PARAMED. CH 13 Pt Assessment Flashcards Preview

Biology 210 > PARAMED. CH 13 Pt Assessment > Flashcards

Flashcards in PARAMED. CH 13 Pt Assessment Deck (127):
1

Field Impression

Based on patient history and chief complaint.
What you THINK is the problem.

2

Scene Size Up

Evaluate the overall safety and stability of emergency scene

3

Access and Egress

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

4

Methemphetamines

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

5

MOI

Mechanism of Injury - way in which trauma occurs

6

NOI

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

7

Multiple Patients same symptoms

Food poisoning or Carbon Monoxide posioning

8

Primary Assessment

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

9

General Impression

Based almost solely on patient presentation and chief complaint

10

Observations of patient

Made in conscious objective and systematic manner

11

Mental Status

AVPU Alert Verbal Pain Unresponsive

12

Skin Color Red

Fever, Hypertension, Allergic Reactions, and CO Posioning

13

Skin Color White

Hypovolemic and Fright

14

Skin Color Blue

Hypoxemia

15

Skin Color Mottled

Shock

16

Vessels Dialate

Skin becomes warm and pink.

17

Vessels Constrict

Skin becomes pallor or white

18

Dryness or moisture of skin

Determines by sympathetic nervous system

19

Skin hot, dry

Excessive heat (heat stroke)

20

Skin hot, wet

Increased internal temperature

21

Skin cool, dry

Exposure to cold

22

Skin cool, wet

Shock

23

Rapid Exam

Quick thorough palpating of body in 60-90 seconds

24

High Priority Patients

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

25

Patient Hx

Gain info. About pt and learn events surrounding incident

26

Chief Complaint

Why someone called 911 today

27

Hx of Present Illness

OPQRST and SAMPLE

28

Signs and Symptoms

What happened and when

29

Past Medical Hx

Learn about pt's pertinent or chronic underlying medical conditions

30

Pertinent Negatives

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

31

Diplopia

Blurred Vision

32

Tinnitus

Ringing in ears

33

Rhinnorhea

Runny nose

34

Polydipsia

Excessive Thirst

35

Polyphagia

Excessive Hunger

36

Hemoptysis

Coughing up blood

37

Coughing

Color or phlegm being produced

38

Cardiac

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

39

Hematology

Hx of blood (anemia, bruising)

40

Lymph Nodes

Swell due to infections with release of WBC's

41

Hematemesis

Blood in vomit

42

GI/GU

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

43

Dysuria

Painful urination

44

Nocturia

Night pee

45

Hematuria

Blood in urine

46

Neurologic

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

47

Differential Diagnosis

Working hypothesis of nature of the problem

48

Facilitation

Use techniques to make patient feel open

49

Reflection

Pausing to cinsider something significant told

50

Clarification

Asking about more hx when something is unclear or vague

51

Confrontation

Make pt aware that something is not consistent with their behavior

52

Interpretation

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

53

Neonates

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

54

Secondary Assessment

Objective information is obtained

55

Blood Pressure

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

56

Systolic

Created by LV when contracting

57

Diastolic

Residual pressure in system when LV is at rest

58

Low Diastolic

Means less myocardial perfusion

59

Temperature

Beware of extrinsic factors that could alter readings. Earwax.

60

Pulse Oximetery

Measures amount of oxygen attached to h Hemoglobin in the blood

61

Full Body Exam

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

62

Focused Exam

Performed on no significant MOI or responsive medical patients

63

A&O

Person place day and event,

64

GCS

Eye, Verbal, Motor,

65

Chest pain

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

66

Abdominal pain

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

67

SOB

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

68

Dizziness

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

GCS Eye Opening

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

70

GCS Verbal Response

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

71

GCS Motor Response

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

72

Skin in cold environment

Shunts blood away from skin by vasoconstriction

73

Skin in hot environment

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

74

Skin layers

2 layers - Dermis and Epidermis

75

Turgor

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

76

Pallor

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

77

Cyanosis

Observed best in face, lips, eyes, nails

78

Edchymosis

Localized bruising or blood collection under skin

79

Nail Beau Line

Transverse depressions - severe infection

80

Nail Clubbing

COPD

81

Nail Psoriasis

Discoloration and pitting - autoimmune disease

82

Visual Acuity

Check each eye in isloation

83

Battle Sign

Discoloration and tenderness of mastoid process

84

Adventitious Breath sounds

Pathological breath sounds

85

Wheezing

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

86

Rales

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

87

Rhonchi

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

88

Stridor

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

89

Splitting

Hearts creates two different sounds when beating

90

S1

"Lub" closure of mitral and tricuspid valves at start of systole.

91

S2

"Dub" closure of aortic and pulmonary valve at end of systole

92

S3

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

93

S4

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

94

Korotkoff Sounds

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

95

Bruit

Abnormal whoosh that indicates turbulent blood flow moving through narrow artery

96

Murmur

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

97

LUQ Pain

Ruptured spleen and/or sickle cell crisis and mononucelosis

98

LLQ Pain

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

99

LRQ Pain

Appendicitis

100

Generalized abdominal pain in Women

Ectopic pregnancy, ruptured ovarian cyst

101

Orthostatic vitals

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

Ascites

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

103

Pathologic Fracture

Normals forces break bone

104

Physiologic Fracture

Abnormal forces break bones (MVA)

105

Lordosis

Inward curve of back

106

Kyphosis

Outward curve of back

107

Scoliosis

Abnormal wave of back

108

Primitive Reflexes

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

109

Cranial Nerve One - Olfactory is

Smell

110

Cranial Nerve Two - Optic is

Sight

111

Cranial Nerve Three - Oculomotor is

Pupil constriction

112

Cranial Nerve Four - Trochlear is

Eye movements

113

Cranial Nerve Five - Trigeminal is

Chewing. Face, sinuses, teeth.

114

Cranial Nerve Six - Abducens is

Eye Movements

115

Cranial Neve Seven - Facial is

Facial Movements

116

Cranial Nerve Eight - Vestibulocochlear is

Hearing and Balance

117

Cranial Nerve Nine - Glossopharyngeal is

Tongue, Throat and Ear.

118

Cranial Nerve Ten - Vagus is

Everything

119

Cranial Nerve Eleven - Accessory is

Shoulder and Neck movements

120

Cranial Nerve Twelve - Hypoglossal is

Tongue, Throat and Neck movements

121

Proprioreception

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

122

Delirium

Actually Sudden Change in menta status.

123

Dementia

Disease ridden

124

Parasthesias

Tingling or sensory changes. Indicates spinal lesion.

125

Dermatones

Distinct areas of skin where sensations correspond to nerves

126

Becks Triad

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

127

Cushings Triad

Slowing pulse, rising BP, abnormal respirations indicates head trauma