Patient Assessment - History Taking, Secondary Assessment, & Reassessment Flashcards
(138 cards)
1
Q
Provides details about the patient’s chief complaint and an account of the patient’s signs and symptoms
A
History taking
2
Q
Info for history taking
A
- Date of the incident
- Age
- Sex
- Race
- Past medical history
- Current health status
3
Q
Past medical history should include ___
A
Pertinent info about the patient’s condition, such as medical problems, traumatic injuries, and surgical procedures
4
Q
Patient’s current health status should include ___
A
Diet, medications, drug use, living environment and hazards, physician visits, and family history
5
Q
Used for gathering additional info about a patient’s history of present illness and current symptoms
A
OPQRST
6
Q
OPQRST
A
- Onset
- Provocation/palliation
- Quality
- Region/radiation
- Severity
- Timing
7
Q
Negative findings that warrant no care or intervention
A
Pertinent negatives
8
Q
Used to obtain a patient’s history
A
SAMPLE history
9
Q
SAMPLE
A
- Signs and symptoms
- Allergies
- Medications
- Pertinent past medical history
- Last oral intake
- Events leading up to the injury or illness
10
Q
In women of child-bearing age, the “L” in SAMPLE also represents ___
A
Last menstrual period
11
Q
The process of going through the steps in a process without considering other options
A
Cookbook medicine
12
Q
Steps in critical thinking in assessment
A
- Gathering
- Evaluating
- Synthesizing
13
Q
If it is determined to be related to domestic violence
A
Call the police immediately
14
Q
Questions to ask a female patient of child-bearing age with lower abdominal pain
A
- When was the last menstrual period
- If bleeding: How many sanitary pads or tampons have you used
- Do you have urinary frequency or burning
- What is the severity of cramping, and are there any foul odors
- Is there a possibility you may be pregnant
- Are you using any form of birth control
15
Q
Questions to ask a male patient of child-bearing age with lower abdominal pain about urinary symptoms
A
- Is there any pain associated with urination
- Do you have any discharge, sores, or an increase in urination
- Do you have burning or difficulty voiding
- Has there been any trauma
16
Q
If ___, you may choose to perform the secondary assessment at the scene
A
The patient is in stable condition and has an isolated complaint
17
Q
If the secondary assessment is not performed at the scene, it is performed ___
A
In the back of the ambulance en route to the hospital
18
Q
Purpose of the secondary assessment
A
To perform a systematic physical examination of the patient
19
Q
Simply looking at your patient for abnormalities
A
Inspection
20
Q
The process of touching or feeling the patient for abnormalities
A
Palpation
21
Q
With palpation, your fingertips are best suited for detecting ___, and the back of your hand is best at noting ___
A
- Texture and consistency
- Temperature
22
Q
The process of listening to sounds the body makes by using a stethoscope
A
Auscultation
23
Q
Secondary assessment steps
A
- Observe the face
- Inspect the area around the eyes and eyelids
- Examine the eyes for redness and contact lenses. Check pupil function
- Look behind the ears for battle sign
- Check the ears for drainage or blood
- Observe and palpate the head
- Palpate the zygomas
- Palpate the maxillae
- Check the nose for blood and drainage
- Palpate the mandible
- Assess the mouth and nose
- Check for unusual breath odors
- Inspect the neck. Observe for jugular vein distention
- Palpate the front and back of the neck
- Inspect the chest, and observe breathing motion
- Gently palpate over the ribs
- Listen to anterior breath sounds (midaxillary and midclavicular)
- Inspect the back. Listen to posterior breath sounds (bases, apices)
- Observe and then palpate the abdomen and pelvis
- Gently compress the pelvis from the sides
- Gently press the iliac crests
- Inspect the extremities; assess distal circulation and motor and sensory function
- Log roll the patient, and inspect the back for tenderness or deformities
24
Q
A brassy crowing sound prominent on inspiration
A
Stridor
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Sounds of stridor suggest ___
A partially occluded upper airway caused by swelling
26
High-pitched crowing sounds may indicate ___
An upper airway obstruction from a foreign body
27
Inhalation to expiration ratio
1:3
28
Assess breathing by ___
1. Watching the chest rise and fall
2. Listening to breath sounds with a stethoscope over each lung
3. If unconscious, feeling for air through the mouth and nose during exhalation
29
Info to obtain while assessing breathing
1. Respiratory rate
2. Rhythm
3. Quality
4. Depth
30
Two rhythms of breathing
1. Regular
2. Irregular
31
Through a stethoscope, normal breathing sounds like
Just the sound of air movement through the bronchi accompanied by a soft, low-pitched murmur
32
If you hear bubbling or gurgling in the upper airway, the patient ___
Probably has fluid in those passages, potentially impeding the exchange of gases
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Sputum
Matter from the lungs
34
A patient who coughs up thick, yellow or green sputum most likely has ___
A respiratory infection
35
Where to place the stethoscope when listening to the lungs
On the back,
1. Over the upper lungs a about 1" below the clavicle at the midclavicular line
2. The midlung fields at the third or fourth intercostal space from the patient's posterior
3. Lower lungs at the sixth intercostal space, midaxillary line
36
Wheezing breath sounds suggest ___
An obstruction or narrowing of the lower airways
37
A high-pitched whistling sound that is most prominent on expiration
Wheezing
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Wet, crackling breath sounds on both inspiration and expiration
Crackles
39
Crackles may indicate
Fluid in the lungs
40
Low pitched, noisy sounds that are most prominent on expiration. Similar to blowing bubbles underwater. Typically associated with a productive cough. Congested breath sound
Rhonchi
41
What to assess with a pulse in secondary assessment
1. Rate
2. Quality
3. Rhythm
42
An adult patient with a pulse rate greater than 100 bpm
Tachycardia
43
An adult patient with a pulse rate less than 60 bpm
Bradycardia
44
Describe a pulse that feels to be at normal strength as ___
Strong
45
Stronger than normal pulse
Bounding
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Pulse that is weak or difficult to feel
Weak or thready
47
If an irregular pulse is found, it's important to determine if ___
It represents a new condition or a normal or chronic condition for the patient
48
A decrease in blood pressure may indicate one of the following ___
1. Loss of blood or its fluid components
2. Loss of vascular tone and sufficient arterial constriction to maintain the necessary pressure
3. Cardiac pumping problem
49
Decreased blood pressure indicates the patient is in the critical stage of ___
Decompensated shock
50
Three sizes of blood pressure cuffs normally carried
1. Thigh
2. Adult
3. Pediatric
51
The sounds of the turbulence and arterial vibrations that are listened to when taking blood pressure
Korotkoff sounds
52
What to look for on the arm before using it to measure blood pressure
1. Dialysis fistula
2. Central lines
3. Mastectomy
4. Injury to the arm
5. Other reason not to use the arm
53
Antecubital space
Crease inside the elbow
54
How high should the BP cuff be placed?
Across the upper arm with its distal edge about 1" above the antecubital space
55
How high should the arm be when measuring BP?
About heart level
56
Where to place the stethoscope with measuring BP?
Over the brachial artery in the antecubital fossa
57
Antecubital fossa
The anterior aspect of the elbow
58
How high to pressurize the BP cuff?
200 mm/Hg or 30 mm/Hg above the point you stop hearing pulse sounds
59
If pulse sounds are heard all the way until the BP cuff reads 0, ___
Record the diastolic as 0 or indicate that it was heard until the gauge read 0
60
Two methods to measure BP
1. Auscultation
2. Palpation
61
How to record a palpated BP
120/P
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Blood pressure lower than the normal range
Hypotension
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Blood pressure higher than the normal range
Hypertension
64
After taking BP in the uninjured limb, you might want to compare ___ with the injured limb
1. Distal skin temp
2. Quality of distal pulse
3. CRT
65
A MAP of greater than ___ is needed to adequately perfuse the vital organs of an adult
65
66
Normal systolic BP for an adult
90 - 120
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Normal systolic BP for an adolescent
110 - 131
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Normal systolic BP for a child (7 years)
97 - 115
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Normal systolic BP for a child (2 years)
86 - 106
70
Normal systolic BP for an infant
72 - 104
71
Normal systolic BP for a neonate
67 - 84
72
Normal pulse rate for adults and children over 10 years old
60 - 100
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Normal pulse rate for preschoolers and school aged children (2 - 10 years old)
60 - 140
74
Normal pulse rate for infants and toddlers (3 months to 2 years)
100 - 190
75
Normal pulse rate for infants (up to 3 months)
85 - 205
76
A neurological assessment should be completed anytime you are confronted with a patient who ___
Has changes in mental status, A possible head injury, stupor, dizziness, drowsiness, or syncope
77
Evaluate ___ to determine the patient's ability to think. Use the ___ if appropriate to determine the patient's mental status
1. The LOC and orientation
2. AVPU scale
78
Helpful in providing additional information on patients with changes in mental status
Glasgow Coma Scale (GCS)
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GCS
Glasgow Coma Scale
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How to report GCS
Note each category score and the total
81
GCS categories
1. Eye opening
2. Best verbal response
3. Best motor response
82
The diameter and reactivity to light of the pupils can reflect the status of ___
The brain's perfusion, oxygenation, and condition
83
Normally unequal pupils
Anisocoria
84
What are the pupils being evaluated for?
1. Become fixed with no reaction to changes in light
2. Dilate with bright light and constrict when light is removed
3. React sluggishly instead of briskly
4. Become unequal in size
5. Become unequal in size when a bright light is introduced or removed from one eye
85
Some causes of depressed brain function
1. Injury of the brain or brainstem
2. Trauma or stroke
3. Brain tumor
4. Inadequate oxygenation or perfusion
5. Drugs or toxins (CNS depressants)
86
GCS eye opening scale
4 - Spontaneous
3 - In response to sound
2 - In response to pressure
1 - None
87
GCS verbal response scale
5 - Oriented conversation
4 - Confused conversation
3 - Inappropriate words
2 - Incomprehensible sounds
1 - None
88
GCS motor response scale
6 - Obeys commands
5 - Localizes to pressure
4 - Withdraws from pressure
3 - Abnormal flexion
2 - Abnormal extension
1 - None
89
If a GCS category can't be tested, note ___
NT or not testable
90
GCS score of ___ may indicate mild dysfunction
13 - 15
91
GCS score of ___ indicates no neurological impairment
15
92
GCS score of ___ may indicate moderate dysfunction
9 - 12
93
GCS score of ___ is indicative of severe dysfunction
8 or less
94
Mnemonic used to assess pupils
PEARRL
95
PEARRL
Pupils
Equal
And
Round
Regular in size
react to Light
96
How to record PEARRL
Pupils = PEARRL
or
Pupils are equal and round, regular in size, and react properly to light
97
,If an abnormalities with the pupils are found, report it ___
Using the long form
98
What are you checking for during a hands-on assessment of neurovascular status?
1. How does the patient move
2. Check bilateral muscle strength and weaknesses
3. Sensory assessment of pain, sensations, and positions
4. Compare distal and proximal sensory & motor responses on one side to the other
99
Steps to assess neurovascular status in a conscious patient
1. Palpate the radial pulse
2. Palpate the posterior tibial and dorsalis pedis pulse
3. Assess capillary refill
4. Assess sensation on the flesh near the tip of the index finger, thumb, and the little finger
5. Check sensation on the flesh near the tip of the big toe
6. Check sensation on the side of the foot
7. (For upper extremity injury) Evaluate motor function by asking the patient to open the hand (only if hand or foot not injured, stop if it causes pain)
8. Ask the patient to make a fist
9. (For lower extremity injury) Ask the patient to flex the toes and foot (ask the patient to "push down on the gas)
10. Ask the patient to extend the foot and ankle and pull toes and foot towards the nose
100
How to assess Head, neck, and cervical spine
1. Gently palpate the scalp and skull for any pain, deformity, tenderness, crepitus, and bleeding (ask a conscious patient if they feel any pain or tenderness)
2. Patient's face symmetrical? Evidence of trauma, such as ecchymoses or hematomas?
3. Facial expressions such as a smile or grimace?
4. Assess pupillary function, shape, and response. PEARRL
5. Check the color of the sclera
6. Assess cheek bones (zygomas) for possible injury
7. Check ears and nose for fluid
8. Check the upper (maxillae) and lower (mandible) jaw
9. (If movement of jaw won't cause pain or injury) Open the mouth and look for broken or missing teeth
10. Note any unusual odors in the mouth
11. Check the neck for signs of swelling or bleeding
12. Palpate the neck for signs of trauma, such as deformities, bumps, swelling, bruising, and bleeding, as well as a crackling sound produced by air bubbles under the skin
13. (If no spinal injury is suspected) Inspect for pronounced or distended jugular veins with the patient sitting at a 45º angle (normal finding in supine patient, not sitting up)
101
Distended jugular veins while sitting up suggests a problem with ___
Blood returning to the heart
102
Air bubbles under the skin
Subcutaneous emphysema
103
How to assess the chest
1. Inspect, visualize, and palpate over the chest area for injury and signs of trauma, including bruising, tenderness, and swelling
2. Watch for both sides of the chest to rise and fall together with breathing
3. Observe for abnormal breathing signs, including retractions or paradoxical motion
4. Feel for grating bones and the patient breaths
5. Palpate the chest for subcutaneous emphysema (especially in cases of severe blunt chest trauma)
6. (If patient reports breathing difficulty or has evidence of chest trauma) Auscultate breath sounds
104
Only one section of the chest rises on inspiration while another area of the chest falls
Paradoxical motion
105
Retractions indicate ___
The patient has some condition, usually medical, that is impairing the flow of air into and out of the lungs
106
Paradoxical motion is associated with ___
A fracture of several ribs (flair), causing a section of the chest to move independently from the rest of the chest wall
107
___ is often associated with rib fractures
Crepitus
108
Subcutaneous emphysema in the chest could indicate ___
Pneumothorax
109
How to assess the abdomen
1. Look for trauma and distention
2. Palpate for tenderness, rigidity, and patient guarding
3. (If awake and alert) Ask about pain as you perform the examination
4. Assess for rebound tenderness
110
How to report findings on abdomen palpation assessment
Firm, soft, tender, or distended
111
What quadrant of the abdomen to start with when palpating?
The quadrant is furthest from the pain
112
Pain created when pressure is released
Rebound tenderness
113
Involuntary muscle contractions of the abdominal wall; an effort to protect the inflamed abdomen
Guarding
114
How to assess the pelvis
1. Inspect for symmetry and obvious signs of injury, bleeding, and deformity
2. (If no pain is reported) Gently press downward and inward on the pelvic bones (do not rock the pelvis)
115
If when assessing the pelvis you feel any movement or crepitus or the patient reports any pain or tenderness, ___
Severe injury may be present
116
How to assess extremities
1. Do all extremities appear to be properly positioned and functioning normally?
2. (If standing) assess posture
3. Look at joints, check for range of motion (ask patient move on their own, never force a painful joint to move)
4. Compare both sides for weakness, atrophy, and assess equality of grip strength
5. Inspect each extremity for symmetry, cuts, bruising, swelling, obvious injuries, and bleeding
6. Palpate along each extremity for deformities (ask about any tenderness or pain)
7. Check for distal pulses for rate, quality, and rhythm
8. Check for motor function by asking the patient to wiggle the fingers and toes
9. Evaluate sensory function by asking the patient to close their eyes. Gently squeeze or finch each finger or toe and ask the patient to identify what you are doing
117
Inability to feel sensation in the extremity may indicate ___
A local nerve injury
118
Inability to feel sensation in several extremities may be a sign of ___
Spinal cord injury
119
How to assess the posterior body
1. Inspect the back for DCAP-BTLS, symmetry, and open wounds
2. Carefully palpate the spine from the neck to the pelvis for tenderness and deformity
120
Assessment tool used to evaluate the effectiveness of oxygenation
Pulse oximetry
121
What is a pulse oximeter
Photoelectric device that monitors the oxygen saturation of hemoglobin in the capillary beds
122
Most pulse oximetry readings are ___
94% to 99%
123
The goal of applying oxygen therapy
Increase oxygen saturation to a normal level
124
With the pulse oximeter, any situation that causes ___ will result in misleading or inaccurate values
Vasoconstriction or loss of red blood cells
125
To get an idea about the patient's metabolism and adequacy of ventilation, you can measure ___ as the patient exhales
CO2 levels in the air
126
Noninvasive method that can quickly and efficiently provide info on a patient's ventilation, circulation, and metabolism
Capnography
127
Waveform capnography shows a graph that indicates ___
How easily, how frequently, and how much the patient is exhaling CO2
128
Capnography monitors can be attached to ___
The end of an advanced airway or onto a nasal cannula
129
Capnography is used to evaluate ___
The effectiveness of breathing treatments and of artificial ventilation and to confirm endotracheal tube placement. It is correlated to lactic acid values in patients with septic shock
130
If the glucose level is low, this can help you identify the ___
Reason a patient is unresponsive
131
If the glucose level is high in a patient with nausea, vomiting, abdominal pain, and a change in mental status, it may signal ___
Dangerous complications of high blood glucose
132
Blood glucose should be assessed in all patients who ____
Are known to have diabetes, have an altered mental status, or have a generalized malaise or weakness. May also be assessed in any patient who you think has a poor general impression
133
Steps to assess blood glucose levels
1. Take standard precautions. Cleanse the site with antiseptic (finger)
2. Puncture the site with the lancet
3. Dispose of the needle in a sharps container
4. Obtain a drop of blood on the test strip. Insert into the glucometer
5. Bandage the puncture site
134
When faced with electronic BP readings that do not correlate with a patient's clinical presentation, it is best to ___
Obtain a manual reading to confirm
135
A ___ is performed at regular intervals during the assessment process, and its purpose is to ID and treat changes in a patient's condition
Reassessment
136
Reassessment should take place ___
1. Every 15 minutes for patients in stable condition
2. Every 5 minutes for patients in unstable condition
137
Steps to reassessment
1. Repeat the primary assessment
2. Reassess vital signs
3. Reassess the chief complaint
4. Recheck interventions
5. ID and treat changes in the patient's condition
6. Reassess patient
138
When reassessing the chief complaint, what questions should be asked?
1. Is the current treatment improving the patient's condition?
2. Has an already identified problem gotten better?
3. Has an already identified problem gotten worse?
4. What is the nature of any newly identified problems?
