Term
| therapeutic effects - pulse |
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Definition
| assess pts heart rate - rhythm - quality |
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Term
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Definition
all pts
every 5 min for als pts
every 15 min for bls pts |
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Term
| contraindications - pulse |
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Definition
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Term
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Definition
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Term
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Definition
1. locate pts pulse
conscious:adult/radial
unconscious: adult carotid and radial simultaneously
infants and small children: brachail or ausculate the apical pulse
2. establish whether pulse is:
-regular
-regularly irregular
-irregularly irregular
-grossly chaotic
3. if the pulse is irregular you must count for 60 sec
-if the pulse is regular you may count the # of pulses in 15sec and multiply by 4
4. establish the quality of the pulse
-absent
-normal
-thready
-bounding
5. communicate and document the pts:
-pulse rate
-rhythm
-quality
6. the student shall demonstrate the ability to locate and palpate the following pulse:
-carotid
-brachial
-radial
-femoral
-dorsalis pedis
-posterior tibal
-ascultate apical |
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Term
| therapeutic effects - respirations |
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Definition
assess pts breathing
-rate
-effort
-quality |
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Term
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Definition
-all pts
-every 5 min for als pts
-every 15 min for bls pts |
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Term
| contraindications - respirations |
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Definition
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Term
| side effects - respirations |
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Definition
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Term
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Definition
explains the procedure to the pt and remind them not to move without instruction
1. locate pts chest/torso
2. count the # of breaths in 30sec and multiply by 2
a. visually observe chest rise and fall
b. place hand on chest to count rise and fall
c. use a stethoscope to ascultate breathing
3. communicate and document respiratory
- rate
- effort
- quality |
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Term
| therapeutic effects - respirations |
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Definition
assess pts breathing
- rate
- effort
- quality |
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Term
| indication - respirations |
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Definition
- all pts
- every 5 min for als pts
- every 15 min for bls pts |
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Term
| contraindications - respirations |
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Definition
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Term
| side effects - respirations |
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Definition
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Term
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Definition
explains the procedure to the pt and remind them not to move without instruction
1. locate pts chest/torso
2. count the number of breaths in 30 sec and multiply by 2
a. visually observe chest rise and fall
b. place hand on chest to count rise and fall
c. use a stethoscope to auscultate breathing
3. communicate and document respiratory
- rate
- effort
- quality |
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Term
| therapeutic efects - lung sounds |
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Definition
| assess for pts breathing rate and quality |
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Term
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Definition
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Term
| contraindications - lung sounds |
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Definition
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Term
| side effects - lung sounds |
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Definition
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Term
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Definition
MEDICAL PTS
1. expose the pts torso and back
2. make sure the earpieces of the stetoscope point anteriorly before you put them in your ears. Place stethoscope on chest and listen for the presence of sound
- intensity
- pitch
- duration
- quality
Inspiratory and expiratory sounds
3. move the stethoscope across and down the anterior chest at the following 8 positions:
a. right and left apexes - just beneath each clavicle
b. right and left bases - eighth or nnth intercostal space, mid-clavicular line
4. move the stethoscope across and down the thoracic back at the following 10 positions:
a. right and left apexes - just beneath each clavicle
b. right and left midaxillary line - fourth or fifth intercoastal space, on the lateral aspect of the chest
c. right and left bases - eighth or ninth intercostal space, mid-clavicular line
5. correctly identify and note any abnormal sounds, locations, timing during the respiratory cycle
TRAUMA PTS
RAPID TRAUMA SURVEY
1. expose the pts torso and back
2. listen with the stethoscope bell over the lateral chest about the 4th intercoastal space in the mid-axillary line on each side
3. Simply note if breath sounds are present and equal bilaterally
DETAILED EXAM
1. expose the pts torso and back
2. place stethoscope bell on chest and ausculatate inspiatory and expiratory sounds moving the stethoscope across and down checking all 8 anterior chest positions, and all 10 thoracic back positions
3. correctly identify and note any abnormal respiratory deficiencies |
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Term
| therapeutic effects - blood pressure |
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Definition
| assess pts blood pressure |
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Term
| indication - blood pressure |
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Definition
- all pts
- every 5 min for als pts
- every 15 min for bls pts |
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Term
| contraindications - blood pressure |
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Definition
1. mastectomy/ lymphatic surgery (affected side)
2. dialysis shunts (affected side)
3. stroke (affected side) |
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Term
| side effects - blood pressure |
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Definition
| CNS injuries if left inflated to long (b/p) |
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Term
| procedure - blood pressure |
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Definition
explains the procedure to the pt and remind them not to move without instruction
1. blood pressure via auscultation
a. choose the arm you will use, remove any clothing that covers the upper arm
b. choose the appropriate size cuff, width 1/2 to 1/3 the circumference of your pts arm
c. turn control vavle counter clockwise to open and squeeze all air out of bladder before applying cuff
c. locate/palpate brachail pulse
d. place the lower edge of the cuff 1 inch above the antecubical space
e. find the center of the bladder and place it directly over the artery. fasten th cuff so its smooth and tight
f. palpate the radial artery and with the other hand close the valve clockwise and squeeze the bulb rapidly to inflate the cuff to approximately 30mmHg over the point the radial pulse disappears
g. position the stethoscope over the brachail artery
h. turn the control valve counterclockwise slowly and steadily deflate the cuff at the rate of 2-3 mmHg per heartbeat
i. as the pressure falls observe the gauge and listen for Korotkoff's sounds. When you hear the first pulse beat note the reading on the manometer (systolic pressure)
j. continue deflating the cuff until the pulsations diminish or become muffled (diastolic pressure)
2. blood pressure via palpation
a. choose the arm you will use, remove any clothing that covers the upper arm
b. choose the appropriate size cuff, width 1/2 - 1/3 the circumference of your pts arm
c. turn control valve counter clockwise to open and sweeze all air out of bladder before applying cuff
d. locate/palpate brachial pulse
e. place the lower edge of the cuff 1 inch above the antecubical space
f. find the center of the bladder and place it directly over the artery. Fasten the cuff so it's smooth and tight
g. locate/palpate brachail/radial pulse
h. the cuff is inflated to a point where the pulse can no longer be felt
i. finger contact is maintained at the pulse location as the cuff is slowly deflated
j. when the pulse becomes palpable the gauge reading is noted (systolic pressure) |
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Term
| therapeutic effects - pulse oximetry |
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Definition
| used to moniter changes in ventilation and oxygenation in pts |
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Term
| indication - pulse oximetry |
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Definition
- baseline taken prior to the administration of any oxygen
- all pts with any respiratory difficulty or distress
- may be taken with vitals on all pts |
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Term
| reading may be inaccurate - pulse oximetry |
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Definition
1. carbon-monoxide toxicity
2. methemoglobinemia
3. pts in shock with hypotension, hypovolemia, or hypothermia
4. pts with poor distal circulation |
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Term
| side effects - pulse oximetry |
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Definition
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Term
| procedure - pulse oximetry |
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Definition
- expalins the procedure to the pt
- prepare equiptment and assemble appropriate probe (re-usable finger or single use tape-on)
- place probe on finger, ear lobe or toe
- record readings for assessment and trend comparison |
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Term
| contraindications - blood glucose |
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Definition
| determining blood glucose level should not delay transport of the critical Trauma pt |
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Term
| therapeutic effects - blood glucose |
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Definition
| to determine a pts blood sugar level |
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Term
| indication - blood glucose |
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Definition
- any pt with an altered mental status
- any pt with a history of diabetes
- all unconscious pts |
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Term
| side effects - blood glucose |
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Definition
- infection if aseptic technique is not followed
- functional characteristics of glucometers may differ by manufacturer |
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Term
| procedure - blood glucose |
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Definition
1. verbalize chacking glucometer for calibration and expiration date
2. prepare the glucometer by inserting the test strip into the proper place on the meter
3. inform the pt about the procedure you are about to do
4. prepare the puncture site by cleaning it with an alcohol prep and allowed to dry
5. lance the lateral aspect of the pts fingertip, using the lancet supplied by the manufacturer according to their recommendations
6. dispose of lancet in sharps container
7. squeeze the finger until a drop of blood presents itself and apply to test strip
8. apply a bandage to the site and have the pt hold pressure until bleeding stops
9. apply a band-aid
10. record findings
11. the student shall identify normal blood glucose limits as 80mg/dl - 140mg/dl |
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Term
| therapeutic effects - skin signs |
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Definition
| to evaluate pts perfusion and temperature |
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Term
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Definition
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Term
| contraindications - skin signs |
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Definition
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Term
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Definition
SKIN COLOR
- evaluates areas that usually are not exposed to sun (ex. palms) or skin that has less pigmentation (ex. lips and nail beds) for color and possible causes
- pallor (decrease in color): shock, dehydration, fright
- cyanosis (bluish color): cardiopulmonary insufficiency, cold environment
- jaundice (yellow orange color):liver disease, RBC destruction
SKIN MOISTURE
- classified as dry (normal) or wet (clammy or diaphoretic)
SKIN TEMPERATURE
- the dorsal surface of the hand is placed on the pts forehead to determine if the skin temperature is warm (normal) hot or cold
- if abnormalities are suspected or focus assessment dictates, a thermometer shall be used to obtain a more accurate temperature by oral, axillary or rectal (most accurate indicator for core body temp)
SKIN TEXTURE
-rough
-smooth
-scaling
-thick
-thin
MOBILITY AND TUGOR
-normal turgor
-poor turgor
-normal mobility
-decreased mobility
LESIONS
-present
-note anatomical position |
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Term
| therpeutic effects - encode |
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Definition
| to be able to effectively communicate the pts needs and conditions and obtain any pt care orders from another entity via a mobile radio system using a standard outline |
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Term
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Definition
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Term
| contraindications - encode |
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Definition
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Term
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Definition
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Term
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Definition
-the use of a medical radio including PTT and channel selections
-identification of unit, porvider and provider level
-description of scene
-pts age, sex and approximate weight (for drug orders)
-pts chief complaint and severity
-brief pertinent history of present illness or injury
-pertinent past medical history, medications, and allergies
-pertinent physical exam findings
-report treatments given so far/changes observed/request for orders
-estimated time of arrival
-other pertinent information |
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