Patient Assessment Chapter 10

Questions and Answers

What are the five parts of the patient assessment process?

Secondary assessment (correct)

Reassessment (correct)

Primary assessment (correct)

Scene size-up (correct)

History taking (correct)

What is scene size-up?

A quick assessment of the scene and surroundings to provide information about scene safety and the mechanism of injury or nature of illness before entering.

What does Situational Awareness refer to?

Knowledge and understanding of your surroundings and situation and the risks they potentially pose to safety.

What is the Incident Command System (ICS)?

A system to manage disasters and mass-casualty incidents with section chiefs reporting to the incident commander. Signup and view all the answers

What is the purpose of Triage?

The medical screening of patients to determine their relative priority of need and the proper place of treatment. Signup and view all the answers

What is a Primary Survey?

An examination of the patient to determine the presence of any life-threatening emergencies. Signup and view all the answers

What are spontaneous respirations?

Breathing that occurs without assistance. Signup and view all the answers

What happens during inspiration?

Diaphragm and intercostal muscles contract. Signup and view all the answers

When assessing breathing, obtain what info?

RR, quality, degree of distress, use of accessory muscles Signup and view all the answers

What accessory muscles are used in labored breathing?

Neck, chest, abdominal. Signup and view all the answers

What are inadequate breathing signs in pediatrics?

Nasal flaring, seesaw breathing, retractions. Signup and view all the answers

What is the tripod position?

An upright position in which the patient leans forward onto two arms stretched forward. Signup and view all the answers

What is the sniffing position?

An upright position that keeps the airway open with the head and chin slightly forward. Signup and view all the answers

What does respiratory failure indicate?

Blood is inadequately oxygenated to meet oxygen demands of the body. Signup and view all the answers

How many breaths per minute should be given to a patient with a pulse but not breathing?

Adult: 10-12, Infant/child: 12-20. Signup and view all the answers

What is perfusion evaluated by?

Skin tone, capillary refill, temperature, moisture. Signup and view all the answers

What is cyanosis?

A bluish discoloration of the skin and mucous membranes. Signup and view all the answers

What is jaundice?

Yellowing of the skin. Signup and view all the answers

What are the signs of liver disease?

Jaundice. Signup and view all the answers

What is the normal skin temperature?

98.6°F. Signup and view all the answers

What should be assessed when evaluating skin?

Color, temperature, moisture, capillary refill. Signup and view all the answers

What does 'diaphoretic' mean?

Characterized by profuse sweating. Signup and view all the answers

How do you assess capillary refill in newborns or infants?

Press on forehead, chin, or sternum. Signup and view all the answers

What does the AVPU scale stand for?

Alert, Verbal, Pain, Unresponsive. Signup and view all the answers

What is orientation in patient assessment?

Tests a patient's mental status by checking memory and thinking ability. Signup and view all the answers

What is the most common test for orientation?

Person, place, time, event. Signup and view all the answers

What is the GCS scale used for?

It evaluates the level of consciousness. Signup and view all the answers

What is a rapid full body scan?

A 60- to 90-second nonsystematic review and palpation of the patient's body to identify injuries. Signup and view all the answers

What should be assessed during a rapid full body scan?

Inspection, palpation, auscultation, DCAP-BTLS. Signup and view all the answers

What is known as the golden hour?

The time from injury to definitive care where treatment of shock and traumatic injuries should occur. Signup and view all the answers

What does the Platinum 10 minutes refer to?

The goal for on-scene time when caring for a trauma or shock patient. Signup and view all the answers

What is significant MOI?

Mechanism of Injury related to high-risk situations. Signup and view all the answers

What is history taking (SAMPLE)?

Provides details about the chief complaint and an account of the patient's signs and symptoms. Signup and view all the answers

What is focal pain?

Pain that is easily identified as being specific to a single location. Signup and view all the answers

What is diffuse pain?

Pain that is spread out over an area and not specific to a single location. Signup and view all the answers

What is referred pain?

Pain felt in a location other than where it originates. Signup and view all the answers

What are pertinent negatives?

Negative findings that warrant no care or intervention. Signup and view all the answers

What are SAMPLE medication questions?

What's prescribed? How much? How often? How much was taken and when? Does patient take recreational drugs? Signup and view all the answers

What sexual history questions should be asked?

Last menstrual period? Periods normal? Frequency of urination or burning? Severity of cramping? Pregnant? How many sexual partners? Signup and view all the answers

What is the purpose of the Secondary Assessment?

To obtain vital signs and perform a systematic physical exam of the patient. Signup and view all the answers

What vital signs should be assessed during the secondary assessment?

Respirations, pulse, blood pressure, level of consciousness, blood glucose, skin signs, pulse oximetry. Signup and view all the answers

What is pulse oximetry?

An assessment tool that measures oxygen saturation of hemoglobin in the capillary beds. Signup and view all the answers

What is the normal SpO2 range?

95-100%. Signup and view all the answers

What is electronic blood pressure measurement?

Linear deflation. Signup and view all the answers

What is the purpose of stepped deflation?

To deflate in intervals, effective on hypotensive or moving patients. Signup and view all the answers

What is capnometry?

The use of a capnometer to measure the amount of expired carbon dioxide. Signup and view all the answers

What is capnography?

It measures CO2 levels and provides waveform based on serial measurements. Signup and view all the answers

What does end-tidal CO2 refer to?

The amount of carbon dioxide present at the end of an exhaled breath. Signup and view all the answers

How is end-tidal CO2 measured?

Percentage of CO2 or millimeters of mercury (mm Hg). Normal range: 35-45 mm Hg. Signup and view all the answers

What is the end-tidal CO2 range?

35-45 mm Hg or 5-6% CO2. Signup and view all the answers

What does a colorimetric device provide?

Qualitative information regarding the presence of CO2 in the patient's exhaled breath. Signup and view all the answers

What do colorimetric CO2 color readings indicate?

Purple indicates less than 0.5%, Tan indicates 0.5% to 2%, Yellow indicates greater than 2%. Signup and view all the answers

When should blood glucose be assessed?

In patients who are diabetic, altered, or report weakness or malaise. Signup and view all the answers

What is the normal blood glucose level?

80-120 mg/dL. Signup and view all the answers

What should be evaluated during a focused assessment for chest pain?

Skin, blood pressure, trauma to chest, external jugular veins, breath sounds, edema. Signup and view all the answers

What should be evaluated during a focused assessment of abdominal pain?

Skin, pulse, blood pressure, trauma to abdomen, palpate abdomen. Signup and view all the answers

What should be evaluated during a focused assessment for shortness of breath?

Skin, pulse, blood pressure, respiratory rate/quality, airway obstruction, accessory muscle use, edema. Signup and view all the answers

What indicators should be assessed during a focused assessment for dizziness?

Skin, pulse, blood pressure, respiratory rate/quality, trauma, stroke, glucose levels. Signup and view all the answers

What should be evaluated during a focused assessment for pain in bones/joints?

Skin, pulse, movement. Signup and view all the answers

What are adventitious sounds?

Crackles, rhonchi, stridor, wheezing, and pleural friction rubs. Signup and view all the answers

What do wheezing breath sounds suggest?

Obstruction of lower airways. Signup and view all the answers

What are crackle breath sounds indicative of?

Heard in inspiration and expiration, suggestive of congestive heart failure. Signup and view all the answers

What do rhonchi breath sounds indicate?

Low pitched, noisy sounds, suggesting congested breath sounds due to mucus in lungs. Signup and view all the answers

What do stridor breath sounds indicate?

They indicate upper airway obstruction and are prominent on inspiration. Signup and view all the answers

What causes stridor?

Bacterial epiglottis, viral croup, burns, anaphylaxis, foreign airway obstruction. Signup and view all the answers

What is a pleural friction rub?

A creaking or grating sound; pain on inspiration. Signup and view all the answers

What is tidal volume?

The amount of air that moves in and out of the lungs during a normal breath. Signup and view all the answers

What is the normal tidal volume of an adult?

500 mL. Signup and view all the answers

What does blood pressure (BP) measure?

The pressure exerted by blood against the walls of arteries. Signup and view all the answers

What is systolic pressure?

Blood pressure in the arteries during contraction of the ventricles. Signup and view all the answers

What is diastolic pressure?

Blood pressure that remains between heart contractions. Signup and view all the answers

When should a neurological exam be performed?

Changes in mental status, head injury, stupor. Signup and view all the answers

What does one dilated pupil indicate?

Pressure on the oculomotor nerve. Signup and view all the answers

What is crepitus?

A grating or grinding sensation caused by fractured bone ends or joints rubbing together. Signup and view all the answers

What does JVD with a patient sitting up indicate?

Issues with blood returning to the heart. Signup and view all the answers

What is paradoxical motion?

Part of the chest goes in as the patient inhales and goes out as the patient exhales. Signup and view all the answers

Paradoxical motion is a sign of a _______.

Flail chest. Signup and view all the answers

What is guarding reflex?

Involuntary muscle contractions of the abdominal wall to minimize pain. Signup and view all the answers

What does rigidity refer to?

Stiffness, unwillingness to change or bend. Signup and view all the answers

What is rebound tenderness?

Pain that the patient feels when pressure is released. Signup and view all the answers

What does rebound tenderness (Blumberg's sign) indicate?

Irritation or inflammation in the abdominal cavity. Signup and view all the answers

What are the steps in the reassessment process?

Repeat primary assessment, reassess vital signs, reassess chief complaint, recheck interventions, identify and treat changes in condition. Signup and view all the answers

Study Notes

Patient Assessment Process

Five key components: Scene size-up, Primary assessment, History taking, Secondary assessment, Reassessment.
Scene size-up includes assessing the safety and mechanism of injury before patient care begins.

Scene Size-Up and Awareness

Scene size-up helps determine safety and injury/illness nature.
Situational awareness refers to understanding surroundings and potential safety risks for the EMS team.

Incident Command System (ICS)

ICS is a structured approach for managing disasters and mass-casualty incidents with section chiefs reporting to an incident commander.

Triage and Emergency Assessments

Triage involves medical screening to prioritize patient needs and treatment locations.
Primary survey checks for life-threatening emergencies focusing on airway, breathing, and circulation.

Breathing and Respiratory Assessment

Spontaneous respirations occur without assistance.
Inspections during breathing assessments include respiratory rate (RR), depth, rhythm, and distress indicators.

Positions and Signs Indicating Breathing Difficulties

Tripod position indicates difficulty breathing; patient leans forward on arms.
Sniffing position helps keep the airway open; patient’s head is slightly forward.

Respiratory Failure and Distress

Respiratory failure occurs when blood oxygenation is inadequate for body needs.
Signs of inadequacy in pediatric patients include nasal flaring and seesaw breathing.

Assessing Breathing and Perfusion

During breath assessments, seek information on respiratory rate, quality, distress level, and accessory muscle use.
Perfusion evaluation involves checking skin tone, capillary refill, temperature, and moisture.

Skin Assessment Indicators

Cyanosis signals oxygen deficiency leading to bluish skin; jaundice indicates liver issues with yellowing skin.
Normal skin temperature averages 98.6°F; assess color, temperature, and moisture during skin evaluations.

Mental Status Evaluation

Orientation checks mental status through memory and cognition by assessing person, place, time, and event.
The AVPU scale measures responsiveness: Alert, Verbal, Pain, Unresponsive.

Secondary and Focused Assessment

Secondary assessment includes obtaining vital signs and performing a systematic physical exam.
Focused assessments evaluate specific complaints like chest pain or abdominal pain, checking vital signs and trauma presence.

Breathing Sounds and Indicators

Abnormal breath sounds include wheezing (lower airway obstruction), crackles (CHF indication), and stridor (upper airway obstruction).
Rhonchi suggests mucus in lungs; pleural friction rub indicates irritation of lung surfaces.

Vital Signs and Monitoring

Normal blood glucose is between 80-120 mg/dL; diabetic or altered patients should have glucose assessed.
Blood pressure gauges arterial pressure during heart contractions (systolic) and between (diastolic).

Neurological and Abdominal Assessment

Neurological exams are critical when there's a change in mental status or head injury.
Guarding reflex indicates peritonitis; rebound tenderness suggests abdominal irritation or inflammation.

Reassessment Steps

Reassessment should repeat primary assessments and vital signs while reevaluating the chief complaint and any interventions applied.
The Golden Hour emphasizes urgency for treating trauma and shock, while Platinum 10 Minutes sets optimal on-scene time goals for patient care.

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Test your knowledge of the patient assessment process with this flashcard quiz covering key concepts from Chapter 10. Focus on the five essential parts of patient assessment and important definitions related to scene safety and assessment techniques.