capillary refill
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
chief complaint
The reason a patient called for help; also, the patient's response to questions such as "What's wrong?" or "What happened?"
diastolic pressure
The pressure that remains in the arteries during the relaxing phase of the heart's cycle (diastole) when the left ventricle is at rest
focused assessment
A type of physical assessment typically performed on patient's who have sustained nonsignificant mechanisms of injury or on responsive medical patients. This type of examination is based on the chief complaint and focuses on one body system or part.
general impression
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.
history taking
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
mechanism of injury (MOI)
The forces, or energy transmission, applied to the body that cause injury
Nature of illness (NOI)
The general type of illness a patient is experiencing
orientation
The mental status of a patient as measured by memory of person (name), place (current location), time (current year , month , and approximate date), and event (what happened)
pertinent negatives
Negative findings that warrant no care or intervention
primary assessment
A step within the patient assessment process that identifies and initiates treatment of immediate and potential life threats
reassessment
A step within the patients 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 mins, whereas a patient in stable condition should be reassessed every 15mins
responsiveness
The way in which a patient responds to external stimuli, including verbal stimuli (sound), tactile stimuli (Touch), and painful stimuli
scene size-up
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
secondary assessment
A step within the patient assessment process in which a systematic physical examination of the patient is performed. The examination may be a systematic exam or an assessment that focuses on a certain area or region of the body, often determined through the chief complaint.
Tachy
rapid, fast
Brady
slow
Hypo
under, below normal
Hyper
over, excessive, high
Card/i
heart
-pnea
pertaining to breathing
cyan
blue
DCAP-BTLS
Deformities, contusions, abrasions, punctures/penetrations, burns, tenderness, lacerations, swelling
MAP
Mean arterial pressure
OPQRST
Onset, provocation/palliation, quality, region/radiation, severity, timing
SAMPLE
Signs/symptoms, allergies, medications, pertinent past history, last oral intake, events leading up
AVPU
Alert and awake, responsive to verbal stimuli, responsive to pain, unresponsive
PEARRL
Pupils equal and round regular in size react to light