Emt Flashcards Week 3 Vital Signs Sample History And Patient Assessment

Front 1

Gathering Key Patient Information
5

Back 1

-Obtain the patient’s name.
-Age,
-gender,
-race
-Look for identification if the patient is unconscious.

Front 2

Chief Complaint

Back 2

•The major sign and/or symptom reported by the patient

Front 3

Symptoms

Back 3

Problems or feelings, what a patient tells you

Front 4

Signs

Back 4

Something you can see feel hear smell or measure, your reports

Front 5

Obtaining a SAMPLE History

S

Back 5

signs and symptoms
–What signs symptoms occurred at onset

Front 6

Obtaining a SAMPLE History

A

Back 6

Allergies
–Allergies to food, meds, anything

Front 7

Obtaining a SAMPLE History

M

Back 7

Medications
– What medications is the patient taking?

Front 8

Obtaining a SAMPLE History

P

Back 8

pertinent past history
– Any medical history

Front 9

Obtaining a SAMPLE History

L

Back 9

Last oral intake
– When did the patient last eat or drink?

Front 10

Obtaining a SAMPLE History

E

Back 10

Events leading to injury or illness
– What event led to this incident

Front 11

OPQRST

O

Back 11

Onset
– When did the problem first start?

Front 12

OPQRST

P

Back 12

Provoking factors
– What creats the problem or makes it worse?

Front 13

OPQRST

Q

Back 13

Quality of pain
– Description of the pain

Front 14

OPQRST

R

Back 14

Radiation of pain or discomfort
– Does pain radiate

Front 15

OPQRST

S

Back 15

Severity
– Intensity of pain on a scale of 1-10

Front 16

OPQRST

T

Back 16

Time
– How long has the patient had this problem?

Front 17

Baseline Vital Signs

4

Back 17

-respiration
-pulse
-blood pressure (BP)
-lung sounds

Front 18

Respiratory Rates

Adults

Back 18

12-20 breaths per min

Front 19

Respiratory Rates

Children

Back 19

15-30 breaths per min

Front 20

Respiratory Rates

Infants

Back 20

25-50 breaths per min

Front 21

Normal Ranges for Pulse Rate

Adults

Back 21

60-100 beats/min

Front 22

Normal Ranges for Pulse Rate

Children

Back 22

70 to 150 beats/min

Front 23

Normal Ranges for Pulse Rate

Infants

Back 23

100-160 beats/min

Front 24

The Skin Color

Back 24

Pink, pale, blue, red, or yellow

Front 25

The Skin Temperature

Back 25

Warm, hot, or cool

Front 26

The Skin Moisture

Back 26

Dry, moist, or wet

Front 27

A drop in blood pressure may indicate

3

Back 27

–Loss of blood
–Loss of vascular tone
–Cardiac pumping problem

Front 28

Measuring Blood Pressure
Diastolic is Pressure during

Back 28

relaxation stage

Front 29

Measuring Blood Pressure
Systolic is Pressure during

Back 29

contraction stage

Front 30

Normal Ranges of Blood Pressure

Adult

Back 30

90-140 sys

Front 31

Normal Ranges of Blood Pressure

Children (1-8 yrs)

Back 31

80-110 sys

Front 32

Normal Ranges of Blood Pressure

Infants (0-1 yrs)

Back 32

50-95 sys

Front 33

Level of Consciousness
A-
V-
P-
U-

Back 33

A –Alert
V – Responsive to Verbal stimulus
P – responsive to Pain
U – Unresponsive

Front 34

Abnormal Pupil Reactions

5

Back 34

•Fixed with no reaction to light
•Dilate with light and constrict without light
•React sluggishly
•Unequal in size
•Unequal with light or when light is removed

Front 35

Pupil Assessment
P-
E-
A-
R-
R-
L-

Back 35

•P - Pupils
•E - Equal
•A - And
•R - Round
•R - Regular in size
•L - React to Light

Front 36

Reassessment of Vital Signs
Reassess stable patients every ______ minutes

Back 36

15

Front 37

Reassessment of Vital Signs
Reassess unstable patients every ______ minutes

Back 37

5

Front 38

Protective equipment

5

Back 38

–Latex or vinyl gloves should always be worn
–Eye protection
– Mask
–Gown
–Turnout gear

Front 39

Chief Complaint

Back 39

•Most serious problem voiced by the patient
•May not be the most significant problem present

Front 40

the 4 questions you ask someone to Test Orientation

Back 40

•Person
•Place
•Time
•Event

Front 41

Caring for Abnormal Mental Status

5

Back 41

•Complete initial assessment.
•Provide high-flow oxygen.
•Consider C-Spine
•initiate transport.
•Support ABCs.

Front 42

when to give High-Flow Oxygen

6

Back 42

•Breathing faster than 20 breath/ min
•Breathing slower than 12 /breath/ min
•Breathing too shallow
•D LOC
•Respiratory distress
•Poor skin color

Front 43

Controlling bleeding (old)

4

Back 43

–Direct pressure
–Elevation
–Pressure points
–Tourniquet

Front 44

Controlling bleeding (new)

2

Back 44

–Direct pressure
–Tourniquet

Front 45

CSM

Back 45

Circulation
Sensation
Movement

Front 46

Priority Patients

8

Back 46

•Difficulty breathing
•Poor general impression
•Unresponsive with no gag reflex
•Severe chest pain
•Signs of poor profusion
•Complicated child birth
•Uncontrolled breathing
•Signs of poor perfusion

Front 47

Patient Assessment Process
Goals of the Focused History and Physical Exam

Back 47

•Understand the circumstances surrounding the chief complaint.
•Obtain objective measurements
•Perform physical exam.

Front 48

Components of Focused History and Physical Exam

Back 48

•Rx
•Baseline Vital Signs
•Physical exam

Front 49

DCAP-BTLS

D

Back 49

Deformities

Front 50

DCAP-BTLS

C

Back 50

Contusions

Front 51

DCAP-BTLS

A

Back 51

Abrasions

Front 52

DCAP-BTLS

P

Back 52

Punctures\ Penetrations

Front 53

DCAP-BTLS

B

Back 53

Burns

Front 54

DCAP-BTLS

T

Back 54

Tenderness

Front 55

DCAP-BTLS

L

Back 55

Lacerations

Front 56

DCAP-BTLS

S

Back 56

Swelling

Front 57

Components of a Rapid Physical Exam

9

Back 57

•Maintain spinal immobilization while checking patient’s ABCs.
•Assess the head.
•Assess the neck.
•Apply a cervical spine immobilization collar.
•Assess the chest.
•Assess the abdomen.
•Assess the pelvis
•Assess all four extremities.
•Roll the patient with spinal precautions

Front 58

Rapid Physical Exam
Head, Neck, and Cervical Spine

3

Back 58

•Feel head and neck for deformity, tenderness, or crepitation.
•Check for bleeding.
•Ask about pain or tenderness

Front 59

Rapid Physical Exam
Chest
3

Back 59

•Watch chest rise and fall with breathing.
•Feel for grating bones as patient breathes.
•Listen to breath sounds.

Front 60

Rapid Physical Exam
Abdomen
3

Back 60

•Look for obvious injury, bruises, or bleeding.
•Evaluate for tenderness and any bleeding.
•Do not palpate too hard.

Front 61

Rapid Physical Exam
Pelvis
2

Back 61

•Look for any signs of obvious injury, bleeding, or deformity.
•Press gently inward and downward on pelvic bones.

Front 62

Rapid Physical Exam
Extremities
3

Back 62

•Look for obvious injuries.
•Feel for deformities.
•Assess CSM
–Pulse
–Motor function
–Sensory function

Front 63

Rapid Physical Exam
Posterior Body
3

Back 63

•Feel for tenderness, deformity, and open wounds.
•Carefully palpate from neck to pelvis.
•Look for obvious injuries

Front 64

Rapid Physical Exam
Specific Chief Complaints
5

Back 64

•Chest pain
•Shortness of breath
•Abdominal pain
•Pain associated with bones or joints
•Dizziness

Front 65

Rapid Physical Exam
Significant Mechanism of Injury
8

Back 65

•Ejection from vehicle
•Death in passenger compartment
•Fall grater than 15-20 FT
•Vehicle rollover
•Ped- Vehicle
•Penetrating trauma to head, chest, or abdomen
•Unresponsiveness A LOC
•High-speed collision

Front 66

Assessment Steps for
Significant MOI
5

Back 66

•Rapid Trauma Assessment
•Baseline vital signs
•SAMPLE history
•CSM
•Reevaluate transport decision

Front 67

Assessment Steps for Trauma Patients Without Significant MOI
5

Back 67

•Focused assessment
•Baseline vital signs
•SAMPLE history
•CSM
•Reevaluate transport decision

Front 68

Assessment Steps for Responsive Medical Patients
5

Back 68

•History of illness
•SAMPLE history
•Focused medical assessment
•Vital signs
•Reevaluate transport decision

Front 69

Assessment Steps for unresponsive Medical Patients
6

Back 69

•ABS’s
•Rapid medical assessment
•AED
•Baseline vital signs
•SAMPLE history
•Reevaluate transport decision

Front 70

Performing the Detailed
Physical Exam
19

Back 70

•Visualize and palpate using DCAP-BTLS.
•Look at the face.
•Inspect the area around the eyes and eyelids.
•Examine the eyes.
•Pull the patient’s ear forward to assess for bruising. (AKA-battle signs)
•Use the penlight to look for drainage or blood in the ears.
•Look for bruising and lacerations about the head.
•Palpate the zygomas.
•Palpate the maxillae.
•Palpate the mandible.
•Assess the mouth and nose for obstructions and cyanosis.
•Check for unusual odors.
•Look at the neck.
•Palpate the front and the back of the neck.
•Look for distended jugular veins.
•Look at the chest.
•Gently palpate over the ribs.
•Listen for breath sounds.
•Listen also at the bases and apices of the lungs.

Front 71

Steps of the Ongoing Assessment
7

Back 71

•Repeat the initial assessment.
•Look for change
•Reassess and record vital signs.
•Repeat focused assessment.
•Reevaluate findings
•Update hospital
•Check interventions

Front 72

Trending

Back 72

keeping track of changes in a patient’s status