Pt Assessment Flashcards
Stethoscope
Used to auscultate sound and vibrations
Otoscope
Used to visualize the inner ear and tympanic membrane (eardrum)
Ophthalmoscope
Used to examine the inside of an eye
Thermometer
Used to measure the pt core body temp
4 Examination Techniques
Inspection, Auscultation, Percussion, Palpation
Inspection
Visual observation
Auscultation
Sense of hearing to obtain physical findings
Percussion
Consists of striking the surface of the body emitting sounds of varying pitch
Palpation
The act of feeling with the hand
Induration
feeling of firmness in the subcutaneous tissue, associated with hemorrhage, infection, or inflammation
Fluctuance
Wavelike motion felt when palpating a fluid-filled structure
Voluntary Guarding
Conscious contraction of the abdominal muscles
Involuntary Guarding
Subconscious contracting of muscles
Respiration
Exchange of carbon dioxide and oxygen between the alveoli and blood vessels
Ventilation
Inhalation and exhalation of air
Tidal Volume
Volume of air moved in and out of the lungs during normal breath
Minute Volume
Amount of air in and out of the lungs in 1 minute/ multiply tidal volume by respiratory rate
Pulse Pressure
difference between systolic and diastolic
AVPU
Used in assessing mental status/ Alert, Verbal, Pain, Unresponsive
Comprehensive Patient Assessment System
Scene size up, Initial assessment, reassessment
Scene size up components
Safety, Number, Mechanism of injury
Purpose of Primary Survey (Initial Assessment)
Find life-threatening conditions and fix them
Critical Body Systems
Respiratory, Circulatory, and Nervous System
General Appearance Includes:
Appearance, Breathing, Circulation
Pt Appearance Refers To:
Mental status, muscle tone, and body position
Abnormal Body positions:
Sniffing Position, Tripod position, head bobbing
Breathing
Presence or absence of visible movement of the chest or abdomen
Circulation
Perfusion ( Skin color )
6 Immediate Life Threats are:
Uncontrolled airway, inadequate breathing, pulselessness, severe bleeding, decreased level of consciousness, and potential spinal injury
3 parts of Secondary Survey
Physical exam, vital signs, SAMPLE history
DCAPBTLS
Deformities, Contusions, Abrasions, Punctures, Bruising, Tenderness, Lacerations, Swelling
Skin Turgor
Skin’s resistance to deformation when pinched
Lesions
Disruptions in the structure of the skin
Clubbing
Flattening of the nail base more than 160 degrees associated with chronic hypoxia
Battle’s Sign
Significant bruising around the mastoid process (behind the ears)
Raccoon Eyes
Bruising around the orbits of the eyes
Exophthalmia
“bug eyed” often appears in pt with grave’s disease
Grave’s Disease
Hyperthyroidism
Nystagmus
pauses in eye motion (often observed when pt look to the side or down)
Diplopia
Double vision
Bruits
Sound made when blood in an artery passes over built up plaque
Vesicular Lung Sounds
Soft, Low pitched sounds heard over healthy lung tissue
Bronchovesicular lung sounds
Medium pitched sounds heard mainly over the major bronchi
Bronchial lung sounds
High Pitched sounds normally heard only over the trachea/manubrium
Crackles
High pitched crackling sounds caused by air passing through moisture
Rhonchi
Loud, low, coarse sounds caused by buildup of mucus or fluid in the trachea or large bronchi
Wheezes
High-pitched whistling sounds caused by air moving through narrowed passages
Friction Rub
Sound like two pieces of sandpaper rubbing together
PMI (Point of maximum impulse)
Fifth intercostal space just lateral to the midclavicular line( hearts apex) Point where the heartbeat is most strongly felt.
S1 sound
“Lubb” sound of the tricuspid and mitral valves closing at the beginning of systole
S2 Sound
“dupp” sound which signals the closing of the pulmonic and aortic valves at the beginning of diastole
Heart Murmor
Whooshing sound that usually follows S2 (abnormal sound that indicates the valve may not be fully closing)
Ecchymosis
Bruising and may suggest internal bleeding
Grey-Turner’s Sign
Bruising of the flanks (May be seen in acute pancreatitis, trauma, and rupturing AAA)
Cullen’s Sign
Yellow Bruising of the umbilical region (may be seen in pancreatitis, or ectopic pregnancy)
Rebound Tenderness
Tenderness that occurs when pressure is released during palpation
STOPEATS
mneumonic for possible causes of LOC, Sugar, Temperature, Oxygen, Increased intracranial pressure, electricity, alcohol, toxins, salts
Decorticate posturing
Flexing
Decerebrate posturing
extension
Assessment Based Management
Taking info from assessment and using it to treat the pt
Pattern Recognition
Determining whether pt’s presentation fits with the pathophysiologic signs and symptoms of illnesses or injuries
Pattern Response
Anticipating the equipment and care needed based on pt history and PE
Tunnel vision
Focusing on one aspect of the situation without taking into account of all possibilities
Resuscitative Approach
Do what you have to on scene and then transport the pt (used when pt has life threatening problems that you can help fix or stabilize)
Contemplative Approach
Conduct the History and PE first then provide interventions as necessary ( Immediate intervention not necessary)
Evacuation approach
Immediate evacuation to the ambulance for transport (Pt needs life saving interventions you can’t provide, or scene is unsafe, unstable or too chaotic)
