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Chapter 8

Patient Assessment

accessory muscles the secondary muscles of respiration. They include the neck muscles (sternocleidomastoids), the chest pectoralis major muscles, and the abdominal muscles.
auscultate to listen to sounds within an organ with a stethoscope
AVPU scale a method of assessing the level of consciousness by determining whether the patient is awake and alert, responsive to verbal stimuli or pain, or unresponsive; used principally early in the assessment process.
blood pressure the pressure of circulating blood against the walls of the arteries.
bradycardia a slow heart rate, less than 60 beats/min.
breath sounds an indication of air movement in the lungs, usually assessed with a stethoscope
capillary refill a test that evaluates distal circulatory system function by squeezing (blanching) blood from an area such as a nail bed and watching the speed of return after releasing the pressure.
capnography a noninvasive method that can quickly and efficiently provide information on a patient's ventilatory status, circulation, and metabolism.
capnomentry the use of a capnometer, a device that measures the amount of expired carbon dioxide.
carbon dioxide carbon dioxide is a component of air and typically makes up 0.3% of air at sea level. It is also a waste product exhaled during expiration by the respiratory system.
chief complaint the reason a patient called for help; also, the patient's response to question's such as "What's wrong?" or "What happened?"
coagulate to form a clot to plug an opening in an injured blood vessel and stop bleeding.
colorimetric devices capnometer or end-tidal carbon dioxide detectors are devices that use a chemical reaction to detect the amount of carbon dioxide present in expired gases by changing colors (qualitative measurement rather than quantitative).
conjunctiva the delicate membrane that lines the eyelids and covers the exposed surface of the eye.
crepitus a grating or grinding sensation caused by th fractured bone ends or joints rubbing together; also air bubbles under the skin that produce a crackling sound or crinkly feeling.
cyanosis a bluish gray skin color that is caused by a reduced level of oxygen in the blood.
DCAP-BTLS a mneumonic for assessment in which each area of the body is evaluated for Deformities, Contusions, Abrasions, Puntures/penetrations, Burns, Tenderness, Lacerations, and Swelling.
diaphoretic pressure characterized by profuse sweating.
diastolic pressure the pressure that remains in the arteries during the relaxing phase of the heart's cycle (diastole) when the left ventricle is at rest.
end-tidal CO2 the amount of carbon dioxide present in exhaled breath.
focused assessment a type of physical assessment that is typically performed on patients who have sustained nonsignificant mechanisms of injury or on responsive medical patients. This type of examination is based on the chief complaint and focuses on one body system/part.
frostbite damage to tissues as the result of exposure to cold; frozen or partially frozen body parts are frostbitten.
full-body scan a systematic head-to-toe examination that is performed during the secondary assessment on a patient who has sustained a significant mechanism of injury, is unconscious, or is in critical condition.
general impression the overall initial impression that determines the priority for patient care; based on the patient's surroundings, the mechanisms of injury, signs and symptoms, and the chief complaint.
Golden Period the time from injury to definitive care, during which treatment of shock and traumatic injuries should occur because survival potential is the best.
guarding involuntary muscles contractions (spasms) of the abdominal wall in an effort to protect and inflamed abdomen; a sign of peritonitis.
history taking a step within the patient assessment process that provides detail about the patient's chief complaint and an account of the patient's signs and symptoms.
hypertension blood pressure that is higher than the normal range.
hypotension blood pressure that is lower than the normal range.
hypothermia a condition in which the internal body temperature falls below 95 F (35 C) after exposure to a cold environment.
incident command system a system implemented to manage disasters and mass- and multiple- casualty incidents in which section chiefs, including finance, logistics, operations, and planning, report to the incident commander. Also referred to as the incident management system.
jaundice yellow skin or sclera that is caused by liver disease or dysfunction.
labored breathing breathing that requires visibly increased effort; characterized by grunting, stridor, and use of accessory muscles.
mechanism of injury (MOI) the way in which traumatic injuries occur; the forces that act on the body to cause damage.
nasal flaring flaring out of the nostrils, indicating that there is an airway obstruction
nature of illness (NOI) The general type of illness a patient is experiencing.
OPQRST an abbreviation for key terms used in evaluating a patient's pain: Onset, Provocation or Palliation, Quality, Region/radiation, Severity, and Timing of Pain.
orientation The mental status of a patient as measured by memory of person (name), place (current location), time (current year, month, and approximate date), and event (what happened).
palpate to examine by touch.
paradoxical motion the motion of the chest wall section that is detached in a flail chest; the motion is exactly the opposite of normal motion during breathing (ie, in during exhalation, out during inhalation).
perfusion circulation of blood within an organ or tissue.
personal protective equipment (PPE) clothing or specialized equipment that provides protection to the wearer.
pertinent negatives negative findings that warrant no care or intervention.
primary assessment a step within the patient assessment process that identifies and initiates treatment of immediate and potential life threats.
pulse the pressure wave that occurs as each heartbeat causes a surge in the blood circulating through the arteries.
pulse oximetry an assessment tool that measures oxygen saturation of hemoglobin in the capillary beds.
rales a crackling, rattling breath sound that signals fluid in the air spaces of the lungs; also called crackles.
reassessment a step within the patient assessment process that is performed at regular intervals during the assessment process. Its purpose is to identify and treat changes in a patient's condition.
How long should pass between each reassessment? A patient in unstable condition should be reassessed every 5 minutes, whereas a patient in stable condition should be reassessed every 15 minutes.
responsiveness the way in which a patient responds to external stimuli, including verbal stimuli (sound), tactile stimuli (touch), and painful stimuli.
retractions movements in which the skin pulls in around the ribs during inspiration.
rhonchi coarse, low-pitched breath sounds heard in patients with chronic mucus in the upper airways.
SAMPLE history a brief history of a patient's condition to determine signs and symptoms, allergies, medications, pertinent past history, last oral intake, and events leading to the injury or illness.
scene size-up a step within the patient assessment process that involves a quick assessment of the scene and the surroundings to provide information about scene safety and the mechanism of injury or nature of illness before you enter and begin patient care.
sclera the white portion of the eye; the tough outer coat that gives protection to the delicate, light-sensitive inner layer.
secondary assessment a step in the patient assessment process in which a systematic physical exam of the patient is performed. the examination may be a systematic full-body scan or a systematic assessment that focuses on a certain area or region of the body (chief complaint)
shallow respirations respirations that are characterized by little movement of the chest wall (reduced tidal volume) or poor chest excursion.
sign objective findings that can be seen, heard, felt, smelled, or measured.
sniffing position an upright position in which the patients head and chin are thrust slightly forward to keep the airway open.
spontaneous respirations breathing that occurs with no assistance.
standard precautions protective measures that have traditionally been developed by the Centers for Disease Control and Prevention for use in dealing with objects, blood, body fluids, and other potential exposure risks of communicable disease.
stridor a harsh, high-pitchedm crowing inspiratory sound, such as the sounds often heard in acute laryngeal (upper airway) obstruction; may sound like crowing and be audible without a stethoscope.
subcutaneous emphysema the presence of air in tissues, causing a characteristic crackling sensation on palpation
symptom subjective findings that the patient feels but that can be identified only by the patient.
systolic pressure the increased pressure in an artery with each contraction of the ventricles (systole).
tachycardia a rapid heart rate, more than 100 beats/min.
tidal volume the amount of air (in milliliters) that is moved in or out of the lungs during one breath.
triage the process of establishing treatment and transportation priorities according to severity of injury and medical need.
tripod position an upright position in which the patient leans forward onto two arms stretched forward and thrusts the head and chin forward.
two- to three- word dyspnea a severe breathing problem in which a patient can speak only two to three words at a time without pausing to take a breath.
vasoconstriction narrowing of a blood vessel.
vital signs the key signs that are used to evaluate the patients overall condition, including respirations, pulse, blood pressure, level of consciousness, and skin characteristics.
Created by: lharbridge