Mod 4: Patient Assessment

blunt-force trauma

injury caused by a blow that DOES NOT penetrate the skin or other body tissue

danger zone

area around wreckage of a vehicle collision or other incident where special safety percautions should be taken

index of suspicion

awareness that there may be injuries

mechanism of injury

the fources that may have caused patient injury

nature of the illness

what is medically wrong with a patient

penetrating trauma

injury caused by an object that passes through the skin or other body tissues

scene size-up

steps taken when approaching the scene of an emergancy call: checking scene safety, Standard Precations, mechanism of injury, number of patients, decideing what additional recources needed

AVPU

memory aid for classifying a patiens level of responsiveness or mental status. ALERT VERBAL PAIN UNRESPONSIVE

ABC's

airway, breathing, circulation

cheif complaint

in emergency medicine, the reason EMS was called, usually in the patients own words

general impression

impression of the patients condition that is formed on first approach, baised on patients environment, cheif complaint, and apprence

interventions

actions taken to correct or manage a patients problems

mental status

level of responsiveness

primary assessment

The first element of a patient assessment; steps taken for the purpose of discovering and dealing with any life-threatening problems.

six parts to primary assessment

general impression, mental status, airway, breathing, circulation, priority of patient for treatment and transfer to hospital

priority

the decision regarding the need for immediate transport of the patient versus further asessment and care at the scene

ABC

airway, breathing, curculation

blood pressure Adult

syst: less than or equal to 120
diast: less than oe equal 80

BP for infants and children

syst: aproxx 80+2 x age(yrs)
diast: approx 2/3 systolic
BP is usually not taken in childeren under 3yrs old

BP adolesent 11 to 14

syst: 114 (88 to 120)
diast: average 76

school age 6 to 10

syst: 105 (80- 115)
diast: average 69

preschool 3 to 5

syst: 99 (78-104)
diast: average 65

high blood pressure

medical condition, exertion, fright, emotional distress, excitement

low blood pressure

blood loss, late sign of shock

dilated pupil

fright, blood loss, drugs, percription eye drops

constricted (smaller than normal) dilation

drugs(narcotics), eye drops

unequal pupil dilation

stroke, head injury, eye injury, artificial eye, eye drops

lack of reactivity of pupil

lack of oxygen to brain

pink skin

normal in light skinned patients, normal at inner eyelids, lips, nail beds of dark-skinned patients

pale skin

constricted blood vessels from blood loss, shock, hypotension, emotional distress

cyanotic(blue- grey) skin

lack of oxygen in blood cells and tissues from inadequate breathing or heat

flushed (red) skin

exposure to heat, emotinal excitement

CCT

color, condition, tempeture

jaundiced (yellow) skin

abnormalities of the liver

mottled (blotchy) skin

occassionally in patients with shock

PERRL

pupil, equal, round, react, light

bradycardia

a slow pulse; pulse below 60 beats per min

constrist

get smaller

dilate

get larger

oxygen saturation (SpO2)

ratio of the amount of OXYGEN PRESENT in the blood TO the amount that could be CARRIED, expressed as a persentage

palpation

touching or feeling.

pulse

rhythmic beats felt as heart pumps blood through the arteries

pulse oximeter

electronic device used to determine the amount of oxgen carried by the blood measures SpO2

pulse quality

the regular or irregular rhythm and strong or weak force of the pulse

pulse rate

number of pulse beats per min

reactivity

pupils of the eyes reacting to light by changing in size

respiratory rate

the number of breaths taken in one min

sphygmomanometer

cuff and gauge used to messure BP

tachycardia

rapid pulse, pulse above 100 beats per min

vital signs

outward signs of what is going on inside the body, including repiration, pulse, skin color, tempeture, pupils, and BP

systolic

pressure created when the HEART CONTRACTS and forces blood INTO the the arteries

diastolic

pressure remaining in the arteries when left ventrical is relaxed and refilling

hypoxia/ (SpO2)/ oxygen saturation

Normal: 96-100%
Mild: 91- 95%
Significant/Moderate: 86- 90%
Severe: 85 or less %

crepitation

the grating sound of feeling of broken bones rubbing together

detailed physical exam

an assessment of the head, neck, chest, abdomen, pelvis, extrinities, and posterior of the body to detect signs and symptoms of injury.

distention

a condition of being streched, inflated, larger than normal

HPI

history of the present illness, info gathered from symptoms and nature of the patients current cincern

jugular vein distention (JVD)

bulging of the neck veins

paradoxical motion

movement of a part of the chest in the opposite direction to the rest of the chest during respiration

PMH

past medical history: info gathered regarding the patients health problems in the past

priapism

peristent erection of the penis that may result from spinal injury and some medical problems

rapid trauma assessment

rapid assesment of the head, neck, chest, abdomen, pelvis, extrimites, and posterior of the body to detect signs and symptoms of injury

SAMPLE

past medical history: Signs/Symptoms, Allergies, Medications, Pertinent Past history, Last oral intake, Events leading up to injury or illness

stoma

permament surgical opening in the neck through which allows patient to breathe

tracheostomy

a surgical incision held open by a metal of plastic tube

trauma partient

a patient suffering from one of more physicsical injury

DCAP- BTLS

Deformities, Contusion(bruise), Abrasions(srape), Punctures/Penetrations, Burns, Tenderness, Lacerations(cuts), Swelling

perfusion

movement of the blood

CSF

ceribral spinal fluid

rear- end collisions

common causes of neck and head injuries from vhichcular accidents

severe falls

determin height of fall, surface fell into, part of patient that hits the surface
Child: 10ft or 2-3 times the childs height
Adult: 20ft

OPQRST

questions asked to get a description of the present illness: Onset, Provokes, Quality, Radiation, Severity, Time

reassessment

procedure for determinaming changes in a patients condition, repeating primary assessment, vital signs, physical exam, and rechecking interventions

trending

changes in a patients condition over time, can show improvement or detrioration

diagnosis

description or label for a patients condition that assist a clinician in further evaluation and treatment