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
