PARAMED. CH 13 Pt Assessment Flashcards
(127 cards)
1
Q
Field Impression
A
Based on patient history and chief complaint.
What you THINK is the problem.
2
Q
Scene Size Up
A
Evaluate the overall safety and stability of emergency scene
3
Q
Access and Egress
A
Enter and exit. Consider a ‘snatch and grab’ by doing absolute least to secure patient.
4
Q
Methemphetamines
A
Growing numbers of abuse. Can become violent. Talk a lot.
5
Q
MOI
A
Mechanism of Injury - way in which trauma occurs
6
Q
NOI
A
Nature of Illness - general type of illness a patient is experiencing
7
Q
Multiple Patients same symptoms
A
Food poisoning or Carbon Monoxide posioning
8
Q
Primary Assessment
A
Most time intensive portion of Assessment. Focus on and manages life threats in 60-90 seconds. (ABC’s)
9
Q
General Impression
A
Based almost solely on patient presentation and chief complaint
10
Q
Observations of patient
A
Made in conscious objective and systematic manner
11
Q
Mental Status
A
AVPU Alert Verbal Pain Unresponsive
12
Q
Skin Color Red
A
Fever, Hypertension, Allergic Reactions, and CO Posioning
13
Q
Skin Color White
A
Hypovolemic and Fright
14
Q
Skin Color Blue
A
Hypoxemia
15
Q
Skin Color Mottled
A
Shock
16
Q
Vessels Dialate
A
Skin becomes warm and pink.
17
Q
Vessels Constrict
A
Skin becomes pallor or white
18
Q
Dryness or moisture of skin
A
Determines by sympathetic nervous system
19
Q
Skin hot, dry
A
Excessive heat (heat stroke)
20
Q
Skin hot, wet
A
Increased internal temperature
21
Q
Skin cool, dry
A
Exposure to cold
22
Q
Skin cool, wet
A
Shock
23
Q
Rapid Exam
A
Quick thorough palpating of body in 60-90 seconds
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
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
