Patient Assessment, ASA classification, documentation Flashcards

1
Q

What is a class one mallampati score

A

full visibility of tonsils, uvula, and soft palate

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2
Q

What is a class two mallampati score

A

hard and soft palate visible, upper portion of tonsils and uvula visible

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3
Q

What is a class three mallampati score

A

hard and soft palate visible, base of uvula visible

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4
Q

What is a class four mallampati score

A

only hard palate visible

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5
Q

What is the significance of a mallampati score

A

the higher the mallampati score, the more difficult it is to intubate the patient.

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6
Q

What is the outline for written documentation

A
SOAP
Subjective (what the patient tells you, CC)
Objective (your findings, measurements)
Assessment (diagnosis, conclusion)
Plan (planned and performed treatment)
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7
Q

What is the outline for Oral communication

A

SBAR
Situation (what’s going on with the patient)
Background (How did we get to this point)
Assessment (What do you think the issue is)
Recommendation (What do you recommend we do)

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8
Q

Results through relationships, Relationships before tasks

A

Results through relationships, relationships before tasks

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9
Q

What kinds of things do you look for as a general assessment

A

countenance (happy or sad)
Distress (pain) of no acute distress (NAD)
Physically healthy or not

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10
Q

What should you remember when doing a general assessment

A

you need to make judgements, but you should not be judgemental

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11
Q

What is the History of present illness (HPI)

A

an elaboration on the patient’s chief complaint. relevant symptoms and characteristics of the symptoms

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12
Q

What does PMH stand for

A

Past medical History

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13
Q

What does PDH stand for

A

Past dental history

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