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Chapter 8 Patient Assessment
Chapter 8 Patient Assessment terms and highlights
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09/06/2013

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Term
Secondary assessment
Definition
Perform a systematic physical examination
Term
DCAP-BTLS
Definition
Deformities, contusions, abrasions, punctures, burns, tenderness, lacerations, swelling
Term
A decrease in blood pressure may indicate?
Definition
Loss of blood, loss of vascular tone and significant arterial constriction, a cardiac pumping problem
Term
Systolic Pressure
Definition
The increased pressure that is caused along the artery with each contraction of the ventricles (systole)
Term
Diastolic
Definition
The residual pressure that remains in the arteries during the relaxing phase of the heart's cycle (diastole) when the left ventricle is at rest
Term
Normal Range for Blood Pressure
Definition
Adult 90-140 (systolic)
Children (1-8 yrs) 80-110 (systolic)
Infants (newborn to 1 yr) 50-95 (systolic)
Term
Hypotension
Definition
Blood pressure is lower than normal
Term
Hypertension
Definition
Blood pressure is higher than normal
Term
MOI
Definition
mechanism of injury- how traumatic injury occurs
Term
blunt trauma
Definition
injury occurs over a broad area and the skin is usually not broken
Term
penetrating trauma
Definition
force of the injury occurs at a small point of contact between the skin and the object. The object pierces the skin and creates an open wound that carries a high potential for infection
Term
NOI
Definition
nature of illness-general type of illness the patient is experiencing
Term
PPE
Definition
personal protective equipment
Term
standard precautions
Definition
protective measures that have been developed by the center for disease control and prevention for use in dealing with objects
Term
triage
Definition
the process of sorting patients based on the severity of each patients condition
Term
Questions to ask when determining if additional resources are required.
Definition
How many pt's are there?
What is the nature of their conditions?
Who contacted EMS?
Does the scene pose a threat to you, your partner or others?
Term
AVPU scale
Definition
a method of assessing the pt's level of consciousness using
A Awake and Alert
V Responsive to Vebal stimuli
P Responsive to Pain
U Unresponsive
Term
Orientation
Definition
tests mental status by checking a patients memory and thinking ability
Does the pt remember? Person(name), Place(current location), Time(current yr, mon, and appx date), Event(what happened to them)
Term
GCS
Definition
Glasgow Coma Scale
Term
The Glasgow Coma Scale defines what?
Definition
the severity of a pt's brain disfunction.
Term
pulse oximeter
Definition
a device that measues the saturation of oxygen to the blood as a percentage
Term
capnometry
Definition
provide a digital reading and wave frm of end tidal CO2 Normal range is 35 to 45 mm Hg
Term
vasoconstriction
Definition
narrowing of blood vessel
Term
tripod position
Definition
upright position in which the patient leans forward onto two arms stretched forward and thrusts the head and chin forward
Term
sign
Definition
object that can be seen, heard, felt, smelled, or measured
Term
spontaneous respirations
Definition
breathing that occurs with no assistance
Term
symptom
Definition
subjective findings that the patient feels but that can be identified only by the pt
Term
SAMPLE
Definition
brief history of a pt's condition to determine signs and symptoms, allergies, medications, pertinent past history, last oral intake, and events leading to the injury or illness
Term
pertinent negatives
Definition
negative findings that warrant no care or intervention
Term
palpate
Definition
to examine by touch
Term
paradoxical motion
Definition
the motion of the chest wall section that is detached in a flail chest; the motion is exactly the opposite of normal motion during breathing
Term
OPQRST
Definition
Onset, Provocation or Palliation, Quality, Region/radiation, Severity, Timing of Pain
Term
Golden Period
Definition
tie from injury to definitive care, during which treatment of shock and traumatic injuries should occur because survival potential is best
Term
gaurding
Definition
involuntary muscle contractions (spasms) of the abdominal wall in an effort to protect an inflamed abdomen
Term
accessory muscles
Definition
the secondary muscles of respiration
include: neck muscles, chest and abdominal muscles
Term
auscultate
Definition
to listen to sounds within an organ with a stethoscope
Term
AVPU scale
Definition
a method of assessing level of consciousness.
A-alert and awake
V-responsive to verbal stimuli
P-pain
U-unresponsive
Term
blood pressure
Definition
pressure of circulating blood against the walls of the arteries
Term
bradycardia
Definition
slow HR, less than 60 beats/min
Term
capillary refill
Definition
test that evaluates distal circulatory system function by squeezing blood from an area such as the nail bed and watching the speed of its return after releasing the pressure
Term
carbon dioxide
Definition
component of air and typically makes up 0.3% of air at sea level, also a waste product exhaled during expiration by the respiratory system
Term
chief complaint
Definition
reason a patient called for help, also the patients response to the questions "What's wrong?" or "What happened?"
Term
crepitus
Definition
a grating or grinding sound caused by fractured bone ends or joints rubbing together, also air bubbles under the skin that produce a crackling sound
Term
cyanosis
Definition
bluish gray skin color
Term
DCAP-BTLS
Definition
assessment mnemonic
D-deformities
C-contusions,
A-abrasions
P-Punctures
B-burns
T-tenderness
L-lacerations
S-swelling
Term
diaphoretic
Definition
profuse sweating
Term
diastolic pressure
Definition
pressure that remains in the arteries during the relaxing phase of the heart's cycle
Term
focused assessment
Definition
type of physical assessment that is typically performed on pt's who have sustained non-significant mechanisms of injury or on responsive medical pt's. Based on the chief complaint and focuses on one body system or part
Term
full-body scan
Definition
systematic head-to-toe examination that is performed during the secondary assessment on a pt who has sustained a significant mechanism of injury, is unconscious or in critical condition
Term
general impression
Definition
overall initial impression that determines the priority for pt care, based on pt's surrounding, MOI, s/s and the chief complaint
Term
golden period
Definition
time from injury to definitive care, during which treatment of shock and traumatic injuries should occur because survival potential is best
Term
gaurding
Definition
involuntary muscle contractions or spasms of the abdominal wall in an effort to protect and inflamed abdomen
a sign of peritonitis
Term
history taking
Definition
a step within the pt assessment process that provides detail about the pt's chief complaint and an account of the pt's s/s
Term
hypertension
Definition
high blood pressure
Term
hypotension
Definition
low blood pressure
Term
incident command system
Definition
system to manage disasers and mass- and multiple-casualty incidents
also referred to as incident management system
Term
jaundice
Definition
yellow skin or sclera that is caused by liver disease
Term
labored breathing
Definition
breathing that requires visibly increased effort, characterized by grunting, stridor and use of accessory muscles
Term
MOI
Definition
mechanism of injury
the way in which traumatic injuries occur, the forces that act on the body to cause damage
Term
nasal flaring
Definition
flaring out of the nostrils indicating that there is an airway obstruction
Term
NOI
Definition
nature of illness
the general type of illness the pt is experiencing
Term
OPQRST
Definition
abbreviation for evaluating a pt's pain
Onset
Provocation
Quality
Region/Radiation
Severity
Timing
Term
palpate
Definition
to examine by touch
Term
paradoxical motion
Definition
the motion of the chest wall section that is detached in a flail chest
the motion is exactly the opposite of normal motion during breathing
Term
perfusion
Definition
circulation of blood within an organ or tissue
Term
PPE
Definition
personal protection equipment
Term
pertinent negative
Definition
negative findings that warrant no care or intervention
Term
primary assessment
Definition
step within the pt assessment process that identifies and initiates treatment of immediate and potential life threats
Term
pulse
Definition
the pressure wave that occurs as each heartbeat causes a surge in the blood circulating through the arteries
Term
pulse oximetry
Definition
an assessment tool that measures oxygen saturation of hemoglobin in the capillary beds
Term
rales
Definition
crackling, rattling breath sound that signals fluid in the air space of the lungs
also called crackles
Term
reassessment
Definition
step within the pt assessment process that is performed at regular intervals during the assessment process
unstable pt - reassess every 5 min
stable pt- reassess every 15 min
Term
responsiveness
Definition
the way in which a person responds to external stimuli, including verbal (sound), tactile (touch), and painful stimuli
Term
retractions
Definition
movements in which the skin pulls in around the ribs during inspiration
Term
rhonci
Definition
coarse, low-pitched breath sounds heard in pt's with chronic mucus in the upper airways
Term
SAMPLE
Definition
Symptoms
Allergies
Medications
Past history
Last oral intake
Events leading to the illness
Term
scene size-up
Definition
quick assessment of the scene and the surroundings to provide information about scene safety and the MOI or the NOI before you enter and begin pt care
Term
secondary assessment
Definition
systematic physical examination of the pt. The examination may be a systematic full-body scan or a systematic assessment that focuses on a certain area or region of the body often determined through the chief complaint
Term
shallow respirations
Definition
characterized by little movements of the chest wall (reduced tidal volume) or poor chest excursion
Term
sign
Definition
objective findings that can be seen, heard, felt, smelled or measured
Term
sniffing position
Definition
upright position in which the pts head and chin are thrust slightly forward to keep the airway open
Term
spontaneous respirations
Definition
breathing that occurs with no assistance
Term
standard precautions
Definition
measures developed by the CDC for dealing with objects, blood, bodily fluids and other potential exposure risks of communicable disease
Term
stridor
Definition
harsh, high-pitched, crowing inspiration sound, such as the sound often heard in acute laryngeal (upper airway) obstruction
may sound like crowing and be audible without a stethescope
Term
subcutaneous emphysema
Definition
presence of air in soft tissues causing a crackling sensation on palpataion
Term
symptom
Definition
subjective findings that the pt feels but that can be identified only by the pt
Term
systolic pressure
Definition
increased pressure in an artery with each contraction of the ventricles
Term
tachycardia
Definition
rapid heart rate, more than 100 beats/min
Term
tidal volume
Definition
the amount of air that is moved in or out of the lungs during one breath
Term
tripod position
Definition
upright position in which the patient leans forward onto two arms stretched forward and thrusts the head and chin forward
Term
vasoconstriction
Definition
narrowing of the blood vessel
Term
vital signs
Definition
key signs used to evaluate the pts overall condition
respirations, pulse, blood pressure, level of consciousness, skin characteristics
Term
triage
Definition
sorting pts into priorities
Term
What is the single, critical, important goal of the primary assessment?
Definition
to identify and initiate treatment of immediate or potential life threats
Term
When using the APVU scale what are characteristics of an ALERT pt?
Definition
eyes open spontaneously as you approach, pt appears aware of you, pt follows commands and the eye visually track people
Term
When using the APVU scale what are characteristics of a pt that responds to verbal stimuli?
Definition
eyes do not open but pt is able to respond
Term
When using the APVU scale what are characteristics of a pt that responds to pain?
Definition
moves or cries out in response to painful stimuli
Term
When using the APVU scale what are characteristics of a pt that is unresponsive?
Definition
pt does not respond spontaneously to verbal or painful stimuli, pt lacks a cough or gag reflex and the ability to protect their airway
Flacid
Term
anisocoria
Definition
a number of the populations that exhibit unequal pupils
Term
You must assume that the pt has depressed brain function as a result of central nervous system depression or injury if the pupils react in any of these 5 ways.
Definition
Become fixed with no reaction to light
Dilate with intro of a bright light and constrict when the light is removed
React sluggishly
Become unequal in size
Become unequal in size when a bright light is introduced or removed from one eye
Term
A patent airway is an __________ airway
Definition
unobstructed
Term
Signs of airway obstruction in an unconscious pt
Definition
Obvious trauma, blood or other obstruction
Noisy breathing, such as snoring, bubbling, gurgling, crowing (stridor)
Extremely shallow or absent breathing
Term
When assessing breathing you must obtain what information? (4 things)
Definition
Respiratory rate
Rhythm, reg or irrg
Quality
Depth (tidal volume)
Term
Where do you check a pulse in pt's older than 1 yr?
Definition
Carotid pulse
Term
What are the progressive steps in controlling bleeding?
Definition
1. place direct pressure
2. place direct pressure and elevate the extremity if bleeding from arms or legs
3. When direct pressure and elevation aren't successful apply a tourniquet
Term
How long should a rapid scan take?
Definition
60-90 seconds
Term
Examples of high priority pt's to be transported immediately (10)
Definition
Difficulty breathing
Poor general impression
unresponsive w/no gag or cough reflex
Severe chest pain
Pale skin or other signs of shock
Complicated child birth
Uncontrolled bleeding
Responsive but unable to follow command
Severe pain in any area of the body
Inability to move any part of the body
Term
Loss of vascular tone and sufficient arterial constriction to maintain the necessary pressure even without any actual or fluid loss indicates a decrease in what?
Definition
Blood pressure
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