Patient Assessment System

Question 1

Hand Hygiene

Answer 1

• soap and water for at least 20 seconds
• sanitizer with at least 60% alcohol
• hands can’t be too dirty for sanitizer

Question 2

Masks

Answer 2

• N95 filters air intake
• cloth masks on filter air on outtake

Question 3

ABCDE Assessment Sequence

Answer 3

airway, breathing, circulation, disability, expose

Question 4

Assess the Airway

Answer 4

• open the airway
• clear obvious obstructions
• observe any labored breathing

Question 5

Assess for Breathing

Answer 5

• look for chest movement - listen for sound of air passing through the upper airway
• if breathing is labored check for injuries on chest

Question 6

Assess for Circulation

Answer 6

check pulse
- carotid artery on neck for at least 10 seconds
- next try radial artery in the wrist

look for severe bleeding

Question 7

Decision on Disability

Answer 7

Deside if further spine protection is needed
- if there is spine injury consider jaw thrust to open airway

Question 8

Expose

Answer 8

Expose and examine major injuries
- without moving patient search for major injuries that may be hidden under clothing

Question 9

ABC or CAB?

Answer 9

CAB is more appropriate for cardiac arrest to begin CPR faster.
- still need to complete all letters of alphabet

Question 10

Secondary Assessment.

Answer 10

• consider the needs of the patient and rescuers
• head to toe physical exam, measurement of vital signs, and a medical history
• see chart for head to toe exam

Question 11

Head

Answer 11

• check ears and nose for fluid and mouth for injusries that may affect airway
• observe face for symmetry
  feel skull for depressions or tenderness
• run fingers through hair to detect bleeding/cuts
• check eyes for injuries or pupil abnormalities and ask about vision

Question 12

Neck

Answer 12

the trachea/windpipe should be in the middle of nect
- feel entire cervical spine from base of skill to top of shoulders to identify pain or issues

Question 13

shoulders

Answer 13

examine shoulders/collar bones for injury
- if possible touch along entire length of collar bones

Question 14

arms

Answer 14

• feel arms from armpit to wrist
• check circulation, sensation, and motion (CSM)
• check radial pulse
• ask patient about any unusual sensations
• have patient squeeze your hands and extend their wrist

Question 15

Chest

Answer 15

• feel chest for deformity or tenderness
• push in from the sides
• ask patient to breathe deeply as you compress the chest
• observe semetry during breathing

Question 16

Abdomen

Answer 16

• feel abdomen for tenderness or muscle rigidity with light pressure
• look for distension, discoloration, and bruising

Question 17

Back

Answer 17

• feel each vertebra from the neck to pelvis
• logroll patient if needed

Question 18

Genitals

Answer 18

check genitals if requested

Question 19

legs

Answer 19

• check legs from groin to ankle
• check CSM in feet one foot at a time
• check pulse or visually inspect any discoloration and check for warmth
• ask patient about any sensations in legs/feet
• assess sensitivity for light touch on small and big toe
• ask patient to push and pull feet against hand pressure

Question 20

Vital Signs

Answer 20

Objective indicators of airway, breathing, circulation, brain function, and body temperature.
responsiveness
pulse
respiration
skin
blood pressure
pupils
temperature

Question 21

measuring vital signs

Answer 21

• general rule measure and record vital signs every 15-20 minutes. (more frequent if patient is bad)

Question 22

Level of Responsiveness (LOR)

Answer 22

Brain function or mental status. Assess and classify using AVPU

Question 23

AVPU

Answer 23

• Awake
• Verbal - not awake but responsive to a verbal stimulus (try louder)
• Pain - not awake but responsive to only a painful stimulus.
• Unresponsive

*(to stimulate pain, pinch muscle at back of shoulder or neck, rub the sternum with knuckles, or squeeze a fingernail)

Question 24

AVPU Awake Scale

Answer 24

A+Ox4 - knows person, place time and event
A+Ox3 knows person, place, time, but not event
A+Ox2 knows person and place, but not time or event
A+Ox1 nows person, but not place, time or event

A+Ox0 - none of above = ‘disoriented’
PPTE - person place time event
A - Awake
O - oriented

Question 25

Heart Rate, rhythm, Strength

Answer 25

normal pulse is 50-100 per minute. Can count for 15 seconds and multiply by 4 or for 30 sec x 2.

note the rhythm and quality or strength of pulse. irregular can be associated with heart disease.

Question 26

skin pigmentation degrees

Answer 26

pinkness (adjective pink,
- redness - heat stroke, carbon monoxide poisoning, fever, or allergic reation.
- paleness - blood has withdrawn due to fridht, shock, fainting, or cooling of the skin.
- cyanosis - blue skinlevel of oxygen in the blood falls or that the patient may be cold
- jaundice - yellow skin or eyes is a sign of liver or gallbladder disease. result of excess bile pigment in the blood.

Question 27

skin - temperature and moisture

Answer 27

face hands may be bad
check body trunk
healthy - warm and relatively dry
fever or heatstroke - Hot/Dry or sweaty/dry

Question 28

skin assessment points

Answer 28

Color
Temperature
Moisture

Question 29

Respiratory Rate, Rhythm, Effort

Answer 29

Report by rate, rhythm, effort, depth, noises, and odors

normal adult breathing is 12-20 per minute (or 3-5 per 15 seconds)

depth and effort

noisy breathing can indicate airway obstruction

smell breath (fruity, acetone + diabetic coma). Foul, fecal smell - a bowel obstruction)

Question 30

Temperature

Answer 30

can be measured orally, rectally, ear, forehead.

ear and forehead are unreliable fore cold person

Question 31

Pupils

Answer 31

clues to brain function to indicate head or eye injury, stroke, drug abuse, or lack of oxygen to brain.

both should be round and equal in size, contract symmetrically when exposed to light and dilate when light dims.

very small equal pupils - drugs?

Question 32

blood pressure

Answer 32

without proper gear, pulse check is helpful. if pulse to limbs is low it’s likely pressure is too and potential shock.

Question 33

medical history

Answer 33

background that may be relevant to current problem.

Question 34

OPQRST

Answer 34

• Onset - suddenly/gradually?
• Provokes/Palliates -what provoked injury?
• Quality - (stabbing, cramping, sharp, dull, or aching)?
• Radiates/Region/Referred
  Where is it? move or radiate? what causes it to move?
• Severity - scale of 1-10 (10 worst)
• Time/Trend - when did it start? frequency? how long does it last? is it getting better or worse?

Question 35

SAMPLE

Answer 35

Symptoms
- (nausea, dizziness, headache)?
Allergies
-exposure?
Medications
- (+ non perscription medications and drugs/alcohol)?
Pertinent medical history
- start with ‘have you been to the hospital ever or do you have physician. (medical tags or forms)
Last intake and output
- when last ate/drank. clear urine = hydration
direa/vomiting may suggest dehydration.
Recent Events
- anything unusual in past few days? (ie changes in diet)

Question 36

The Assessment

Answer 36

review of information gather and development of ‘problem list’

Question 37

The Plan

Answer 37

prioritize the problem list and develop treatment plan

Question 38

SOAP Report

Answer 38

-Subjective/Summary/Story
Objective/Observations/Findings

Assessment

Plan

Question 39

Extended Patient Care

Answer 39

Daily Needs
- warm, clean and comfortable
- water, clear soups and juices
- avoid lots of sugar or caffeine
- excess sugar can delay fluid absorption
excess caffeine increase fluid loss
- eating may not be good for damaged airway
- arrange to go to bathroom best you can (pee in bottle diaper, bed pan, or t shirt used as diaper)

Question 40

Emotional Support: Psychological First Aid

Answer 40

avoid making promises you are unsure of “your going to be just fine”
- no blame

Question 41

Evauation Decision

Answer 41

A thorough patient assessment is important for accurate evac plan.