Lecture 3/Chapter 10 Flashcards
SAMPLE
Signs and Symptoms, Allergies, Medications, Pertinent Medical History, Last Oral Intake, Events Leading to Injury or Illness
Signs and Symptoms
Evaluate using OPQRST
Allergies
Ask the patient if they are allergic to any medications, food, etc.
Medications
Ask the patient if they have been prescribed with any medications, and, if so, if they have been taking them as prescribed
Pertinent Medical History
Ask the patient if they have had any past medical problems i.e., heart disease, high blood pressure, asthma, diabetes, etc.
Last Oral Intake
Ask the patient what was the last thing they drank and when.
Events Leading to Injury or Illness
Ask the patient what they were doing when their issue began and if they know what caused it
OPQRST
Onset, Provoke and Palliate, Quality, Region and Radiation and Recurrence, Severity, and Time
Onset
Ask the patient if their pain came on gradually or suddenly?
Provoke and Palliate
Ask the patient if anything makes the pain worse or better?
Provoke and Palliate
Ask the patient if anything makes the pain worse or better?
Quality
Ask the patient to describe the pain, i.e., sharp, dull, throbbing, tearing, etc.
Region, Radiation, and Recurrence
Ask the patient where the pain is, does the pain radiate anywhere in their body, and has this pain happened before.
Severity
Ask the patient how they would rate the pain from 0 to 10
Time
How long has the pain been going on
BELLSRPGO
Blood Pressure, Eyes, Lung Sounds, Level of Consciousness, Skin Signs, Respirations, Pulse, GCS, and Oximeter
Blood Pressure
Average is 90-140 over 60-100; preferred method of taking blood pressure is Auscultation, second method is Palpation
How does auscultation work?
Put the correct size cuff on the patient, use stethoscope on the arm and under the cuff, pump it up until you can’t hear the heart pumping anymore, start slowly releasing the pressure. When you hear the first pump sound, record the # (systolic pressure), and when you hear the last pump sound, record the # (diastolic pressure).
Eyes
Check the patient’s pupils using PERLA: are they equal, round, react to light properly, and accommodate
Level of Consciousness
Ask the patient: what is your name, where are we, what time is it currently, and do you know what happened to you?
Lung Sounds
Listen to the right side, left side, middle, and lower lobes. Make sure everything sounds the same
What are the different lung sounds?
Normal: clear bilaterally
Abnormal: noisy breathing
Rales: fluid in the lungs, crackling noise
Wheezing: bronchial constriction; creepy noise
Rhonchi: coarse bubbling
Stridor: upper airway obstruction; high pitched wheeze coming from the trachea/throat
Skin Signs
Check the patient for color, temperature, and moisture. If the patient has dark skin, check the mucus membranes (under eyelids)
Respirations
Check the patient’s breathing for the rate, rhythm and quality
What to look for with rates?
Fast, slow, normal
What to look for with rhythms ?
Regular or irregular
What to look for with quality?
Strong/weak (pulse) or equal chest rise and fall and noises (respirations)