Patient Assessment Flashcards

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1
Q

OPQRST

A
  • Onset
  • Provocation
  • Quality
  • 4 R’s (Region, Radiation, Reoccurrence, Relief)
  • Severity
  • Time
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2
Q

AVPU

A
  • Alert (Awake, eyes open, tracks you)
  • Verbal
  • Pain
  • Unresponsive
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3
Q

BRIM

A
  • Breathing
  • Response
  • Eyes
  • Motor
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4
Q

SAMPLE

A
  • Signs + Symptoms
  • Allergies
  • Medications
  • Pertinent past history
  • Last oral intake
  • Events
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5
Q

DCAP

A
  • Deformities
  • Contusions
  • Abrasions
  • Penetration
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6
Q

Steps of SCENE SIZE UP

A
  1. Take standard precautions
  2. Ensure scene safety
  3. Determine MOI/NOI
  4. Number of patients
  5. Additional resources?
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7
Q

General Impression

A
  • Estimate age
  • Sex
  • Trauma or Medical
  • Chief Complaint
  • Note life threats
  • Establish in-line stabilization
  • Sick/Not sick or Stable/Unstable
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8
Q

Onset ([O]PQRST)

A
  • When and how did the symptoms begin.

- Rapid or gradual

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9
Q

Provocation (O[P]QRST)

A
  • What were you doing when it started?

- What makes it better or worse?

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10
Q

Quality (OP[Q]RST)

A

Please describe the pain or condition

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11
Q

4 Rs (OPQ[R]ST)

A
  • Region: Where?
  • Radiation: Does it radiate?
  • Reoccurrence: Constant or comes +goes?
  • Relief: Have you done anything to relieve the pain?
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12
Q

Severity (OPQR[S]T)

A

How bad is the pain on a scale of 0-10?

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13
Q

Time (OPQRS[T])

A
  • What time did it start?

- When did it get so bad that you called 911?

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14
Q

Breathing ([B]RIM)

A
  • General rate and rhythm

- Same as your ABC’s

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15
Q

Response (B[R]IM)

A
  • Oriented
  • Confused
  • Inappropriate words
  • Incomprehensible words
  • No response
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16
Q

Eyes (BR[I]M)

A

Same as AVPU

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17
Q

Motor (BRI[M])

A
  • Obeys commands
  • Localizes Pain
  • Withdraws to pain
  • Flexion
  • Extension
  • No response
18
Q

Signs + Symptoms ([S]AMPLE)

A
  • OPQRST would be Symptoms

- Second assessment would Signs

19
Q

Allergies (S[A]MPLE)

A
  • Drug or Food allergies

- If no known allergies document NKA (No Known Allergies)

20
Q

Medications (SA[M]PLE)

A

-Mostly concerned with prescribed meds.

21
Q

Pertinent part history (SAM[P]LE)

A

-Are they under a doctor’s care for any illnesses?

22
Q

Last oral intake (SAMP[L]E)

A

-This matter for diabetic, surgery etc.

23
Q

Events (SAMPL[E])

A
  • Events leading to this situation

- Good time to re-evaluate assesment findings

24
Q

Pulse

A

-count pulse for 15 sec then x4 or 30 sec x2

-Note:
•Rate
•Rythm (regular/irregular)
•Quality (strong/weak)

25
Q

Respirations

A
  • Same as pulse

- 94% and below requires oxygen

26
Q

Blood Pressure

A
-Systolic
  •Top number
  •Pressure while heart beats
-Diastolic 
  •Bottom number
  •Pressure while heart rests
27
Q

Eyes

A

-Check pupil response

-PERL
Pupils Equal and Reactive to Light

28
Q

Lung sounds

A

-Listen at 3rd intercostal space, mid axillary line

29
Q

Level Consciousness

A
-Patient Orientation 
   •Person 
   •Place
   •Time
   •Event
30
Q

Skin

A

-Check skin pigmentation (It will NEVER LIE TO YOU)

31
Q

Treatment

A
  • Position of Comfort
  • 02 it needed
  • Treat based on Assessment
  • Follow local protocols and scope of practice
32
Q

Reassessment

A
  • Primary Assessment
  • Secondary Assessment
  • Vital Signs
33
Q

Medical Patient

A
  • Focused secondary if patient is able to explain symptoms

- Rapid head to toe for any unconscious or disoriented patient

34
Q

Trauma Patient

A
  • Perform a modified secondary for any stable patient with minor trauma
  • Perform a rapid secondary assessment
35
Q

5 parts of Patient Assessment

A
  1. Scene size up/ Primary Assessment
  2. OPQRST/ BRIM-AVPU
  3. Vital Signs
  4. Secondary Assessment/ History Meds, Allergies
  5. Treatment (Rx)/ Reassessment
36
Q

BTLS

A
  • Burns
  • Tenderness
  • Lacerations
  • Swelling/scars
37
Q

MOI

A

Mechanism Of Injury

38
Q

NOI

A

Nature Of Illness

39
Q

Systolic blood pressure

A

Top number, which is the amount of pressure exerted on the walls of the arteries during the contraction and ejection of blood from the left ventricle.

40
Q

Diastolic blood pressure

A

Bottom number, which is the amount of pressure on the artery walls while the ventricle is at rest and not contracting.