Medical Patient Assessment Flashcards
1
Q
introduction to patient assessment
A
- one of the most important skills you will develop is the ability to assess a patient
- identify your patients problems -> always do CC first**
- set your care priorities
- develop a differential diagnosis
- develop a patient care plan
- execute your plan
2
Q
sick versus not sick
A
- determine whether the patient is sick or not sick
- if the patient is sick -> determine how sick
- every time you assess a patient…:
- ask yourself whether your patient is sick or not sick
- quantify how sick the patient is
3
Q
scene size-up
A
- evaluate overall safety and stability of the scene
- important to protect yourself first
- safe and secure access into the scene
- ready egress out of the scene
- specialty resources needed
- is PPE requires?
- first step of patient assessment process is the scene size up
- during the size up you also make a determination of the mechanism of injury or nature of the patients illness
4
Q
mechanism of injury (MOI)
A
- forces that act on the body to cause damage
- is it a medical complaint?
- is a traumatic complaint?
5
Q
nature of illness (NOI)
A
- general type of illness a patient is experiencing
- what is their chief complaint?**
- the patient is the most knowledgeable about what’s going on with them and how they have been treated in the past
6
Q
standard precautions
A
- treat all patients as potentially infectious
- wear: gloves (wash hands* after removal), eye protection, gown, HEPA or N95 mask
- personal protective equipment (PPE)
- clothing/equipment that provide protection against substances posing health/safety risk
- ex. steel toe boots, helmets, heat-resistant outerwear, self-contained breathing apparatus
7
Q
primary assessment: form a general impression
A
- based on initial presentation and CC
- first step is to form a general impression of the pts condition
- identify threats to the ABCs -> these life threats should be addressed immediately
- make conscious, objective, and systematic observations
- is patient stable or unstable, sick or not sick
- observe level of consciousness
- determine your priorities of care
- is the situation an emergency
- are they sick or not sick
- is the patient conscious and alert -> (this is different from if they are answering questions appropriately)
- once life threats have been addressed in the primary assessment move onto history taking
8
Q
assess the airway
A
- is airway open and patent
- listen for noisy breathing
- if they are talking the airway must be fairly open
- open the airway and position the patient properly
- move from simple to complex: position**, obstruction
- people with trouble breathing want to lay down bc they are tired but sitting up straight will help them
- fore all unresponsive patients:
- establish responsiveness and assess breathing
- if ineffective or absent, open the airway
- mechanical means require an airway adjunct
9
Q
assess breathing
A
- is the patient breathing?
- if not -> you must breathe for him or her
- if so -> is he or she breathing adequately
- consider minute volume -> respiratory rate multiplied by the tidal volume
- assess breathing/respiratory rate (normal 12-20/min)
- look for chest rise and fall
- assess for breathe sounds and air movement
10
Q
assess circulation
A
- palpate the pulse: count # of beats in 15 seconds and multiply times 4 (normal 60-100)
- less than 60 -> bradycardia
- more than 100 -> tachycardia
- what other symptoms do they have if they are bradycardic or tachycardic
- force: normal feels “full”
- rhythm: normal is regular
- report your findings:
- rate, force, and rhythm
- inspect skin for obvious signs of bleeding
11
Q
capillary refill
A
- evaluates ability to restore blood
- assessing circulation
- low blood pressure and low hydration status is slow capillary refill
- to test:
- place thumb on patients finger and compress
- remove pressure
- adequate perfusion: color restored within 2 seconds
12
Q
assess and control external bleeding
A
- perform a rapid exam
- venous bleeding -> is steady dark red blood flow
- arterial bleeding: spurting flow of bright red blood -> pulsating flow
- capillaries bleeding: slow flow of blood
- evaluate unresponsive patients by running your gloved hands from head to toe
- use a tourniquet
13
Q
identify and treat life threats
A
- conditions that can cause sudden death: airway obstruction, respiratory arrest, severe bleeding
- determine if a life threat is present and, if so, immediately address it
- a patient who is dying will…:
- become less aware of surroundings
- stop making attempts to communicate
- lose consciousness
- have inadequate respiratory pattern
- become unresponsive to external stimuli
- muscles of the jaw will become slack
- life threat > CC
14
Q
perform a rapid exam
A
- guidelines:
- inspect
- palpate
- auscultate- process of listening with stethoscope
- history taking:
- gain information about the patient and the events: surrounding the incident
- ask open ended questions, avoid leading
- ask age appropriate questions (normal language)
- be patient
15
Q
techniques for history taking
A
- appearance and demeanor:
- clean, neat, and professional
- good attitude
- ID your service and certification level
- try to interview in a private setting
- make eye contact
16
Q
responsive medical patients
A
- chief complaint (CC)
- should be recorded in patients own words
- should include:
- what is wrong
- why treatment is being sought
- how long have they had this CC
17
Q
OPQRST (for responsive patients)
A
- onset- when did it start
- provocation- does anything you do make it better or worse
- quality- what does it feel like (tight, pressure)
- region/radiation/referral- does (pain) it go anywhere else
- severity- pain on a scale of 1-10
- time- how long has this been occurring
18
Q
SAMPLER (for responsive patients)
A
- signs and symptoms
- allergies
- medications
- pertinent past history- medical history
- last oral intake- what did they eat
- events that led to injury or illness
- risk factors- histories of disease
19
Q
past medical history should include (for responsive patients)
A
- current medications and dosages
- allergies
- childhood illnesses
- adult illnesses
- past surgeries
- past hospitalization and disabilities
- any prior history of this particular condition
- family history
- travel history
20
Q
unresponsive patients
A
- rely on…
- head-to-toe physical examination
- normal diagnostic tools
- family and friends
- look for clues -> pill containers, medical jewelry
21
Q
communication techniques
A
- pay attention to signs or symptoms that are inconsistent with working diagnosis
- differential diagnosis
- what could it alternately be?
- encourage dialogue- use layperson terminology
22
Q
differential diagnosis
A
- a working hypothesis of the nature of the problem (what could it alternately be?)
- multiple diagnosis that could be true for your patient
23
Q
getting history on sensitive topics
A
- alcohol and drug abuse
- alcohol and drugs can mask symptoms they are having
- patients may give an unreliable history
- alcohol can mask signs and symptoms
- keep a professional attitude
- domestic violence
24
Q
special challenges in history taking
A
- limited education or intelligence
- language barriers
- hearing problems
- visual impairment/ blindness
- go to family and friends
25
Q
secondary assessment
A
- process by which quantifiable, objective information is obtained from a patient about his or her overall state of health
- including obtaining vital signs and performing head to toe survey
- if the patient is stable take vital signs every 15 minutes
- if the pt is unstable take vitals every 5 minutes
- inspection, palpation, percussion, and auscultation
- consists of two elements:
- obtaining vital signs
- performing a head to toe survey
26
Q
inspection
A
-looking at a patient
27
Q
palpation
A
- touching to obtain information
- pulses- use finger
- skull- use palms
- skin- use back of hand
28
Q
percussion
A
- striking surface of the body, typically where it overlies various body cavities
- detects changes in the densities of the underlying structures
- density of organs
29
Q
auscultation
A
- listening with a stethoscope
- you listen to belly, lungs
- requires:
- keen attention
- understanding of what “normal” sounds like
- lots of practice
30
Q
vital signs: pulse
A
- assess rate, presence, location, quality, regularity
- to palpate, gently compress an artery against a bony prominence
- count for 15 seconds and multiply by four
- check for central pulse in unresponsive patients
- normal pulse rate between 60-100 for adults
- is quality ok? -> weak thready pulse -> circulation can be bad
31
Q
vital signs: respiration
A
- assess rate by inspecting the patients chest
- quality:
- pathologic respiratory patterns or rhythms
- tripod positioning, accessory muscle use, retractions
- rate should be measured for 30 seconds and multiplied by two for pediatric patients
32
Q
vital signs: blood pressure
A
- product of cardiac output and peripheral vascular resistance
- systolic pressure- top #
- diastolic pressure
- measured using a cuff
- ideally should be auscultated
- normal bp - 120/80
