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ems > Patient Assessment > Flashcards

Patient Assessment Flashcards

Chapter 10

1
Q

symptom

A

subjective findings that the patient feels but that can be identified only by the patient

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2
Q

sign

A

objective finding that can be seen, heard, felt, smelled, or measured

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3
Q

field impression

A

the conclusion about the cause of the patient’s condition after considering the situation, history, and examination findings

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4
Q

scene size up

A

a step within the patient assessment process that involves a quick assessment of the scene and the surroundings to provide info about the scene safety and the mechanism of injury or nature of illness before you enter and begin patient care

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5
Q

situational awareness

A

knowledge and understanding of one’s surroundings and the ability to recognize potential risks to the safety of the patient or EMS team

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6
Q

mechanism of injury (MOI)

A

the forces, or energy transmission, applied to the body that cause injury

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7
Q

nature of illness (NOI)

A

the general type of illness a patient is experiencing

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8
Q

chief complaint

A

the reason a patient called for help; the patient’s response to questions such as “whats wrong?” or “what happened?”

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9
Q

personal protective equipment (PPE)

A

protective equipment that blocks exposure to a pathogen or a hazardous material

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10
Q

standard precautions

A

protective measures that have traditionally been developed by the Centers for Disease Control and Prevention (CDC) for use in dealing with objects, blood, body fluids, and other potential exposure risks of communicable disease

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11
Q

incident command system

A

a system implemented to manage disasters and mass- and multiple-casualty incidents in which section chiefs, including finance, logistics, operations, and planning, report to the incident commander

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12
Q

triage

A

the process of establishing treatment and transportation priorities according to severity of injury and medical need

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13
Q

primary assessment

A

a step within the patient assessment process that identifies and initiates treatment of immediate and potential life threats

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14
Q

vital signs

A

the key signs that are used to evaluate the patient’s overall condition, including respirations, pulse, blood pressure, level of consciousness, and skin characteristices

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15
Q

general impression

A

the overall initial impression that determines the priority for patient care; based on the patient’s surroundings, the mechanism of injury, signs and symptoms, and the chief complaint

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16
Q

AVPU scale

A

a method of assessing the level of consciousness by determining whether the patient is awake and alert, responsive to verbal stimuli or pain, or unresponsive; used principally early in the assessment process

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17
Q

responsiveness

A

the way in which a patient responds to external stimuli, including verbal stimuli (sound), tactile stimuli (touch), and painful stimuli

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18
Q

orientation

A

the mental status of a patient as measured by memory of person (name), place (current location), time (current year, month, and approximate date), and event (what happened).

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19
Q

altered mental status

A

a change in the way a person thinks and behaves that may signal disease in the central nervous system or elsewhere in the body

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20
Q

distracting injury

A

any injury that prevents the patient from noticing other injuries he or she may have, even severe injuries; for example, a painful femur or tibia fracture that prevents the patient from noticing back pain associated with a spinal fracture

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21
Q

perfusion

A

the flow of blood through body tissues and vessels

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22
Q

spontaneous respirations

A

breathing that occurs without assistance

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23
Q

perfusion

A

the flow of blood through body tissues and vessels

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24
Q

shallow respirations

A

respirations characterized by little movement of the chest wall (reduced tidal volume) or chest excursion

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25
Q

retractions

A

movements in which the skin pulls around the ribs during inspiration

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26
Q

accessory muscles

A

the secondary muscles of respiration. they include the neck muscles (sternocleidomastoids), the chest pectoralis major muscles, and the abdominal muscles

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27
Q

nasal flaring

A

widening of the nostrils, indicating that there is an airway obstruction

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28
Q

two-to three-word dyspnea

A

a severe breathing problem in which a patient can speak only two to three words at a time without pausing to take a breath

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29
Q

tripod position

A

an upright position in which the patient leans forward onto two arms stretched forward and thrusts the head and chin forwards

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30
Q

sniffing position

A

an upright position in which the patient’s head and chin are thrust slightly forward to keep the airway open

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31
Q

labored breathing

A

breathing that requires greater than normal effort; may be slower or faster than normal and characterized by grunting, stridor, and use of accessory

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32
Q

pulse

A

the wave of pressure created as the heart contracts and forces blood out the left ventricle and into the major arteries

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33
Q

palpate

A

to examine by touch

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34
Q

conjunctiva

A

the delicate membrane that lines the eyelids and covers the exposed surface of the eye

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35
Q

cyanosis

A

a blue skin discoloration that is caused by a reduced level of oxygen in the blood

36
Q

jaundice

A

yellow skin or sclera that is caused by liver disease or dysfunction

37
Q

sclera

A

the tough, fibrous, white portion of the eye that protects the more delicate inner structures

38
Q

diaphoretic

A

characterized by light or profuse sweating

39
Q

capillary refill

A

definition: a test that evaluates distal circulatory system function by squeezing (blanching) blood from an area such as the nail bed and watching the speed of its return after releasing the pressure

40
Q

hypothermia

A

a condition in which the internal body temperature falls below 95F (35C)

41
Q

frostbite

A

damage to tissues as the result of exposure to cold; frozen or partially frozen body parts are frostbitten

42
Q

vasoconstriction

A

narrowing of a blood vessel

43
Q

DCAP-BTLS

A

a mnemonic for assessment in which each area of the body is evaluated for deformities, contusions, abrasions, punctures/penetrations, burns, tenderness, lacerations, and swelling

44
Q

crepitus

A

a grating or grinding sensation caused by fractured bone ends or joints rubbing together

45
Q

history taking

A

a step within the patient assessment process that provides detail about the patient’s chief complaint and an account of the patient’s signs and symptoms

46
Q

OPQRST

A

a mnemonic used in evaluating a patient’s pain: onset, provocation/palliation, quality, region/radiation, severity, and timing

47
Q

pertinent negatives

A

negative findings that warrant no care or intervention

48
Q

SAMPLE History

A

a brief history of a patient’s condition to determine signs and symptoms, allergies, medications, past history, last oral intake, and events leading to the injury or illness

49
Q

secondary assessment

A

a step within the patient assessment process in which a systematic physical examination of the patient is performed. the examination may be a systematic exam or an assessment that focuses on a certain area or region of the body, often determined through the chief complaint.

50
Q

auscultate

A

to listen to sounds within an organ with a stethoscope

51
Q

focused assessment

A

a type of physical assessment typically performed on patients who have sustained nonsignificant mechanisms of injury or on responsive medical patients. this type of examination is based on the chief complaint and focused on one body system or part

52
Q

stridor

A

a harsh, high pitchced, respiratory sound, generally heard during inspiration, that is caused by partial blockage or narrowing of the upper airway; may be audible without a stethoscope

53
Q

breath sounds

A

an indication of air movement in the lungs, usually assess with a stethoscope

54
Q

tidal volume

A

the amount of air (in milliliters) that is moved into or out of the lungs during one breath

55
Q

wheezing

A

a high-pitched, whistling breath sound that is most prominent on expiration, and which suggests an obstruction or narrowing of the lower airways; occurs in asthma and bronchiolitis

56
Q

crackles

A

a crackling, rattling breath sound that signals fluid in the air spaces of the lungs

57
Q

rhonchi

A

course, low-pitched breath sounds heard in patients with chronic mucus in the upper airways

58
Q

tachicardia

A

a rapid heart rate, more than 100 beats/min

59
Q

bradycardia

A

a slow ♡ rate, less than 60 beats/min

60
Q

blood pressure

A

the pressure that the blood exerts agains the walls of the arteries as it passes through them

61
Q

systolic pressure

A

the increased pressure in an artery with each contraction of the ventricles (systole)

62
Q

diastolic pressure

A

the pressure that remains in the arteries during the relaxing phase of the heart’s cycle (diastole) when the left ventricle is at rest

63
Q

hypotension

A

blood pressure that is lower than the normal range

64
Q

hypertension

A

blood pressure that is higher than the normal range

65
Q

mean arterial pressure (MAP)

A

the average pressure in the circulatory system during one cardiac cycle

66
Q

subcutaneous emphysema

A

a characteristic crackling sensation felt on palpation of the skin, caused by the presence of air in soft tissues

67
Q

paradoxical motion

A

the motion of the portion of the chest wall that is detached in a flail chest; the motion — in during inhalation, out during exhalation — is exactly the opposite of normal chest wall motion during breathing
(not bilateral chest movement)

68
Q

guarding

A

involuntary muscle contractions (spasm) of the abdominal wall; an effort to protect the inflamed abdomen

69
Q

pulse oximetry

A

an assessment tool that measures oxygen saturation of hemoglobin in the capillary beds

70
Q

metabolism

A

the biochemical processes that result in production of energy from nutrients within the cells

71
Q

carbon dioxide

A

a component of air that typically makes up 0.03% of air at sea level; also a waste product exhaled during expiration by the respiratory

72
Q

capnography

A

a noninvasive method to quickly and efficiently provide information on a patient’s ventilatory status, circulation, and metabolism; effectively measures the concentration of carbon dioxide in expired air over time

73
Q

reassessment

A

a step within the patient assessment process performed at regular intervals during the assessment process to identify and treat changes in a patient’s condition. a patient in unstable condition should be reassessed every 5 minutes, whereas a patient in stable condition should be reassessed every 15 minutes.

74
Q

what does the assessment process begin with?

A

the scene size up, which identifies real or potential hazards. the patient should not be approached until these hazards have been dealt with in a way that eliminates or minimizes risk to the emts and the patient or patients.

75
Q

What does a primary assessment include?

A

Forming an initial general impression of the patient, including the LOC (loss of consciousness), and identifies any life-threatening conditions to the XABCs

76
Q

Why is a primary assessment performed?

A

To assist in prioritizing time and mode of transport. Any life threats must be treated before moving on to the next step of the assessment.

77
Q

What is the AVPU scale used for?

A

to assess a patient’s LOC depending on how well he or she responds to external stimuli

78
Q

What is the AVPU scale?

A

A - Awake and alert
V - Responsive to verbal stimuli
P - Responsive to pain
U - unresponsive

79
Q

How do you evaluate orientation?

A

by asking about…
- Person: the patient is able to remember their names
- place: the patient is able to identify his or her current location
- time: the patient is able to tell you the current year, month, and day of the week
- event: the patient is able to describe what happened ( the MOI or the NOI)

80
Q

Why are the ABCs assessed?

A

to evaluate the patient’s general condition

81
Q

What does history taking include?

A

An investigation of the patient’s chief complaint or history of present illness.

82
Q

When is a SAMPLE history generally taken?

A

During the history taking. This info can be obtained from the patient, family, friends, bystanders, caregivers, or medical alert devices or documentations

83
Q

What is the SAMPLE mnemonic?

A

Signs/symptoms, allergies, medications, pertinent past history (do you have any current medical conditions?), last oral intake, and events leading up to the illness or injury

84
Q

What is the secondary assessment?

A

A systematic physical examination of the patient. This can be a systematic head-to-toe physical examination or an assessment that focuses on a certain area or region of the body which is often determined through the chief complaint.

85
Q

Why do we do a reassessment?

A

It gives us the opportunity to reevaluate the chief complaint and to reassess interventions to ensure that that are still being delivered correctly. This info may be used to identify and treat changes in the patient’s condition.

85
Q

How often should a patient in stable condition be reassessed?

A

every 15 minutes

86
Q

how often should a patient in unstable condition be reassessed?

A

Every 5 minutes

ems (4 decks)

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