Chapter 8: Patient Assessment Flashcards
Auscultate
To listen to sounds within an organ with a stethoscope.
AVPU Scale
Method of assessing the level of consciousness by determining whether a patient is:
- Awake and alert
- Responsive to verbal stimuli
- Responsive to painful stimuli
- Unresponsive
What is Blood pressure?
The pressure of circulating blood against the walls of the arteries.
What is Bradycardia?
A slow heart rate, less than 60 beats/min
What are breath sounds?
An indication of air movement in the lungs, usually assessed with a stethoscope.
Accessory Muscle
The secondary muscles of respiration. Include: Neck muscles Chest pectoralis major muscles Abdominal muscles
What is the Glasgow Coma Scale?
Measures: Eye opening: 1- none 2- pain 3- speech 4- spontaneous
Best verbal response 1- none 2- incomprehensible 3- confused 4- oriented
Best Motor Response 1- none 2- abnormal extension 3- abnormal reflexion 4- withdraws to pain 5- localized pain 6- obeys commands
What are the signs of respiratory distress?
Agitation, anxiety, restlessness
Stridor and wheezing
Accessory muscle use; intercostal muscle retractions
Tachypnea
Mild tachycardia
Nasal flaring, seesaw breathing, head bobbing
What are the signs of respiratory failure?
Lethargy; difficulty to rouse Tachypnea with periods of bradypnea or agonal Respirations. Inadequate chest rise/poor excursion Inadequate respiratory rate or effort Bradycardia Diminished muscle tone.
Who factors determine a high priority patient?
Difficulty breathing Poor general impression Unresponsive with no gag or cough reflex Severe chest pain Pale skin or other signs of poor perfusion Complicated childbirth
What does SAMPLE stand for?
Signs and Symptoms Allergies Medication Pertinent medical history Last oral intake Events leading up to illness/injury
What does OPQRSTI stand for?
Onset Provocation Quality Radiation Severity Timing Intervention
What does DECAP-BLS stand for
Deformities
Contusions
Abrasions
Puncture/penetration
Burns
Tenderness
Lacerations
Swelling
What things does a decrease in blood pressure indicate?
Loss of blood or its fluid components
Loss of vascular tone and diffident arterial constriction to maintain the necessary pressure even without any fluid or blood loss
A cardiac pumping problem
What is conjunctiva?
The delicate membrane that lines the eyelids and covers the exposed surface of the eye.
