*(PT III. Chapter 8) History Taking, Vital Signs, And Monitoring Devices Flashcards
What are associated symptoms?
Anything the patient complains of in addition to the chief complaint.
What is glucometry?
Assessment of blood glucose levels.
What are pertinent negatives?
Anything relevant to the chief complaint that the patient denies.
What is trending in patient care?
Routine monitoring and reassessment to identify changes.
What is the chief complaint?
The patient’s primary reason for calling EMS.
What should be included in the History of Present Illness (HPI)?
- Basic patient information (age, sex, weight).
- Additional information about the chief complaint.
- Associated signs and symptoms.
- General health status.
- Past medical history.
- Medications.
- Allergies.
What are open-ended questions, and when are they used?
- Require descriptive responses, not just “yes” or “no.”
- Used when more detail is needed from the patient’s perspective.
Examples:
- “Why did you call for help today?”
- “How would you describe the pain?”
What are closed questions, and when are they used?
- Can be answered with “yes” or “no.”
- Preferred when time is short or the patient has difficulty speaking.
Example: “Are you choking?”
What are active listening techniques?
- Maintain eye contact and show you are listening.
- Repeat what the patient says to clarify and elicit more information.
- Avoid interrupting or making biased or judgmental statements.
- Show empathy and ask important questions first.
What is the SAMPLE history mnemonic?
- Signs and Symptoms: Objective findings (e.g., wheezing) and subjective feelings (e.g., pain).
- Allergies: Includes Rx, OTC, and food allergies.
- Medications: Current and recent medications, including illicit drugs.
- Past Pertinent History: Relevant past medical history.
- Last Oral Intake: Most recent food and fluid intake.
- Events Leading to Incident: Details about events causing the complaint.
What is the OPQRST mnemonic for symptom assessment?
- Onset: “What were you doing when the pain started?”
- Provocation: “Does anything make it better or worse?”
- Quality: “How would you describe the pain?”
- Radiation: “Does the pain move anywhere?”
- Severity: “Rate the pain on a scale of 0 to 10.”
- Time: “When did the pain start?”
What are associated symptoms and pertinent negatives?
- Associated Symptoms: Additional symptoms related to the chief complaint.
- Pertinent Negatives: Relevant symptoms the patient denies.
What are special considerations for sensitive topics?
- Limit questions to necessary and relevant ones.
- Be direct, professional, and non-judgmental.
- Provide as much privacy as possible.
What are examples of challenging patient situations?
- Patients under the influence of alcohol or drugs.
- Victims of assault or abuse.
- Non-communicative or overly talkative patients.
- Anxious or frightened patients.
- Patients with cognitive disabilities or behavioral problems.
- Hostile or threatening patients.
- Pediatric patients.
How is respiratory rate assessed?
Observe the chest rise and fall or auscultate with a stethoscope. Count breaths for 30 seconds and double it for breaths per minute.
What are normal respiratory rates?
- Adults: 12-20 breaths per minute.
- Children (school-age): 18-30 breaths per minute.
- Toddlers: 24-40 breaths per minute.
- Infants: 30-60 breaths per minute.
What are abnormal respiratory rates?
- Tachypnea: Over 20 breaths per minute in adults.
- Bradypnea: Under 12 breaths per minute in adults.
What is tidal volume?
The amount of air moving in and out of the lungs with each breath. Normal for adults: 400-500 mL.
What is minute volume?
Minute volume = tidal volume × respiratory rate.
Example: 400 mL tidal volume × 12 breaths/min = 4,800 mL.
What are the common lung sounds?
- Normal: Clear and equal bilaterally.
- Wheezing: High-pitched, whistling, more noticeable on expiration.
- Crackles/Rales: Wet, crackling on inspiration and expiration.
- Rhonchi: Low-pitched, congested sounds, often due to mucus.
What are normal pulse rates?
- Adults: 60-100 bpm.
- Children: 80-120 bpm.
- Infants: 100-180 bpm.
What are abnormal pulse rates?
- Tachycardia: Over 100 bpm in adults.
- Bradycardia: Under 60 bpm in adults.
How is blood pressure defined?
- Systolic: Pressure during heart contraction.
- Diastolic: Pressure between contractions.
What is pulse pressure?
The difference between systolic and diastolic pressure. Normal: 25%-50% of systolic pressure.
What are normal blood pressure values?
- Adults: Below 120/80 mmHg.
- Children (ages 1-10): 80 + 2(age)/two-thirds systolic (e.g., 5-year-old: 90/60).
What are abnormal blood pressure findings?
- Wide pulse pressure: Above 50% of systolic pressure (e.g., 210/100).
- Narrow pulse pressure: Below 25% of systolic pressure.
How is orthostatic hypotension assessed?
Measure BP and pulse while supine and standing. A systolic BP drop >20 mmHg or diastolic drop >10 mmHg is abnormal.
What are the sizes and reactions of pupils?
- Normal: 2-5 mm in light.
- Dilated: “Mydriasis.”
- Constricted: “Miosis.”
- Pupils should react to light quickly and equally.
What are common skin abnormalities?
- Pale: Poor circulation.
- Cyanosis: Lack of oxygen.
- Flushed: Excessive heat or fever.
- Jaundice: Liver disease.
- Mottling: Poor blood flow.
What is normal body temperature?
- Average: 98.6°F (37°C).
- Fever: 100.4°F (38°C) rectal, ear, or temporal; 100°F (37.8°C) oral; 99°F (37.2°C) axillary.
What is capillary refill?
The time it takes for capillaries to refill after blanching.
- Normal: ≤2 seconds.
- Delayed (>2 seconds): Indicates possible shock.
How do you document skin findings?
Examples:
- “Skin warm, pink, dry.”
- “Skin cool, clammy, capillary refill 3 seconds.”
