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Patient Assessment - Vocabulary
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Terms in this set (73)
The secondary muscles of respiration. They include the neck muscles (sternocleidomastoids), the chest pectoralis major muscles, and the abdominal muscles.
altered mental status
A change in the way a person thinks and behaves that may signal disease in the central nervous system or elsewhere in the body.
To listen to sounds with a stethoscope
A method of assessing the level of consciousness by determining whether the patient is
awake and alert,
responsive to verbal stimuli or
responsive to painful stimuli, or
used principally early in the assessment process.
blood pressure (BP)
The pressure that the blood exerts against the walls of the arteries as it passes through them.
slow heart rate (HR less than 60 bpm)
An indication of air movement in the lungs, usually assessed with a stethoscope.
A test that evaluates distal circulatory system function by squeezing (blanching) blood from an area such as a nail bed and watching the speed of its return after releasing the pressure.
A noninvasive method to quickly and efficiently provide information on a patient's ventilatory status, circulation, and metabolism; effectively measures the concentration of carbon dioxide in expired air over time.
Carbon Dioxide (CO2)
A component of air that typically makes up 0.3% of air at sea level; also a waste product exhaled during expiration by the respiratory system.
Chief Complaint (CC)
The reason a patient called for help; also, the patient's response to questions such as "What's wrong?" or "What happened?"
The delicate membrane that lines the eyelids and covers the exposed surface of the eye.
Crackling, rattling breath sounds signaling fluid in the air spaces of the lungs; formerly called rales.
A grating or grinding sensation caused by fractured bone ends or joints rubbing together.
a blue discoloration of the skin caused by a lack of adequate oxygen in the blood
A mnemonic for assessment in which each area of the body is evaluated for
Characterized by profuse sweating.
The pressure that remains in the arteries during the relaxing phase of the heart's cycle (diastole) when the left ventricle is at rest. (the bottom number of a blood pressure)
an injury that prevents the patient from noticing other injuries he/she may have, even severe injuries; for example, a painful femur and tibia fracture that prevents the patient from noticing back pain associated with a spinal fracture.
the conclusion about the cause of the patient's condition after considering the situation, history, and examination findings.
a typical physical assessment typically performed on patients who have sustained non-significant mechanisms of injury or on responsive medical patients. this type of examination is based on the chief complaint and focuses on one body part or system.
Damage to tissues as the result of exposure to cold; frozen or partially frozen body parts are frostbitten.
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.
The time from injury to definitive care, during which treatment of shock and traumatic injuries should occur because survival potential is best; also called the Golden Period.
Involuntary muscle contractions (spasms) of the abdominal wall in an effort to protect an inflamed abdomen; a sign of peritonitis.
A step within the patient assessment process that provides detail about the patient's chief complaint and an account of the patient's signs and symptoms.
blood pressure that is higher than the normal range
blood pressure that is lower than the normal range
A condition in which the internal body temperature falls below 95°F (35°C).
Incident Command System (ICS)
A system implemented to manage disasters and mass- and multiple-casualty incidents in which section chiefs, including finance, logistics, operations, and planning, report to the incident commander.
yellowing of the skin or scelra that is caused by liver disease or dysfunction
Breathing that requires greater than normal effort; may be slower or faster than normal characterized by grunting, stridor and usually requires the use of accessory muscles.
Mean Arterial Pressure (MAP)
The average pressure in the circulatory system during one cardiac cycle.
mechanism of injury (MOI)
The forces, or energy transmission, applied to the body that cause injury.
the biochemical processes that result in production of energy from nutrients within the cells.
Widening of the nostrils, indicating that there is an airway obstruction.
nature of illness (NOI)
The general type of illness a patient is experiencing.
An abbreviation for key terms used in evaluating a patient's pain:
Provocation or Palliation,
Quality or Quantity,
Severity or Scale, and
Timing of pain
The mental status of a patient as measured by memory of
place (current location),
time (current year, month, and approximate date, time of day), and
event (what happened).
to examine by touch
The motion of the portion of the chest wall that is detached in a flail chest; the motion—in during inhalation, out during exhalation—is exactly the opposite of normal chest wall motion during breathing.
The flow of blood through body tissues and vessels.
Personal Protective Equipment (PPE)
Protective equipment that blocks exposure to a pathogen or a hazardous material.
Negative findings that warrant no care or intervention.
A step within the patient assessment process that identifies and initiates treatment of immediate and potential life threats.
A wave of blood created as the heart contracts and forces blood out of the left ventricle and into the major arteries.
Pulse Oximetry (SpO2)
An assessment tool that measures oxygen saturation of hemoglobin in the capillary beds.
A step within the patient assessment process performed at regular intervals during the assessment process to identify and treat changes in a patient's condition. A patient in unstable condition should be reassessed every 5 minutes, whereas a patient in stable condition should be reassessed every 15 minutes.
The way in which a patient responds to external stimuli, including verbal stimuli (sound), tactile stimuli (touch), and painful stimuli.
movements in which the skin pulse in and around ribs during inspiration.
Coarse, low-pitched breath sounds heard in patients with chronic mucus in the upper airways. (junkie)
A brief history of a patient's condition to determine signs and symptoms,
pertinent past history,
last oral intake, and
events leading to the injury or illness.
A step within the patient assessment process that involves a quick assessment of the scene and the surroundings to provide information about scene safety and the mechanism of injury or nature of illness before you enter and begin patient care.
the tough, fibrous, white portion of the eye that protects the more delicate inner structures.
A step within the patient assessment process in which a systematic physical examination of the patient is performed. The examination may be a systematic full-body scan or a systematic assessment that focuses on a certain area or region of the body, often determined through the chief complaint.
Respirations characterized by little movement of the chest wall (reduced tidal volume) or poor chest excursion.
Objective findings that can be seen, heard, felt, smelled, or measured.
knowledge and understanding of one's surroundings and the ability to recognize potential risks to the safety of the patient or EMS team
An upright position in which the patient's head and chin are thrust slightly forward to keep the airway open.
Breathing that occurs without assistance.
Protective measures that have traditionally been developed by the Centers for Disease Control (CDC) and Prevention for use in dealing with objects, blood, body fluids, and other potential exposure risks of communicable disease.
A harsh, high-pitched respiratory sound, generally heard during inspiration, that is caused by partial blockage or narrowing of the upper airway; may be audible without a stethoscope.
A characteristic crackling sensation felt on palpation of the skin, caused by the presence of air in soft tissues.
Subjective findings that the patient feels but that can be identified only by the patient.
The increased pressure in an artery with each contraction of the ventricles (systole). (the top number in a BP)
A rapid heart rate, more than 100 beats/min.
tidal volume (TV)
The amount of air (in milliliters) that is moved in or out of the lungs during one breath.
The process of establishing treatment and transportation priorities according to severity of injury and medical need.
An upright position in which the patient leans forward onto two arms stretched forward and thrusts the head and chin forward.
two- to 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.
narrowing of blood vessels
The key signs that are used to evaluate the patient's overall condition, including
AVPU (Level of Consciousness)
A high-pitched, whistling sound that is most prominent on expiration, and which suggests an obstruction or narrowing of the lower airways; occurs in asthma or bronchitis.
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