Patient Assessment - History Taking, Secondary Assessment, & Reassessment Flashcards
Provides details about the patient’s chief complaint and an account of the patient’s signs and symptoms
History taking
Info for history taking
- Date of the incident
- Age
- Sex
- Race
- Past medical history
- Current health status
Past medical history should include ___
Pertinent info about the patient’s condition, such as medical problems, traumatic injuries, and surgical procedures
Patient’s current health status should include ___
Diet, medications, drug use, living environment and hazards, physician visits, and family history
Used for gathering additional info about a patient’s history of present illness and current symptoms
OPQRST
OPQRST
- Onset
- Provocation/palliation
- Quality
- Region/radiation
- Severity
- Timing
Negative findings that warrant no care or intervention
Pertinent negatives
Used to obtain a patient’s history
SAMPLE history
SAMPLE
- Signs and symptoms
- Allergies
- Medications
- Pertinent past medical history
- Last oral intake
- Events leading up to the injury or illness
In women of child-bearing age, the “L” in SAMPLE also represents ___
Last menstrual period
The process of going through the steps in a process without considering other options
Cookbook medicine
Steps in critical thinking in assessment
- Gathering
- Evaluating
- Synthesizing
If it is determined to be related to domestic violence
Call the police immediately
Questions to ask a female patient of child-bearing age with lower abdominal pain
- When was the last menstrual period
- If bleeding: How many sanitary pads or tampons have you used
- Do you have urinary frequency or burning
- What is the severity of cramping, and are there any foul odors
- Is there a possibility you may be pregnant
- Are you using any form of birth control
Questions to ask a male patient of child-bearing age with lower abdominal pain about urinary symptoms
- Is there any pain associated with urination
- Do you have any discharge, sores, or an increase in urination
- Do you have burning or difficulty voiding
- Has there been any trauma
If ___, you may choose to perform the secondary assessment at the scene
The patient is in stable condition and has an isolated complaint
If the secondary assessment is not performed at the scene, it is performed ___
In the back of the ambulance en route to the hospital
Purpose of the secondary assessment
To perform a systematic physical examination of the patient
Simply looking at your patient for abnormalities
Inspection
The process of touching or feeling the patient for abnormalities
Palpation
With palpation, your fingertips are best suited for detecting ___, and the back of your hand is best at noting ___
- Texture and consistency
- Temperature
The process of listening to sounds the body makes by using a stethoscope
Auscultation
Secondary assessment steps
- Observe the face
- Inspect the area around the eyes and eyelids
- Examine the eyes for redness and contact lenses. Check pupil function
- Look behind the ears for battle sign
- Check the ears for drainage or blood
- Observe and palpate the head
- Palpate the zygomas
- Palpate the maxillae
- Check the nose for blood and drainage
- Palpate the mandible
- Assess the mouth and nose
- Check for unusual breath odors
- Inspect the neck. Observe for jugular vein distention
- Palpate the front and back of the neck
- Inspect the chest, and observe breathing motion
- Gently palpate over the ribs
- Listen to anterior breath sounds (midaxillary and midclavicular)
- Inspect the back. Listen to posterior breath sounds (bases, apices)
- Observe and then palpate the abdomen and pelvis
- Gently compress the pelvis from the sides
- Gently press the iliac crests
- Inspect the extremities; assess distal circulation and motor and sensory function
- Log roll the patient, and inspect the back for tenderness or deformities
A brassy crowing sound prominent on inspiration
Stridor
Sounds of stridor suggest ___
A partially occluded upper airway caused by swelling
High-pitched crowing sounds may indicate ___
An upper airway obstruction from a foreign body
Inhalation to expiration ratio
1:3
Assess breathing by ___
- Watching the chest rise and fall
- Listening to breath sounds with a stethoscope over each lung
- If unconscious, feeling for air through the mouth and nose during exhalation
Info to obtain while assessing breathing
- Respiratory rate
- Rhythm
- Quality
- Depth
Two rhythms of breathing
- Regular
- Irregular
Through a stethoscope, normal breathing sounds like
Just the sound of air movement through the bronchi accompanied by a soft, low-pitched murmur
If you hear bubbling or gurgling in the upper airway, the patient ___
Probably has fluid in those passages, potentially impeding the exchange of gases
Sputum
Matter from the lungs
A patient who coughs up thick, yellow or green sputum most likely has ___
A respiratory infection
Where to place the stethoscope when listening to the lungs
On the back,
1. Over the upper lungs a about 1” below the clavicle at the midclavicular line
2. The midlung fields at the third or fourth intercostal space from the patient’s posterior
3. Lower lungs at the sixth intercostal space, midaxillary line
Wheezing breath sounds suggest ___
An obstruction or narrowing of the lower airways
A high-pitched whistling sound that is most prominent on expiration
Wheezing
Wet, crackling breath sounds on both inspiration and expiration
Crackles
Crackles may indicate
Fluid in the lungs
Low pitched, noisy sounds that are most prominent on expiration. Similar to blowing bubbles underwater. Typically associated with a productive cough. Congested breath sound
Rhonchi
What to assess with a pulse in secondary assessment
- Rate
- Quality
- Rhythm
An adult patient with a pulse rate greater than 100 bpm
Tachycardia
An adult patient with a pulse rate less than 60 bpm
Bradycardia
Describe a pulse that feels to be at normal strength as ___
Strong
Stronger than normal pulse
Bounding
Pulse that is weak or difficult to feel
Weak or thready
If an irregular pulse is found, it’s important to determine if ___
It represents a new condition or a normal or chronic condition for the patient
A decrease in blood pressure may indicate one of the following ___
- Loss of blood or its fluid components
- Loss of vascular tone and sufficient arterial constriction to maintain the necessary pressure
- Cardiac pumping problem
Decreased blood pressure indicates the patient is in the critical stage of ___
Decompensated shock
Three sizes of blood pressure cuffs normally carried
- Thigh
- Adult
- Pediatric
The sounds of the turbulence and arterial vibrations that are listened to when taking blood pressure
Korotkoff sounds
What to look for on the arm before using it to measure blood pressure
- Dialysis fistula
- Central lines
- Mastectomy
- Injury to the arm
- Other reason not to use the arm
Antecubital space
Crease inside the elbow
How high should the BP cuff be placed?
Across the upper arm with its distal edge about 1” above the antecubital space
How high should the arm be when measuring BP?
About heart level
Where to place the stethoscope with measuring BP?
Over the brachial artery in the antecubital fossa
Antecubital fossa
The anterior aspect of the elbow
How high to pressurize the BP cuff?
200 mm/Hg or 30 mm/Hg above the point you stop hearing pulse sounds
If pulse sounds are heard all the way until the BP cuff reads 0, ___
Record the diastolic as 0 or indicate that it was heard until the gauge read 0
Two methods to measure BP
- Auscultation
- Palpation
How to record a palpated BP
120/P
Blood pressure lower than the normal range
Hypotension
Blood pressure higher than the normal range
Hypertension
After taking BP in the uninjured limb, you might want to compare ___ with the injured limb
- Distal skin temp
- Quality of distal pulse
- CRT
A MAP of greater than ___ is needed to adequately perfuse the vital organs of an adult
65
Normal systolic BP for an adult
90 - 120
Normal systolic BP for an adolescent
110 - 131
Normal systolic BP for a child (7 years)
97 - 115
Normal systolic BP for a child (2 years)
86 - 106
Normal systolic BP for an infant
72 - 104
Normal systolic BP for a neonate
67 - 84
Normal pulse rate for adults and children over 10 years old
60 - 100
Normal pulse rate for preschoolers and school aged children (2 - 10 years old)
60 - 140
Normal pulse rate for infants and toddlers (3 months to 2 years)
100 - 190
Normal pulse rate for infants (up to 3 months)
85 - 205
A neurological assessment should be completed anytime you are confronted with a patient who ___
Has changes in mental status, A possible head injury, stupor, dizziness, drowsiness, or syncope
Evaluate ___ to determine the patient’s ability to think. Use the ___ if appropriate to determine the patient’s mental status
- The LOC and orientation
- AVPU scale
Helpful in providing additional information on patients with changes in mental status
Glasgow Coma Scale (GCS)
GCS
Glasgow Coma Scale
How to report GCS
Note each category score and the total
GCS categories
- Eye opening
- Best verbal response
- Best motor response
The diameter and reactivity to light of the pupils can reflect the status of ___
The brain’s perfusion, oxygenation, and condition
Normally unequal pupils
Anisocoria
What are the pupils being evaluated for?
- Become fixed with no reaction to changes in light
- Dilate with bright light and constrict when light is removed
- React sluggishly instead of briskly
- Become unequal in size
- Become unequal in size when a bright light is introduced or removed from one eye
Some causes of depressed brain function
- Injury of the brain or brainstem
- Trauma or stroke
- Brain tumor
- Inadequate oxygenation or perfusion
- Drugs or toxins (CNS depressants)
GCS eye opening scale
4 - Spontaneous
3 - In response to sound
2 - In response to pressure
1 - None
GCS verbal response scale
5 - Oriented conversation
4 - Confused conversation
3 - Inappropriate words
2 - Incomprehensible sounds
1 - None
GCS motor response scale
6 - Obeys commands
5 - Localizes to pressure
4 - Withdraws from pressure
3 - Abnormal flexion
2 - Abnormal extension
1 - None
If a GCS category can’t be tested, note ___
NT or not testable
GCS score of ___ may indicate mild dysfunction
13 - 15
GCS score of ___ indicates no neurological impairment
15
GCS score of ___ may indicate moderate dysfunction
9 - 12
GCS score of ___ is indicative of severe dysfunction
8 or less
Mnemonic used to assess pupils
PEARRL
PEARRL
Pupils
Equal
And
Round
Regular in size
react to Light
How to record PEARRL
Pupils = PEARRL
or
Pupils are equal and round, regular in size, and react properly to light
,If an abnormalities with the pupils are found, report it ___
Using the long form
What are you checking for during a hands-on assessment of neurovascular status?
- How does the patient move
- Check bilateral muscle strength and weaknesses
- Sensory assessment of pain, sensations, and positions
- Compare distal and proximal sensory & motor responses on one side to the other
Steps to assess neurovascular status in a conscious patient
- Palpate the radial pulse
- Palpate the posterior tibial and dorsalis pedis pulse
- Assess capillary refill
- Assess sensation on the flesh near the tip of the index finger, thumb, and the little finger
- Check sensation on the flesh near the tip of the big toe
- Check sensation on the side of the foot
- (For upper extremity injury) Evaluate motor function by asking the patient to open the hand (only if hand or foot not injured, stop if it causes pain)
- Ask the patient to make a fist
- (For lower extremity injury) Ask the patient to flex the toes and foot (ask the patient to “push down on the gas)
- Ask the patient to extend the foot and ankle and pull toes and foot towards the nose
How to assess Head, neck, and cervical spine
- Gently palpate the scalp and skull for any pain, deformity, tenderness, crepitus, and bleeding (ask a conscious patient if they feel any pain or tenderness)
- Patient’s face symmetrical? Evidence of trauma, such as ecchymoses or hematomas?
- Facial expressions such as a smile or grimace?
- Assess pupillary function, shape, and response. PEARRL
- Check the color of the sclera
- Assess cheek bones (zygomas) for possible injury
- Check ears and nose for fluid
- Check the upper (maxillae) and lower (mandible) jaw
- (If movement of jaw won’t cause pain or injury) Open the mouth and look for broken or missing teeth
- Note any unusual odors in the mouth
- Check the neck for signs of swelling or bleeding
- Palpate the neck for signs of trauma, such as deformities, bumps, swelling, bruising, and bleeding, as well as a crackling sound produced by air bubbles under the skin
- (If no spinal injury is suspected) Inspect for pronounced or distended jugular veins with the patient sitting at a 45º angle (normal finding in supine patient, not sitting up)
Distended jugular veins while sitting up suggests a problem with ___
Blood returning to the heart
Air bubbles under the skin
Subcutaneous emphysema
How to assess the chest
- Inspect, visualize, and palpate over the chest area for injury and signs of trauma, including bruising, tenderness, and swelling
- Watch for both sides of the chest to rise and fall together with breathing
- Observe for abnormal breathing signs, including retractions or paradoxical motion
- Feel for grating bones and the patient breaths
- Palpate the chest for subcutaneous emphysema (especially in cases of severe blunt chest trauma)
- (If patient reports breathing difficulty or has evidence of chest trauma) Auscultate breath sounds
Only one section of the chest rises on inspiration while another area of the chest falls
Paradoxical motion
Retractions indicate ___
The patient has some condition, usually medical, that is impairing the flow of air into and out of the lungs
Paradoxical motion is associated with ___
A fracture of several ribs (flair), causing a section of the chest to move independently from the rest of the chest wall
___ is often associated with rib fractures
Crepitus
Subcutaneous emphysema in the chest could indicate ___
Pneumothorax
How to assess the abdomen
- Look for trauma and distention
- Palpate for tenderness, rigidity, and patient guarding
- (If awake and alert) Ask about pain as you perform the examination
- Assess for rebound tenderness
How to report findings on abdomen palpation assessment
Firm, soft, tender, or distended
What quadrant of the abdomen to start with when palpating?
The quadrant is furthest from the pain
Pain created when pressure is released
Rebound tenderness
Involuntary muscle contractions of the abdominal wall; an effort to protect the inflamed abdomen
Guarding
How to assess the pelvis
- Inspect for symmetry and obvious signs of injury, bleeding, and deformity
- (If no pain is reported) Gently press downward and inward on the pelvic bones (do not rock the pelvis)
If when assessing the pelvis you feel any movement or crepitus or the patient reports any pain or tenderness, ___
Severe injury may be present
How to assess extremities
- Do all extremities appear to be properly positioned and functioning normally?
- (If standing) assess posture
- Look at joints, check for range of motion (ask patient move on their own, never force a painful joint to move)
- Compare both sides for weakness, atrophy, and assess equality of grip strength
- Inspect each extremity for symmetry, cuts, bruising, swelling, obvious injuries, and bleeding
- Palpate along each extremity for deformities (ask about any tenderness or pain)
- Check for distal pulses for rate, quality, and rhythm
- Check for motor function by asking the patient to wiggle the fingers and toes
- Evaluate sensory function by asking the patient to close their eyes. Gently squeeze or finch each finger or toe and ask the patient to identify what you are doing
Inability to feel sensation in the extremity may indicate ___
A local nerve injury
Inability to feel sensation in several extremities may be a sign of ___
Spinal cord injury
How to assess the posterior body
- Inspect the back for DCAP-BTLS, symmetry, and open wounds
- Carefully palpate the spine from the neck to the pelvis for tenderness and deformity
Assessment tool used to evaluate the effectiveness of oxygenation
Pulse oximetry
What is a pulse oximeter
Photoelectric device that monitors the oxygen saturation of hemoglobin in the capillary beds
Most pulse oximetry readings are ___
94% to 99%
The goal of applying oxygen therapy
Increase oxygen saturation to a normal level
With the pulse oximeter, any situation that causes ___ will result in misleading or inaccurate values
Vasoconstriction or loss of red blood cells
To get an idea about the patient’s metabolism and adequacy of ventilation, you can measure ___ as the patient exhales
CO2 levels in the air
Noninvasive method that can quickly and efficiently provide info on a patient’s ventilation, circulation, and metabolism
Capnography
Waveform capnography shows a graph that indicates ___
How easily, how frequently, and how much the patient is exhaling CO2
Capnography monitors can be attached to ___
The end of an advanced airway or onto a nasal cannula
Capnography is used to evaluate ___
The effectiveness of breathing treatments and of artificial ventilation and to confirm endotracheal tube placement. It is correlated to lactic acid values in patients with septic shock
If the glucose level is low, this can help you identify the ___
Reason a patient is unresponsive
If the glucose level is high in a patient with nausea, vomiting, abdominal pain, and a change in mental status, it may signal ___
Dangerous complications of high blood glucose
Blood glucose should be assessed in all patients who ____
Are known to have diabetes, have an altered mental status, or have a generalized malaise or weakness. May also be assessed in any patient who you think has a poor general impression
Steps to assess blood glucose levels
- Take standard precautions. Cleanse the site with antiseptic (finger)
- Puncture the site with the lancet
- Dispose of the needle in a sharps container
- Obtain a drop of blood on the test strip. Insert into the glucometer
- Bandage the puncture site
When faced with electronic BP readings that do not correlate with a patient’s clinical presentation, it is best to ___
Obtain a manual reading to confirm
A ___ is performed at regular intervals during the assessment process, and its purpose is to ID and treat changes in a patient’s condition
Reassessment
Reassessment should take place ___
- Every 15 minutes for patients in stable condition
- Every 5 minutes for patients in unstable condition
Steps to reassessment
- Repeat the primary assessment
- Reassess vital signs
- Reassess the chief complaint
- Recheck interventions
- ID and treat changes in the patient’s condition
- Reassess patient
When reassessing the chief complaint, what questions should be asked?
- Is the current treatment improving the patient’s condition?
- Has an already identified problem gotten better?
- Has an already identified problem gotten worse?
- What is the nature of any newly identified problems?
