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Biology 210 > PARAMED. CH 13 Pt Assessment > Flashcards

PARAMED. CH 13 Pt Assessment Flashcards

1
Q

Field Impression

A

Based on patient history and chief complaint.

What you THINK is the problem.

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2
Q

Scene Size Up

A

Evaluate the overall safety and stability of emergency scene

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3
Q

Access and Egress

A

Enter and exit. Consider a ‘snatch and grab’ by doing absolute least to secure patient.

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4
Q

Methemphetamines

A

Growing numbers of abuse. Can become violent. Talk a lot.

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5
Q

MOI

A

Mechanism of Injury - way in which trauma occurs

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6
Q

NOI

A

Nature of Illness - general type of illness a patient is experiencing

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7
Q

Multiple Patients same symptoms

A

Food poisoning or Carbon Monoxide posioning

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8
Q

Primary Assessment

A

Most time intensive portion of Assessment. Focus on and manages life threats in 60-90 seconds. (ABC’s)

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9
Q

General Impression

A

Based almost solely on patient presentation and chief complaint

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10
Q

Observations of patient

A

Made in conscious objective and systematic manner

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11
Q

Mental Status

A

AVPU Alert Verbal Pain Unresponsive

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12
Q

Skin Color Red

A

Fever, Hypertension, Allergic Reactions, and CO Posioning

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13
Q

Skin Color White

A

Hypovolemic and Fright

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14
Q

Skin Color Blue

A

Hypoxemia

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15
Q

Skin Color Mottled

A

Shock

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16
Q

Vessels Dialate

A

Skin becomes warm and pink.

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17
Q

Vessels Constrict

A

Skin becomes pallor or white

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18
Q

Dryness or moisture of skin

A

Determines by sympathetic nervous system

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19
Q

Skin hot, dry

A

Excessive heat (heat stroke)

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20
Q

Skin hot, wet

A

Increased internal temperature

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21
Q

Skin cool, dry

A

Exposure to cold

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22
Q

Skin cool, wet

A

Shock

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23
Q

Rapid Exam

A

Quick thorough palpating of body in 60-90 seconds

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24
Q

High Priority Patients

A

Poor general impression, unresponsive, altered, impaired breathing, hypoperfusion, childbirth, chest pain with systolic less than 100, uncontrolled bleeding, severe pain, multiple injuries

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25
Q

Patient Hx

A

Gain info. About pt and learn events surrounding incident

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26
Q

Chief Complaint

A

Why someone called 911 today

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27
Q

Hx of Present Illness

A

OPQRST and SAMPLE

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28
Q

Signs and Symptoms

A

What happened and when

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29
Q

Past Medical Hx

A

Learn about pt’s pertinent or chronic underlying medical conditions

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30
Q

Pertinent Negatives

A

A lack of certain signs and symptoms ( nausea vomiting LOC SOB chest pain diarrhea )

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31
Q

Diplopia

A

Blurred Vision

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32
Q

Tinnitus

A

Ringing in ears

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33
Q

Rhinnorhea

A

Runny nose

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34
Q

Polydipsia

A

Excessive Thirst

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35
Q

Polyphagia

A

Excessive Hunger

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36
Q

Hemoptysis

A

Coughing up blood

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37
Q

Coughing

A

Color or phlegm being produced

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38
Q

Cardiac

A

Questions towards heart and vessels, orthopnea, edema and past cardiac hx

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39
Q

Hematology

A

Hx of blood (anemia, bruising)

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40
Q

Lymph Nodes

A

Swell due to infections with release of WBC’s

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41
Q

Hematemesis

A

Blood in vomit

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42
Q

GI/GU

A

Ask about… appetite, digestion, bowel movements, food allergies, diarrhea, bowel regularity, changes in stool ( size shape smell Color), flatulence, jaundice and past GI Hx

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43
Q

Dysuria

A

Painful urination

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44
Q

Nocturia

A

Night pee

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45
Q

Hematuria

A

Blood in urine

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46
Q

Neurologic

A

Ask about… Hx seizures or syncope, loss of sensation, weakness in extremities, paralysis loss of coordination or memory, muscle twitches or tremors, facial assymetry

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47
Q

Differential Diagnosis

A

Working hypothesis of nature of the problem

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48
Q

Facilitation

A

Use techniques to make patient feel open

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49
Q

Reflection

A

Pausing to cinsider something significant told

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50
Q

Clarification

A

Asking about more hx when something is unclear or vague

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51
Q

Confrontation

A

Make pt aware that something is not consistent with their behavior

52
Q

Interpretation

A

Inferring cause of pts distress then asking pt if inference is correct

53
Q

Neonates

A

Ask about congenital anomalies, feeding issues, jaundice, Illness or developmental landmarks

54
Q

Secondary Assessment

A

Objective information is obtained

55
Q

Blood Pressure

A

Force exerted on walls of vessels. Product of cardiac output and peripheral vascular resistance

56
Q

Systolic

A

Created by LV when contracting

57
Q

Diastolic

A

Residual pressure in system when LV is at rest

58
Q

Low Diastolic

A

Means less myocardial perfusion

59
Q

Temperature

A

Beware of extrinsic factors that could alter readings. Earwax.

60
Q

Pulse Oximetery

A

Measures amount of oxygen attached to h Hemoglobin in the blood

61
Q

Full Body Exam

A

Head-to-toe Exam that includes both looking and palpating

62
Q

Focused Exam

A

Performed on no significant MOI or responsive medical patients

63
Q

A&O

A

Person place day and event,

64
Q

GCS

A

Eye, Verbal, Motor,

65
Q

Chest pain

A

Evaluate…. skin, pulse, blood pressure, trauma, assess Jvd, listen to breath sounds, assess pedal edema

66
Q

Abdominal pain

A

Evaluate… skin, pulse, bp, look trauma, palpate

67
Q

SOB

A

Evaluate… skin, pulse, bp, rate and depth of breathing, assess airway obstruction, listen to breath sounds, assess hypoxemia, assess pedal edema

68
Q

Dizziness

A

Evaluate… skin, pulse, bp, adequacy of respirations, LOC, check head for signs of stroke, facial droop, slurred speech, one sided weakness. Hx inner ear problems

69
Q

GCS Eye Opening

A

Spontaneous = 4 Verbal = 3 Pain = 2 None = 1

70
Q

GCS Verbal Response

A

Oriented = 5 Confused Convo = 4 Speak Nonsense = 3 Mumbles = 2 None = 1

71
Q

GCS Motor Response

A

Follows = 6 Localizes = 5 Withdraws = 4 Decorticate = 3 Deceberate = 2 None = 1

72
Q

Skin in cold environment

A

Shunts blood away from skin by vasoconstriction

73
Q

Skin in hot environment

A

Radiates heat from the body by dialate vessels and bringing closer to the surface of skin

74
Q

Skin layers

A

2 layers - Dermis and Epidermis

75
Q

Turgor

A

Pulling skin to see withdrawal. In older patients use skin in the chest

76
Q

Pallor

A

Present when RBC perfusion to capillary beds of skin is poor (lips or conjunctiva)

77
Q

Cyanosis

A

Observed best in face, lips, eyes, nails

78
Q

Edchymosis

A

Localized bruising or blood collection under skin

79
Q

Nail Beau Line

A

Transverse depressions - severe infection

80
Q

Nail Clubbing

A

COPD

81
Q

Nail Psoriasis

A

Discoloration and pitting - autoimmune disease

82
Q

Visual Acuity

A

Check each eye in isloation

83
Q

Battle Sign

A

Discoloration and tenderness of mastoid process

84
Q

Adventitious Breath sounds

A

Pathological breath sounds

85
Q

Wheezing

A

High pitched whistling sound. If unilateral aspirated foreign body is suspected. If bilateral, suspect asthma.

86
Q

Rales

A

Wet breath sounds indicate cardiac failure or infection. (Crackles)

87
Q

Rhonchi

A

Congested breath sounds. Low pitch and rattling quality. Indicates fluid in larger airways. Also may indicate aspiration of fluid.

88
Q

Stridor

A

Crowing sound often heard without stethoscope. Narrowing, swelling, or obstruction of upper airway. Indicates epiglotittis, croup, inhalation burns, partial foreign body obstruction.

89
Q

Splitting

A

Hearts creates two different sounds when beating

90
Q

S1

A

“Lub” closure of mitral and tricuspid valves at start of systole.

91
Q

S2

A

“Dub” closure of aortic and pulmonary valve at end of systole

92
Q

S3

A

Abnormally increasing filling pressures in the atria secondary to moderate to severe heart failure

93
Q

S4

A

“Gallop” rhythm, moderately pitched sound occurs before S1. Indicates decreased stretching compliance of the LV or increased pressure in the atria

94
Q

Korotkoff Sounds

A

Related to pts bp. Only can hear first and fifth sounds

95
Q

Bruit

A

Abnormal whoosh that indicates turbulent blood flow moving through narrow artery

96
Q

Murmur

A

Abnormal whoosh like sound heard over heart that indicates turbulent blood flow around cardiac valve

97
Q

LUQ Pain

A

Ruptured spleen and/or sickle cell crisis and mononucelosis

98
Q

LLQ Pain

A

Especially w, hx of vomiting, constipation, nausea, and fever => diverticulitis

99
Q

LRQ Pain

A

Appendicitis

100
Q

Generalized abdominal pain in Women

A

Ectopic pregnancy, ruptured ovarian cyst

101
Q

Orthostatic vitals

A

tilt test or standing. Volume depleted pt’s cant move fluid to core with normal sympathetic response. Decrease up to 20mmHg and increase in pulse by 20 beats per minute

102
Q

Ascites

A

Collection of fluid within abdominal cavity. Typically seen with liver disease

103
Q

Pathologic Fracture

A

Normals forces break bone

104
Q

Physiologic Fracture

A

Abnormal forces break bones (MVA)

105
Q

Lordosis

A

Inward curve of back

106
Q

Kyphosis

A

Outward curve of back

107
Q

Scoliosis

A

Abnormal wave of back

108
Q

Primitive Reflexes

A

Babinski, grasping and sucking signs. Indicates separation of cerebral cortex and brainstem

109
Q

Cranial Nerve One - Olfactory is

A

Smell

110
Q

Cranial Nerve Two - Optic is

A

Sight

111
Q

Cranial Nerve Three - Oculomotor is

A

Pupil constriction

112
Q

Cranial Nerve Four - Trochlear is

A

Eye movements

113
Q

Cranial Nerve Five - Trigeminal is

A

Chewing. Face, sinuses, teeth.

114
Q

Cranial Nerve Six - Abducens is

A

Eye Movements

115
Q

Cranial Neve Seven - Facial is

A

Facial Movements

116
Q

Cranial Nerve Eight - Vestibulocochlear is

A

Hearing and Balance

117
Q

Cranial Nerve Nine - Glossopharyngeal is

A

Tongue, Throat and Ear.

118
Q

Cranial Nerve Ten - Vagus is

A

Everything

119
Q

Cranial Nerve Eleven - Accessory is

A

Shoulder and Neck movements

120
Q

Cranial Nerve Twelve - Hypoglossal is

A

Tongue, Throat and Neck movements

121
Q

Proprioreception

A

Understanding and interpretation of an extremity and is part of cerebellum.

122
Q

Delirium

A

Actually Sudden Change in menta status.

123
Q

Dementia

A

Disease ridden

124
Q

Parasthesias

A

Tingling or sensory changes. Indicates spinal lesion.

125
Q

Dermatones

A

Distinct areas of skin where sensations correspond to nerves

126
Q

Becks Triad

A

Narrowed pulse pressure, muffled heart tones, and JVD associated with cardiac tamponade

127
Q

Cushings Triad

A

Slowing pulse, rising BP, abnormal respirations indicates head trauma

Biology 210 (13 decks)

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