American EMT Chapter 10 Vocab: Patient Assessment

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.

Accessory muscles

The secondary muscles of respiration. They include the neck muscles (sternocleidomastoids), the chest pectoralis major muscles, and the abdominal muscles.

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).

Shallow respirations

Respirations characterized by little movement of the chest wall (reduced tidal volume) or poor chest excursion.

Subcutaneous Emphysema

A characteristic crackling sensation felt on palpation of the skin, caused by the presence of air in soft tissues.

Paradoxical

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.

Vasoconstriction

Narrowing of a blood vessel

Stridor

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.

Incident Command System

A system implemented to manage disasters and mass-casualty incidents in which section chiefs, including finance/administration, logistics, operations, and planning, report to the incident commander.

Frostbite

Damage to tissues as the result of exposure to cold; frozen or partially frozen body parts are frostbitten.

Reassessment

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.

Triage

The process of establishing treatment and transportation priorities according to severity of injury and medical need.

Vital signs

The key signs that are used to evaluate the patient’s overall condition, including respirations, pulse, blood pressure, level of consciousness, and skin characteristics.

Nature of illness

The general type of illness a patient is experiencing.

Pulse

The wave of pressure created as the heart contracts and forces blood out the left ventricle and into the major arteries.

guarding

Involuntary muscle contractions (spasm) of the abdominal wall to minimize the pain of abdominal movement; a sign of peritonitis.

Personal Protective Equipment (PPE)

Protective equipment that blocks exposure to a pathogen or a hazardous material.

Breath sounds

An indication of air movement in the lungs, usually assessed with a stethoscope.

Standard precautions

Protective measures that have traditionally been developed by the Centers for Disease Control and Prevention (CDC) for use in dealing with objects, blood, body fluids, and other potential exposure risks of communicable disease.

Field impression

The conclusion about the cause of the patient’s condition after considering the situation, history, and examination findings.

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.

Chief complaint

The reason a patient called for help; also, the patient’s response to questions such as “What’s wrong?” or “What happened?”

Focused assessment

A type of physical assessment typically performed on patients 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.

Blood pressure

The pressure that the blood exerts against the walls of the arteries as it passes through them.

Pulse oximeter

An assessment tool that measures oxygen saturation of hemoglobin in the capillary beds.

Bradycardia

A slow heart rate, less than 60 beats/min.

Tachycardia

A rapid heart rate, more than 100 beats/min.

AVPU Scale

A method of assessing the level of consciousness by determining whether the patient is awake and alert, responsive to verbal stimuli or pain, or unresponsive; used principally early in the assessment process.

Situational awareness

Knowledge and understanding of one’s surroundings and the ability to recognize potential risks to the safety of the patient or EMS team.

Jaundice

Yellow skin or sclera that is caused by liver disease or dysfunction.

Rales

Crackling, rattling breath sounds that signal fluid in the air spaces of the lungs.

Crepitus

A grating or grinding sensation or sound caused by fractured bone ends or joints rubbing together.

Hypertension

Blood pressure that is higher than the normal range.

Retractions

Movements in which the skin pulls in around the ribs during inspiration.

Conjunctiva

The delicate membrane that lines the eyelids and covers the exposed surface of the eye.

Spontaneous Respirations

Breathing that occurs without assistance.

Wheezing

A high-pitched, whistling breath sound that is most prominent on expiration, and which suggests an obstruction or narrowing of the lower airways

Capnography

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.

Hypothermia

A condition in which the internal body temperature falls below 95 degrees F (35 degrees C).

Mean arterial pressure

The average pressure in the circulatory system during one cardiac cycle.

Diastolic pressure

The pressure that remains in the arteries during the relaxing phase of the heart’s cycle when the left ventricle is at rest.

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 details about the patient’s chief complaint and an account of the patient’s signs and symptoms.

2-3 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.

Cyanosis

A blue skin discoloration that is caused by a reduced level of oxygen in the blood. Although paleness, or a decrease in blood flow, can be difficult to detect in dark-skinned people, it may be observed by examining mucous membranes inside the inner lower eyelid and capillary refill. On general observation, the patient may appear ashen or gray.

Cellular metabolism

The biochemical processes that result in production of energy from nutrients within the cells; also called cellular respiration.

Symptom

Subjective findings that the patient feels but that can be identified only by the patient.

Systolic Pressure

The increased pressure in an artery with each contraction of the ventricles.

Nasal flaring

Widening of the nostrils, indicating that there is an airway obstruction.

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.

Distracting Injury

Any injury that prevents the patient from noticing other injuries he or she may have, even severe injuries; for example, a painful femur or tibia fracture that prevents the patient from noticing back pain associated with a spinal fracture.

Primary Assessment

A step within the patient assessment process that identifies and initiates treatment of immediate and potential life threats.

Diaphoretic

Characterized by light or profuse sweating.

CO2

A component of air that typically makes up 0.03% of air at sea level; also a waste product exhaled during expiration by the respiratory system.

Tidal volume

The amount of air (in milliliters) that is moved into or out of the lungs during one breath.

Pertinent Negatives

Negative findings that warrant no care or intervention.

SAMPLE History

A brief history of a patient’s condition to determine signs and symptoms, allergies, medications, pertinent past history, last oral intake, and events leading to the injury or illness.

Tripod position

An upright position in which the patient leans forward onto two arms stretched forward and thrusts the head and chin forward.

Golden Hour/Period

The time from injury to definitive care, during which treatment of shock and traumatic injuries should occur because survival potential is best.

Auscultate

To listen to sounds within an organ with a stethoscope.

Palpate

To examine by touch.

DCAP-BTLS

A mnemonic for assessment in which each area of the body is evaluated for Deformities, Contusions, Abrasions, Punctures/penetrations, Burns, Tenderness, Lacerations, and Swelling.

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.

Perfusion

The flow of blood through body tissues and vessels.

Rhonci

Coarse, low-pitched breath sounds heard in patients with chronic mucus in the upper airways.

Sign

Objective finding that can be seen, heard, felt, smelled, or measured.

Sclera

The tough, fibrous, white portion of the eye that protects the more delicate inner structures.

Sniffing position

An upright position in which the patients head and chin are thrust slightly open to keep the airway patent