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Medical Assessment Principles
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Medical Assessment Principles

Created by
@AdmiringInspiration

Questions and Answers

What are the 4 goals of assessment?

  • Evaluate the patient (correct)
  • Gather key info (correct)
  • Learn the history (correct)
  • Learn overall health (correct)

    • What key patient information do you gather first?

    Name, age, gender, race

    What is the chief complaint?

    Major symptom reported by patient regardless of overall significance

    What is a symptom?

    <p>Problem/complaint from patient</p> Signup and view all the answers

    What is a sign?

    <p>Condition that can be seen, heard, felt, smelled, measured</p> Signup and view all the answers

    What is SAMPLE History?

    <p>Signs/Symptoms, Allergies, Medications, Pertinent past history, Last oral intake, Events leading up to illness/injury</p> Signup and view all the answers

    What does OPQRST stand for?

    <p>Onset, Provocation, Quality, Radiation, Severity, Time</p> Signup and view all the answers

    Baseline vitals always include what?

    <p>Respiration, pulse, BP, lung sounds</p> Signup and view all the answers

    What vitals likely include?

    <p>Skin temperature, capillary refill, pupils, LOC</p> Signup and view all the answers

    What are the 6 assessments of respirations?

    <p>Rate, quality, rhythm, effort, noise, depth</p> Signup and view all the answers

    What are normal respirations for an adult?

    <p>12-20 breaths per minute</p> Signup and view all the answers

    What are normal respirations for a child?

    <p>15-30 breaths per minute</p> Signup and view all the answers

    What are normal respirations for an infant?

    <p>25-50 breaths per minute</p> Signup and view all the answers

    What is pulse oximetry?

    <p>An assessment tool that measures oxygen saturation of hemoglobin in the capillary beds</p> Signup and view all the answers

    What are the 3 pulse assessments?

    <p>Rate, strength, regularity</p> Signup and view all the answers

    What is the normal pulse for an adult?

    <p>60-100 bpm</p> Signup and view all the answers

    What is the normal pulse for children?

    <p>70-150 bpm</p> Signup and view all the answers

    What is the normal pulse for an infant?

    <p>100-160 bpm</p> Signup and view all the answers

    What are the 3 skin assessments?

    <p>Color, temperature, moisture</p> Signup and view all the answers

    How do you check capillary refill?

    <p>Squeeze the tip of a finger for 2 seconds and then release</p> Signup and view all the answers

    What does a drop in BP indicate?

    <p>Loss of blood, loss of vascular tone, cardiac pumping problem</p> Signup and view all the answers

    What is diastolic pressure?

    <p>The pressure when the ventricles are relaxing</p> Signup and view all the answers

    What is systolic pressure?

    <p>Blood pressure in the arteries during contraction of the ventricles</p> Signup and view all the answers

    BP is measured as?

    <p>Systolic/diastolic in mmHg</p> Signup and view all the answers

    What is a healthy BP?

    <p>120/80</p> Signup and view all the answers

    What does AVPU stand for?

    <p>Alert, Verbal, Pain, Unresponsive</p> Signup and view all the answers

    What does PEARRL stand for?

    <p>Pupils equal and round, regular in size, react to light</p> Signup and view all the answers

    How often do you reassess a stable patient?

    <p>15 minutes</p> Signup and view all the answers

    How often do you assess an unstable patient?

    <p>5 minutes</p> Signup and view all the answers

    What are the 5 main parts of patient assessment?

    <p>Scene size-up, primary assessment, history taking, secondary assessment, reassessment</p> Signup and view all the answers

    What are the 6 aspects of BSI?

    <p>All body fluids present infection risk, protective equipment, gloves, eye protection, mask, gown</p> Signup and view all the answers

    What are 7 things to look for in Scene Size up?

    <p>Dispatch info, inspection of scene, scene hazards, safety concerns, MOI/NOI, number of patients - triage, additional resources</p> Signup and view all the answers

    What are examples of potential hazards?

    <p>Oncoming traffic, unstable surfaces, leaking gas, downed electrical lines, potential violence, fire/smoke, hazardous materials, crash or reduce scene, crime scene, infection</p> Signup and view all the answers

    What are the 5 aspects of scene safety?

    <p>Park in a safe area, speak with law enforcement, safety of you and your partner comes first, safety of patient and bystanders comes next, request additional resources if needed</p> Signup and view all the answers

    What does MOI stand for?

    <p>Mechanism of Injury</p> Signup and view all the answers

    What does NOI stand for?

    <p>Nature of illness</p> Signup and view all the answers

    What is a symptom?

    <p>Subjective from the patient, family, or bystander</p> Signup and view all the answers

    What is a sign?

    <p>Objective, you see, feel, smell it</p> Signup and view all the answers

    What are additional resources you may call for?

    <p>Additional units, air transport, non-medical, fire suppression, rescue</p> Signup and view all the answers

    Study Notes

    Goals of Assessment

    • Gather key information regarding the patient's condition.
    • Evaluate the patient's health status systematically.
    • Understand the patient's medical history.
    • Assess overall health to inform treatment decisions.

    Key Patient Information

    • Essential details to collect include name, age, gender, and race.

    Chief Complaint

    • The primary symptom reported by the patient, which may not reflect its overall significance.

    Symptoms and Signs

    • Symptoms are problems or complaints indicated by the patient.
    • Signs are observable conditions that can be seen, heard, felt, smelled, or measured.

    SAMPLE History

    • Acronym representing key history elements:
      • Signs/Symptoms
      • Allergies
      • Medications
      • Pertinent past history
      • Last oral intake
      • Events leading to illness/injury

    OPQRST

    • A mnemonic for assessing pain:
      • Onset
      • Provocation
      • Quality
      • Radiation
      • Severity
      • Time

    Baseline Vital Signs

    • Always includes:
      • Respiration rate
      • Pulse
      • Blood Pressure (BP)
      • Lung sounds

    Additional Vital Signs

    • May include skin temperature, capillary refill, pupil response, and level of consciousness (LOC).

    Respiratory Assessment

    • Assessments should include rate, quality, rhythm, effort, noise, and depth.
    • Normal adult respiration: 12-20 breaths per minute.
    • Normal child respiration: 15-30 breaths per minute.
    • Normal infant respiration: 25-50 breaths per minute.

    Pulse Oximetry

    • Measures oxygen saturation of hemoglobin; normal reading is 95% or higher.
    • Assess pulse based on rate, strength (bounding, strong, thready), and regularity.

    Normal Pulse Rates

    • Adult pulse: 60-100 beats per minute (bpm).
    • Child pulse: 70-150 bpm.
    • Infant pulse: 100-160 bpm.

    Skin Assessment

    • Evaluate color, temperature, and moisture of the skin.

    Capillary Refill Check

    • Squeeze the tip of a finger for 2 seconds, then release.
    • Poor perfusion is indicated if refill takes longer than 2 seconds; useful in pediatric assessments.

    Blood Pressure Insights

    • A drop in blood pressure can indicate:
      • Blood loss
      • Loss of vascular tone
      • Cardiac pumping issues.
    • Diastolic pressure indicates relaxation of ventricles; systolic pressure indicates blood pressure during ventricular contraction.
    • Blood pressure expressed as systolic/diastolic in mmHg, with a healthy reading at 120/80.

    Patient Assessment Methodology

    • AVPU scale: Alert, Verbal, Pain response, Unresponsive.
    • PEARRL assessment for pupils: Equal and round, regular in size, reactive to light.

    Reassessment Intervals

    • Stable patients require reassessment every 15 minutes.
    • Unstable patients should be reassessed every 5 minutes.

    Patient Assessment Components

    • Scene size-up
    • Primary assessment
    • History taking
    • Secondary assessment
    • Reassessment

    Body Substance Isolation (BSI)

    • Recognizes risks from all body fluids.
    • Equipment includes gloves, eye protection, masks, and gowns.

    Scene Size-Up Considerations

    • Review dispatch information, inspect the scene, identify safety concerns, determine mechanism of injury/nature of illness, triage patients, and request additional resources.

    Potential Hazards

    • Be aware of oncoming traffic, unstable surfaces, gas leaks, electrical hazards, potential violence, fires, smoke, hazardous materials, and crime scenes.

    Scene Safety Protocols

    • Prioritize safety of personnel and bystanders, park in a safe area, communicate with law enforcement, and call for additional resources if necessary.

    Mechanism of Injury (MOI) and Nature of Illness (NOI)

    • Assess MOI to evaluate possible injury extent based on force, duration, and affected body areas.
    • For NOI, gather clues and listen for the chief complaint.

    Subjective vs. Objective Data

    • Symptom: Subjective data reported by the patient, family, or bystander.
    • Sign: Objective data that can be observed or measured directly.

    Additional Resources

    • Can include requests for additional units, air transport, non-medical support, fire suppression, and rescue services.

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    Description

    This quiz covers essential principles of patient assessment in a medical context. It focuses on key components such as gathering patient information, understanding symptoms, and utilizing mnemonics like SAMPLE and OPQRST. Assess your knowledge on how to evaluate health status and inform treatment decisions.

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