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Patient Assessment Abbreviations > Patient Assessment Abbreviations > Flashcards

Patient Assessment Abbreviations Flashcards

1
Q

BSI

A

Body Substance Isolation (BSI). Those items that act as a barrier to body fluids, ie. latex gloves.

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2
Q

NOI

A

Nature Of Illness (NOI): This describes a medical emergency.

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3
Q

MOI

A

Mechanism Of Injury (MOI) This describes a trauma.

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4
Q

C-Spine

A

Cervical Spine

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5
Q

LOC

A

Level Of Consciousness measured using AVPU. Are they alert, verbal, respond to pain, or are they unresponsive.

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6
Q

AVPU

A

What you use to determine Level Of Consciousness (LOC). Are they (A) alert, (V) verbal, respond to (P) pain, or are they (U) unresponsive.

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7
Q

CC

A

Chief Complaint. What the patients main complaint is, ie. my chest hurts, or my leg is injured.

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8
Q

CAB

A

THE MOST IMPORTANT THING!!! When you see your patient for the first time you need to immediately check to see if the have blood (C) circulating in their body - typically done by checking the pulse. Check to see if they have an open (A) airway - nothing in the way of their breathing. You need to check to see if they are (B) breathing - and breathing fast enough.

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9
Q

SAMPLE

A

SAMPLE is used to help you remember what you need to ask your patient. S = Signs and Symptoms (Know the difference between signs and symptoms) A = Questions about allergies. M = Questions about medication. P = Past pertinent history. L = Last oral intake - when did the patient last eat or drink. E = Events leading to the medical/trauma problem.

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10
Q

S in SAMPLE

A

In SAMPLE. S = Signs and Symptoms. Signs are things you see on your patient, ie. sweat, blue skin, hives, rash.

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11
Q

A in SAMPLE

A

In SAMPLE. All questions you ask your patient about (A) allergies. “Are you allergic to anything?”

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12
Q

M in SAMPLE

A

In SAMPLE. All questions you ask your patient about (M) medications, ie. Are you on any medications? Are you on any new medications? Are you taking any recreational drugs? Have you recently stopped taking any drugs?

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13
Q

P in SAMPLE

A

In SAMPLE. All questions you ask your patient about (P) past pertinent history, ie. Has this happened before? Is this related to anything?

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14
Q

L in SAMPLE

A

In SAMPLE. All questions you ask your patient about their (L) last oral intake, ie, when was the last time you ate something? When was the last time you drank something?

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15
Q

E in SAMPLE

A

In SAMPLE. All questions you ask your patient about (E) events leading up to the medical/trauma problem.

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16
Q

OPQRST

A

OPQRST is used to help you remember what you need to ask your patient. O = Onset. P. Provoke. Q = Quality of Pain. R = Radiates.
S = Severity of Pain (1-10 scale). T = Time oriented questions

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17
Q

O in OPQRST

A

In OPQRST. When was the onset of this problem? When did this problem start?

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18
Q

P in OPQRST

A

In OPQRST. What provoked this problem? What made it hapen?

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19
Q

Q in OPQRST

A

In OPQRST. What is the quality of the pain? Describe the pain to me. Is it a sharp pain, a dull pain?

20
Q

R in OPQRST

A

In OPQRST. Is the pain radiating? Does the pain or sensation move.

21
Q

S in OPQRST

A

In OPQRST. What is the severity of the pain. On a scale of 1 to 10, 10 being the worst pain you ever felt, and 1 almost no pain, how would you rank it?

22
Q

T in OPQRST

A

In OPQRST. Any time questions. How often? How far apart?

23
Q

hx.

A

History

24
Q

R/O

A

Rule Out. Based on the questions I asked I know what the problem isn’t. I have ruled it out.

25
Q

O2T

A

Oxygen Therapy. Anytime you administer (give) oxygen.

26
Q

NC

A

Nasal Canula is the tube that goes in the nostrils to deliver oxygen

27
Q

NRM

A

None Rebreather Mask. The mask with the sack that delivers high flow oxygen to a patient that is breathing.

28
Q

BVM

A

Bag Valve Mask is the oxygen delivery devise you squeeze to force oxygen into your patient.

29
Q

BVMA

A

Bag Valve Mask Assist. When you use the BVM to assist someone in breathing - used when the patient is breathing too fast or too slow.

30
Q

BVMV

A

Bag Valve Mask Ventilate. When you use the BVM to breath for a patient that is NOT breathing on their own.

31
Q

DCAPBTLS

A

DCAPBTLS is used to remind you what to look for when checking the patients body.

32
Q

D in DCAPBTLS

A

In DCAPBTLS. Deformities. Anything that loo

33
Q

C in DCAPBTLS

A

In DCAPBTLS. Contusion - a big bruise.

34
Q

A in DCAPBTLS

A

In DCAPBTLS. Abrasion - a scrape.

35
Q

P in DCAPBTLS

A

In DCAPBTLS. Puncture - a hole in the body created by the penetration of a sharp object.

36
Q

B in DCAPBTLS

A

In DCAPBTLS. Burns or bruises

37
Q

T in DCAPBTLS

A

In DCAPBTLS. Tenderness. Always ask the patient if what you are inspecting hurts.

38
Q

L in DCAPBTLS

A

In DCAPBTLS. Laceration - A slice in the skin or flesh.

39
Q

S in DCAPBTLS

A

In DCAPBTLS. Swelling - Something that is larger than normal due to an injury, ie. a swollen ankle.

40
Q

GSW

A

Gun Shot Wound

41
Q

FX

A

Fracture - a broken bone

42
Q

CSM

A

Circulation - Sensory - Motor: What you need to check for in the hands and foot.

43
Q

C in CSM

A

In CSM - Circulation: There is a pulse and capillary refill under the nail bed.

44
Q

S in CSM

A

In CSM - Sensory: Check to see the patient can feel which finger or toe you are touching.

45
Q

M in CSM

A

In CSM - Motor: Check to see the patient is able to move fingers and toes.

46
Q

JVD

A

Jugular Vein Distention - Jugular veins in the neck sticking out. Sign of heart problem.

47
Q

ETA

A

Estimated Time of Arrival - When you will be arriving.

Patient Assessment Abbreviations (1 decks)

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