Pt Assess Exam

adolescent

a young person age 12-18 years

ageism

the assumption that older people are less healthy or capable; can lead to poor patient assessment and care

barotrauma

injury caused by pressure to enclosed body surfaces, for example, from too much pressure in the lungs

conventional reasoning

a type of reasoning in which a child looks for approval from peers and society

early adult

a young adult age 18 to 40 years

fontanelles

areas where the newborn’s or infant’s skull has not fused together; usually disappear at approximately 18 months of age

gender identity

a personal sense of oneself as male or female (or less commonly, both or neither)

geriatrics

the assessment and treatment of disease in someone who is age 65 years or older

infant

a young child age 1 month to 1 year

life expectancy

the average number of years a person can be expected to live

middle adult

an adult age 40 to 65 years

moro reflex

an infant reflex in which, when an infant is caught off guard, the infant opens their arms wide, spreads the fingers, and seems to grab at things

newborn

a person age birth to 1 month

older adult

an adult age 65 years or older

palmar grasp reflex

an infant reflex that occurs when something is placed in the infant’s palm; the infant grasps the object

pediatrics

a specialized medical practice devoted to the care of the young

postcoventional reasoning

a type of reasoning in which a child bases decisions on their conscience

pre conventional reasoning

a type of reasoning in which a child acts almost purely to avoid punishment or to get what they want

preschooler

a child age 3 to 6 years

rooting reflex

an infant reflex that occurs when something touches an infant’s cheek, and the infant instinctively turns their head toward the touch

school age

a person who is 6 to 12 years of age

sexual orientation

a person’s emotional, romantic, or sexual attraction to other people

sucking reflex

an infant reflex in which the infant starts sucking when their lips are stroked

toddler

a child age 1 to 3 years

trust versus mistrust

the stage of development from birth to approximately 18 months of age during which infants gain trust in their parents or caregivers if their world is planned, organized, and routine

backboard

a long, flat board made of rigid, rectangular material that is used to provide support to a patient who is suspected of having a hip, pelvic, spinal, or lower extremity injury; also called a spine board, trauma board, and longboard

bariatrics

a branch of medicine concerned with the management (prevention or control) of obesity and allied diseases

basket stretcher

a rigid stretcher commonly used in technical and water rescues that surrounds and supports the patient uet allows water to drain through holes in the bottom; also called a stokes basket or litter

body mechanics

the relationship between the body’s anatomic structures and the physical forces associated with lifting, moving, and carrying; the ways in which the body moves to achieve a specific action

diamond carry

a carrying technique in which one clinician is located at the head end of the stretcher or backboard, one at the food end, and one at each side of the patient; each of the two clinicians at the sides uses one hand to support the stretcher or backboard so that all are able to face forward as they walk

emergency move

a move in which the patient is dragged or pulled from a dangerous scene before assessment and care are provided

extremity lift

a lifting technique that is used for patients who are supine or in a sitting position with no suspected extremity or spinal injuries

flexible stretcher

a stretcher that is a rigid carrying device when secured around a patient but can be folded or rolled when not in use; also called a soft stretcher

portable stretcher

a stretcher with a strong, rectangular, tubular metal frame and rigid fabric stretched across it

power grip

a technique in which the stretcher or backboard is gripped by inserting each hand under the handle with the palm facing up and the thumb extended, fully supporting the underside of the handle on the curved palm with the fingers and thumb

rapid extrication technique

a technique to move a patient from a sitting position inside a vehicle to supine on a backboard in less than 1 minute when conditions do not allow for standard methods of spinal motion restriction

scoop stretcher

a stretcher that is designed to be split into two or four sections that can be fitted around a patient who is lying on teh ground or other relatively flat surface

stair chair

a lightweight folding device that is used to carry an alert, seated patient up or down stairs

wheeled ambulance stretcher

a specially designed stretcher that can be rolled along the ground. a collapsible undercarriage allows it to be loaded into the ambulance; also called an ambulance stretcher

ALS assist

an intervention in which a clinician trained in basic life support provides assistance, while remaining within their cope of practice, to a clinician who is performing an advanced life support procedure

anchoring

a decision making error in which the clinician settles on one possible cause of the patient’s problems early and fails to consider other options

biases

fixed beliefs that are not based on objective knowledge

community paramedicine

a health care model in which experienced paramedics receive advanced training to equip them to provide additional services in the prehospital environment, such as health evaluations, monitoring of chronic illnesses or conditions, and patient advocacy

continuum of care

the concept of consistent patient care across the entire health care team from first patient contact to patient discharge; working together with unified goal results in improved individual and team performance, better patient and clinician safety, and improved patient outcome

crew resource management (CRM)

a set of procedures for use in environments where human error can have disastrous consequences. it empowers people within a team to communicate effectively with one another with a goal of improving team situational awareness, patient and crew safety, and overall communication

mobile integrated healthcare (MIH)

a method of delivering health care that involves providing health care within the community rather than at a physician’s office or hospital

overconfidence

a decision-making error in which the clinician overestimates their ability and chooses the wrong treatment path or ignores others’ input, resulting in harmful actions

situational awareness

a state of sustained knowledge and understanding of one’s surroundings and of potential risks to the safety of the patient or EMS team

team

in the context of EMS, a group of health care clinicians who are assigned specific roles and are working interdependently in a coordinated manner under a designated leader

team leader

the team member who provides role assignments, coordination, oversight, centralized decision making, and support for the team to accomplish their goals and achieve desired results

accessory muscles

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

auscultate

to listen to sounds within an organ with a stethoscope

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

blood pressure

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

bradycardia

a slow heart rate, less than 60 beats/min

breath sounds

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

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

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

carbon dioxide

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

central pulses

pulses that are closest to the core (central) part of the body where the vital organs are located; include the carotid, femoral, and apical pulses

chief complaint

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

chief concern

the condition requiring the most urgent intervention as determined by the clinician’s assessment of the patient; it is not always the same as the chief complaint

cognitive disabilities

conditions that impair a person's ability to remember information, process information, make decisions, or communicate in a normal fashion

conjunctiva

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

crackles

a crackling, rattling breath sound that signals fluid in the air spaces of the lungs

crepitus

a grafting or grinding sensation caused by fractured bone ends or joints rubbing together

cyanosis

skin discoloration that is caused by a reduced level of oxygen in the blood. the blood and vessels appear blue, and the lips, mucous membranes, nail beds, and skin over the blood vessels appear blue or gray

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

diaphoretic

characterized by light or profuse sweating

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

distracting injury

any injury that prevents the patient from noticing other injuries, even severe injuries; for example, a painful femur or tibia fracture that prevents the patient from noticing back pain associated with a spinal fracture

ecchymosis

a buildup of blood beneath the skin caused by an injury that appears as a blue or black discoloration; also called a bruise

field impression

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

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

frostbite

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

general impression

the overall initial impression that determines the priority for patient care; based on the patients surroundings, the mechanism of injury, signs and symptoms, and the chief complaint

golden period

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 hour

guarding

involuntary muscle contraction (spasm) of the abdominal wall; an effort to protect the inflamed abdomen

hematoma

a mass of blood that has collected within damaged tissue beneath the skin

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

hypertension

blood pressure that is higher than the normal range

hypotension

blood pressure that is lower than the normal range

hypothermia

a condition in which the internal body temperature falls below 95 degrees

jaundice

yellow skin or sclera that is caused by liver disease or dysfunction. in individuals with dark skin, the discoloration may be more evident in the sclera

labored breathing

breathing that requires greater than normal effort; may be slower or faster than normal and characterized by grunting, stridor, and use of accessory muscles

length-based resuscitation tape

a tape used to estimate an infant’s or child’s weight on the basis of body length; appropriate drug doses and equipment sizes are listed on the tape

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

metabolism

the biochemical processes that result in production of energy from nutrients within the cells

nasal flaring

widening of the nostrils, indicating an airway obstruction

nature of illness (NOI)

the general type of illness a patient is experiencing

OPQRST

a mnemonic used in evaluating a patient’s pain; onset, provocation/palliation, quality, region/radiation, severity, and timing

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)

palpate

to examine by touch

paradoxical chest motion

respirations in which the chest moves inward during inhalation and outward during exhalation, opposite of the chest wall’s normal motion during breathing

pediatric assessment triangle (PAT)

a structured assessment tool used to rapidly form a general impression of the infant or child without touching them; consists of assessing appearance, work of breathing, and circulation to the skin

perfusion

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

pertinent negative

negative finding that warrant no care or intervention