
Brief history from bystanders or family

62
Q

What does the secondary assessment include?

A

History
Vitals
Detailed secondary (head-to-toe) assessment

63
Q

What is one of the main challenges in completing a history

A

To get as much relevant patient information and history to provide rational for treatment and transport decisions

64
Q

What are some obstacles when trying to collect a patient history

A

Establishing a rapport in a patient that you have just met
Conduct primary and secondary assessments and implements treatments simultaneously
Do so within the time constraints of effective prehospital care and the patients primary problem

65
Q

Define Chief Complaint

A

It is the main reason that you were called to attend to the patient
Differentiate from the primary cause

66
Q

Define Differential Diagnosis

A

The working diagnosis that you come up with based on the patient’s signs and symptoms and the variety of potential causes

67
Q

What is Rapport?

A

By asking the patient the right questions you will discover their chief complaint and symptoms
By responding with empathy, you will win their trust and encourage them to discuss their problems with you

68
Q

When you are setting the stage during history taking, what are you doing?

A

Looking for the patients chart if there is one available (nursing home, hospital transfer)
Ensure that insight does not turn into bias
As much as possible choose an environment that allows for the most effective interaction

69
Q

What are some good ways to use language and communication?

A

Use appropriate language
Use an appropriate level of questioning, but do not appear condescending
Generally start with open-ended questions and progress to more closed questions
Avoid a pre-arranged script of questions, modify questioning in response to the patients response

70
Q

When using Active Listening, what does it mean to use Facilitation?

A

Eye contacts, facial gestures, posture, verbal cues

71
Q

When using Active Listening, what does it mean to use Reflection?

A

To repeat your patient’s words back to them

72
Q

When using Active Listening, what does it mean to use Clarification?

A

What means one thing to you may mean something different to the patient, so ensure to explain what you are saying to the patient and understand what they are saying to you

73
Q

What are some topics that your patient’s may experience problem’s talking to you about, sensitive topics?

A

Sexual activities, violence, physical deformities

74
Q

In a comprehensive history, what is the preliminary data?

A 
Date and Time
Age
Sex
Race
Birthplace
Occupation
75
Q

In a comprehensive history, what is the chief complaint?

A

It is the main reason that you were called, the primary cause

Ask the patient, “What seems to be the problem?”

76
Q

When completing a comprehensive history and you are using OPQRST-ASPN ,what does it mean?

A 
Onset of the problem
Provocative/Palliative factors
Quality
Region/Radiation
Severity
Time
Associated Symptoms
Pertinent Negatives
77
Q

When completing a comprehensive history, what is a SAMPLE history?

A 
Signs and Symptoms
Allergies
Medications
Past/Present Medical History
Last...
Events preceeding
78
Q

When completing a comprehensive history, what is included in a Past History?

A 
General state of health
Childhood diseases
Adult diseases
Psychiatric illnesses
Accidents or injuries
Surgeries or hospitalizations
79
Q

When completing a comprehensive history, what is included in the current health status?

A 
Current medications and rx information
Allergies
Tobacco
Alcohol, drugs and related substances (use/misuse)
Diet
80
Q

When discussing medications with the patient, what are you asking?

A

Are they compliant?

What is the dose and frequency

81
Q

What is included in a current health status?

A 
Screening tests
Immunizations
Sleep patterns
Exercise and leisure activities
Environmental hazards
Use of safety measures
Family history
Home situation
Daily life
Important exercises
Religious beliefs
The patients outlooks
82
Q

What is a review of systems?

A

It is a functional inquiry
It is a system-by-system series of questions designed to identify problems your patient has not already identified
Mainly determined by patient chief complaint, condition and clinical status

83
Q

What systems are included in a review of systems?

A 
General (Overall)
Skin
HEENT
Respiratory
Cardiac
Gastrointestinal
Urinary
Genitalia
Peripheral Vascular
MSK
Neurologic
Hematologic
Endocrine
Psychiatric
84
Q

What are some special challenges when questioning patients?

A 
Silence
Overly talkative patients
Multiple symptoms
Anxiety
Depression
Sexually attractive or seductive patients
Confusing behavior
Patients needing reassurance
Anger
Intoxication
Crying
Limited intelligence
Language problems
Hearing
Speech
To busy talking with family or friends
85
Q

What are some causes of dilated or unresponsive pupils?

A 
Cardiac Arrest
CNS Injury
Hypoxia/Anoxia
LSD, Atropine, Amphetamines, Barbiturate Drug Use
Lack of Light
86
Q

What are some causes of constricted or unresponsive pupils?

A 
CNS Injury
CNS Disease
Narcotic Use
Eye Medications
Bright Light
87
Q

What are some causes of unequal pupils?

A 
CVA
Head Injury
Direct trauma to the eye
Eye Medications
Prosthetics
88
Q

When assessing the Skin, what is considered normal?

A

Color: Pink
Temperature: Warm
Moisture: Dry

89
Q

When evaluating skin color, what are causes of Pale (Pallor) skin?

A

Decreased perfusion
Cold Injury
Dehydration
Shock

90
Q

When evaluating skin color, what are some causes of Cyanosis (blue)?

A

Cardiorespiratory insufficiency

Cold environment

91
Q

When evaluating skin color, what are some causes of red color skin?

A

Fever
Inflammation
CO Poisoning

92
Q

When evaluating skin color, what are some causes of jaundiced skin?

A

Liver problems

RBC Destruction

93
Q

When evaluating skin temperature, what are some causes of cold skin?

A

Decreased perfusion

Cold related illness/injury

94
Q

When evaluating skin temperature, what are some causes of hot skin?

A

Possible fever

Heat related illness/injury

95
Q

When evaluating skin moisture, what are some causes of clammy skin?

A

Shock
CV Compromise
Heat Illness/Injury

96
Q

When evaluating skin moisture, what are some causes of diaphoretic skin?

A

Shock
CV Compromise
Heat Illness/Injury

97
Q

What is the approximate temperature that the body works hard at maintaining?

A

37 degrees Celcius

98
Q

Where are the four main sites to obtain a temperature?

A

Oral
Rectal
Axillary
Tympanic

99
Q

What is the purpose of the physical exam?

A

It is to investigate areas that you suspect are involved in your patients primary problem

100
Q

What are the four aspect’s that build the foundation of physical assessment?

A

Inspection
Palpation
Auscultation
Percussion

101
Q

What are you looking for when assessing the head? (6)

A 
DCAP-BLS
Drainage of fluid or blood from the ears, nose or mouth
Raccoon eyes
Battle sign
Burns of the face, nasal hairs or mouth
Pupils PEARLA
102
Q

When assessing the head and you look in the mouth, what are you assessing? (3)

A

The color of the mucous membranes
Blood, vomitus, summer teeth, lacerated/swollen tongue
Suctioning as necessary

103
Q

When assessing the head and you are palpating the bones of the face, what are you assessing?

A

Looking for the presence of any tenderness, instability or crepitation

104
Q

When assessing the neck, what are we inspecting for? (2)

A

DCAP-BLS

Distended neck veins

105
Q

When assessing the neck, what are we palpating for? (3)

A

Anterior Neck for tracheal deviation
Cervical vertebrae for tenderness and deformity
Anterior and posterior neck for subcutaneous emphysema

106
Q

When assessing the chest ,what are we assessing? (3)

A

DCAP-BLS
Auscultate
Palpating for TIC

107
Q

What are three types of chest wall abnormalities?

A

Funnel chest
Pigeon chest
Barrel chest

108
Q

When assessing the posterior chest, we should palpate for tactile fremitus, what is this?

A

Vibrations felt during speech

109
Q

When assessing the abdomen, how many quadrants are we inspecting and palpating?

A

Four

110
Q

What are the other three things we are looking for when assessing the abdomen?

A

DCAP-BLS
Tenderness, rigidity, masses
Nausea, vomitting

111
Q

What is Cullen’s sign?

A

It is a discoloration around the umbilicus suggestive of intra-abdominal hemorrhage

112
Q

What is Grey-Turner’s sign?

A

It is discoloration over the flanks suggesting intra-abdominal bleeding

113
Q

What is an ascites?

A

Swelling in the flanks and abdomen

114
Q

What is Borborygmi?

A

It is loud, prolonged, gurgling bowel sounds

115
Q

What are the five things we are looking for when assessing the pelvis?

A 
DCAP-BLS
Incontinence
Priapism
TIC if no obvious pain
Pelvic squeeze
116
Q

What are the steps of conducting a pelvic squeeze?

A

Push posteriorly on the iliac crests
Push medially on the iliac crests
Push down on symphysis pubis
DO NOT ROCK THE PELVIS FROM SIDE TO SIDE

117
Q

When assessing the extremities, what are the four things we are looking for?

A

DCAP-BLS
TIC
PMS
Compare to the opposite extremity

118
Q

When assessing the MSK system, what are doing with the joints?

A

Observing
Inspecting
Palpating
Checking structure and mobility

119
Q

What are the 6 P’s of assessment on extremities?

A 
Pain
Pallor
Paresthesia
Pulses
Paralysis
Pressure
120
Q

What is considered normal cap refill?

A

Less than 2 seconds

121
Q

When do you assess the posterior body?

A

If not already immobilized, do so when log rolling onto backboard

122
Q

What is considered a normal spinal curvature?

A

Concave in cervical region
Convex in thorax
Concave in lumbar region

123
Q

What is Lordosis?

A

Exaggerated lumbar concavity (Swayback)

124
Q

What is Kydphosis?

A

Exaggerated thoracic concavity (hunchback)

125
Q

What is Scoliosis?

A

Lateral curvature of the spine

126
Q

When conducting a neurological exam, what two questions are we trying to answer?

A

Are the findings symmetrical or unilateral?

If they are unilateral, where do they originate?

127
Q

What are the five areas of the Neurological exam?

A 
Mental status and speech
Cranial nerves
Motor system
Sensory system
Reflexes
128
Q

What are the seven areas we are assessing when assessing mental status and speech?

A 
Level of response
Appearance and behaviour
Speech and language
Mood
Thought and perceptions
Insight and judgment
Memory and attention
129
Q

What are some motor activities that you would see with anxiety?

A

Tense posture
Restlessness
Fidgeting

130
Q

What are some motor activities that you would see with agitation?

A

Crying
Hand wringing
Pacing

131
Q

What are some motor activities that you would see with depression?

A

Hopeless
Slumped posture
Slowed movements

132
Q

What are some motor activities that you would see with manic behaviour?

A

Singing
Dancing
Expansive movements

133
Q

What are the twelve cranial nerves?

A 
I. Olfactory
II. Optic
III. Oculomotor
IV. Trochlear
V. Trigeminal
VI. Abducens
VII. Facial
VIII. Acoustic
IX. Glossopharyngeal
X. Vagus
XI. Accessory
XII. Hypoglossal
134
Q

What is the function of the Olfactory nerve?

A

Sensory (smell)

135
Q

What is the function of the Optic nerve?

A

Sensory (sight)

136
Q

What is the function of the Oculomotor nerve?

A

Motor (Pupil construction, rectus muscles)

137
Q

What is the function of the Trochlear nerve?

A

Motor (Superior oblique muscles)

138
Q

What is the function of the Trigeminal nerve?

A

Sensor (Opthalmic{forehead}, maxillary{cheek}, mandibular{chin})
Motor (Chewing muscles)

139
Q

What is the function of the Abducens nerve?

A

Motor (Lateral rectus muscle)

140
Q

What is the function of the Facial nerve?

A

Sensory (Tongue)

Motor (Facial muscles)

141
Q

What is the function of the Acoustic nerve?

A

Sensory (Hearing and balance)

142
Q

What is the function of the Glossopharyngeal nerve?

A

Sensory (Posterior pharynx, taste to anterior tongue)

Motor (Posterior pharynx)

143
Q

What is the function of the Vagus nerve?

A

Sensory (Taste to posterior tongue)

Motor (Posterior palate and pharynx)

144
Q

What is the function of the Accessory nerve?

A

Motor (Trapezius and sternocleidomastoid muscles)

145
Q

What is the function of the Hypoglossal nerve?

A

Motor (Tongue)

146
Q

What are three pieces of information can be collected as vital signs?

A

ECG (4, 12, 15 lead)
O2 Sats
Blood Glucose

147
Q

What is the purpose of an on-going assessment? (4)

A

To continue monitoring the patient’s status en route and provide treatment as necessary
Detects trends
Determines changes
Assesses intervention’s effects

148
Q

When doing the on-going assessment, why are we reassessing vital signs?

A

Observe changes, that occur over time, in the patients condition that may indicate the need for a change in care or treatment

149
Q

During the on-going assessment, why are we assessing interventions? (2)

A

To assess the response to the management plan

Continuous assessment of the patient may allow the paramedic to recognize a ‘trend’ in the assessment components

150
Q

What are the components of an on-going assessment? (7)

A 
Repeat initial assessment 
- Stable patient, q 15 mins
- Unstable patient, q 5 mins
Reassess mental status
Reassess airway
Monitor breathing for rate and quality
Reassess the circulation
Reestablish patient/transport priorities
Don't forget to consider hypo/hyperthermia
151
Q

What should the radio patch include?

A 
Ambulance Identification
Patient profile (age and sex)
Chief complaint
If trauma, give MOI and major injuries only
Mental status
Vital signs
Treatments already given
ETA

Patient Assessment (7 decks)

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