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Patient Assessment

Chapter 8

QuestionAnswer
Accessory Muscles The secondary muscles of respiration.
AVPU A method of assessing a patient's level of consciousness by determining whether a patient is Awake and alert, responsive to Verbal stimulus or Pain, or Unresponsive; used principally in the initial assessment.
Body substance isolation (BSI) An infection control concept and practice that assumes that all body fluids are potentially infectious.
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 nail bed and watching the speed of its return after releasing the pressure.
Chief complaint The reason a patient called for help; also, the patient's response to general questions such as "what's wrong?" or "What happened?"
Coagulate To form a clot to plug an opening in an inured blood vessel and stop bleeding.
Conjunctiva The delicate membrane that lines the eyelids and covers the exposed surface of the eye.
Crepitus A grating or grinding sensation caused by fractured bone ends or joints rubbing together; also air bubbles under the skin that produce a crackling sound or crinkly feeling.
Chief complaint The reason a patient called for help; also, the patient's response to general questions such as "what's wrong?" or "What happened?"
Coagulate To form a clot to plug an opening in an inured blood vessel and stop bleeding.
Conjunctiva The delicate membrane that lines the eyelids and covers the exposed surface of the eye.
Crepitus A grating or grinding sensation caused by fractured bone ends or joints rubbing together; also air bubbles under the skin that produce a crackling sound or crinkly feeling.
Cyanosis Bluish-gray skin color that is caused by reduced oxygen levels in blood.
DCAP-BTLS A mnemonic for assessment in which each area of the body is evaluated for Deformities, Contusions, Abrasions, Punctures/Penetrations, Burns, Tenderness, Lacerations, and Swelling.
Detailed physical exam The part of the assessment process in which a detailed area-by-area exam is performed on patients whose problems cannot be readily identified or when more specific information is needed about problems identified in the focused history and physical exam.
Focused history and physical exam The part of the assessment process in which the patient's major complaints or any problems that are immediately evident are further and more specifically evaluated.
Frostbite Damage to tissues as the results of exposure to cold; frozen or partially frozen body parts.
General impression The overall initial impression that determines the priority for patient care; based on the patient's surroundings, the mechanism of injury, signs and symptoms, and the chief complaint.
Golden Hour the time from injury to definitive care, during which treatment of shock or traumatic injuries should occur because survival potential is best.
Guarding Involuntary muscle contractions (spasm) of the abdominal wall in an effort to protect the inflamed abdomen; a sign of peritonitis.
Hypothermia A condition in which the internal body temperature falls below 95 degrees F or (35 C) after exposure to a cold environment.
Initial Assessment The part of the assessment process that helps you to identify any immediately or potentially life-threatening conditions so that you can initiate lifesaving care.
Jaundice A yellow skin color that is seen in patients with liver disease or dysfunction.
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.
Ongoing assessment The part of the assessment process in which problems are reevaluated and responses to treatment are assessed.
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).
OPQRST The six pain questions; Onset, Provoking factors, Quality, Radiation, Severity, time
Palpate Examine by touch
Paradoxical motion The otion 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 inhalation, out during exhalation)
Rales Crackling, rattling, breath sound that signals fluid in the air spaces of the lungs; also called crackles.
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 which chronic mucus in the upper airways.
SAMPLE history A key brief history of a patient's condition to determine Signs/Symptoms, Allergies, Medications, pertinent past history, Last oral intake, and Events leading to the illness/injury.
Scene size-up A quick assessment of the scene and the surroundings made to provide information about its 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 give protection to the delicate, light-sensitive, inner layer.
Stridor A harsh, high-pitched inspiratory sound that is 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 soft tissues, causing a characteristic crackling sensation on palpation.
Triage The process of establishing treatment and transportation priorities according to severity of injury and medical need.
Two-two-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.
Created by: azoch