Patient Assessment Details Flashcards
assess the level of consciousness with the _____ scale
AVPU (alert, responds to verbal or painful stimuli, unresponsive)
what questions can you ask to assess mental status?
who, what, when, where
when assessing the airway, the 2 points are earned by…
opening and assessing the airway, then adding an adjunct if indicated
when assessing for breathing, the 4 points are earned by…
assess breathing, initiate appropriate oxygen therapy, assure adequate ventilation, and manage any injury that may compromise breathing/ventilation
when assessing circulation, the 4 points are earned by…
checking the pulse, assess skin, assess and control major bleeding, initiate shock treatment
if you cannot assess the skin well, what is another good place to look?
the sclera, the white portion of the eye
qualities of the skin to assess
the skin’s color, temperature, moisture, and the capillary refill
DCAP-BTLS stands for…
deformity, contusions, abrasions, punctures, burns, tenderness, lacerations, and swelling
deformity is described as…
misshapen body part
contusions are described as…
bruising, blood under the skin
abrasions are described as…
loss of damage to the skin by rubbing or scraping
tenderness is described as…
pain when the area is palpated
OPQRST stands for…
onset, provocation, quality, radiation, severity, and timing
onset can be assessed by asking…
what were you doing when the symptoms started?
provocation can be assessed by asking…
what makes the symptoms worse/better?
quality can be assessed by asking…
how do the symptoms feel? waves, pressure, etc.
radiation can be assessed by asking…
does the pain or symptoms move anywhere? where is the pain?
severity can be assessed by asking…
rate your pain on a scale of 1 to 10
timing can be assessed by asking…
how long have you had the symptoms?
SAMPLE stands for…
signs and symptoms, allergies, medications, past medical history, last oral intake, and events leading to the NOI/MOI
if you hear a brassy crowing sound, it is called…
stridor
what does stridor tell us?
obstruction in the upper airway
if you hear wheezing, what does that tell you?
obstruction and narrowing of the lower airway
if you hear wet, muffled, or _____ in the lungs, we call that…
crackles
crackles in the lungs tell us…
fluid in the lungs
rhonchi breath sounds tell us…
junk in the lungs!
if you hear congested breath sounds or blowing bubbles under water, that tells us…
rhonchi
normal pupils are…
equal, round, good size, and react to light
wheezing occurs with ___ and ____
asthma and bronchoconstriction
crackles and ____ are the same lung sounds that produce…
rales, fluid in the lower airways
turgor means…
the elasticity of your skin, how well it returns back to its normal position.
what does pallor mean?
very pale skin
synonym for sonorous
snoring sound!
if the patient is gurgling, then…
fluids are pooling in the airway and a gag reflex is not present
what are Cheyne-Stokes respirations?
an abnormal breathing pattern characterized by alternating periods of rapid, deep breathing and shallow or absent breathing
what are ataxic respirations?
ineffective, irregular breaths that may or may not have a pattern to them
