IBAM Module 2

SOLER

sit squarely in relation to patient

SOLER

maintain open position

SOLER

lean slightly toward patient

SOLER

maintain eye contact

SOLER

relax

OPQRST

onset of event

OPQRST

provocation (provoking factors)

OPQRST

quality of pain

OPQRST

region (where) and radiation (travels)

OPQRST

severity (scale 1-10)

Wong-Baker Scale

face pain scale used when patient cannot speak

AMPLE

allergies

AMPLE

medications

AMPLE

pertinent medical history (past medical)

AMPLE

last oral intake

AMPLE

events

SOAP

subjective

SOAP

objective

SOAP

assesment

SOAP

plan

Subjective

what patient tells you

Objective

what you observe

PMH

past medical history

PSH

past surgical history

SOC HX

social history

Sensitive Topics

sexual history, mental health, alcohol and drug use, family violence, death and dying

FDLMP

first day of last menstrual period

Vital Signs

measurable physical signs of what is goin on inside the body, they include pulse, respirations, tempurature, blood pressure, and oxygen saturation

Pulse

found where an artery is close to body’s surface crosses over rigid object

Pulse Rate in Adult

60-100 BPM

Pulse Rate in Child (6-10 y/o)

70-110 BPM

Pulse Rate in Infant (6-10 months)

80-140 BPM

Pulse Rate in Infant (0-5 months)

90-140 BPM

Tachycardia

is described when an adult patient pulse rate exceeds 100 BPM

Bradycardia

is described when an adult patient pulse rate is less than 60 BPM

Systolic

blood pressure when the heart is contracting and is typically the first number recorded (pressure on artery walls)

Diastolic

refers to the time when the heart is in a relaxing phase of the heart cycle (pressure on artery walls when relaxed)

Blood Pressure in Adult

systolic - avg 120mmHg (90-140mmHg)

diastolic - avg 80mmHg (60-90mmHg)

Blood Pressure in Child (6-10 y/o)

systolic - avg 105mmHg (80-115mmHg)

diastolic - avg 69mmHg

Respiratory Rates in Adults

12-20 b/m

Respiratory Rates in Child (6-10 y/o)

15-30 b/m

Respiratory Rates in Infant (6-12 months old)

20-30 b/m

Respiratory Rates in Infant (0-5 months old)

25-40 b/m

Trachypena

rapid and shallow breathing, an increased respiratory rate, typically exceeding 20 breaths per minute in adults

Bradypena

abnormally slow breathing rate, a respiratory rate below 12 breaths per minute in adults

Apena

a medical condition where breathing temporarily stops or becomes very shallow

Blood Pressure is measured in?

mmHg

B/P is written as?

systolic/diastolic

Normal Body Tempurature

96.80 - 100.4 degrees F (36-38 degrees C)

Febrile

with fever

Afebrile

without fever

Oxygen Saturation SpO2

amount of oxygen your blood carries

Normal SpO2

96% - 100%

Mild Hyoxia SpO2

91% - 95%

Significant/Moderate Hypoxia SpO2

86% - 90%

Severe Hypoxia SpO2

85% or less

Black Wounds

dead tissue

Yellow Wounds

infected wound

Red Wound

uninfected wound

Inflammatory Phase Time Frame

3-5 days

Fibroplastic/Proliferation Phase Time Frame

5 days - 3 weeks

Maturation/Remodeling Phase Time Frame

3 weeks - 2 years

Contusion

injury to soft tissue under the epidermis from blunt force trauma, bruise

Abrasion

wound were the surface layer of skin (epidermis) is scraped away

Laceration

a tear in tissue, from blunt force or sharp trauma

Surgical Incision

an intentional cut made with sharp instrument

Burn

injury to tissues caused by contact with thermal, chemical, electrical, radiation, light

First Degree Burn

superficial burn, epidermis

Second Degree Burn

partial thickness burn, dermis

Third Degree Burn

full thickness burn

Infection

Avulsion

skin is torn away, still attached

Amputation

A part of the body is partially or completely severed or torn from body

Degloving

an avulsion type injury were skin and tissue of hand are torn off leaving the muscle and or bone

Puncture

Wounds were depth cannot be visualized caused by narrow, sharp, pointed object

Bite

are considered contaminated

Projectile

Impalment

puncture from projectile this is still in skin

Fracture

a break, rupture, or crack in bone

Sprain

when ligament is damaged

Strain

when tendon is damaged

Hemostasis

process which causes bleeding to stop

Inflammation

a localized, proactive response caused by injury or destruction of tissue

Wound

trauma to tissues of body

Edema

The accumulation of excessive fluid build up

Infection

invasion of bacterial into a would causing a local or systemic response

Scar

tissue replacing tissue destroyed by injury or disease

Primary Injury (Pressure Wave)

pressure injuries

Secondary Injury (Blast Wave)

projectiles cause injuries by impact

Tertiary Injury

propel patient causing further injuries

Quaternary Injury

exposed to harmful chemicals, toxins, or by structural collapse

mmHg

millimeters of mercury

Things that affect SpO2

shock, hypothermia, carbon monoxide poisoning, excessive movement, nail polish, anemia

Step 1 of Medical Documentation

patient info (name, ssn, unit, contact, date of birth)

Step 2 of Medical Documentation

patient vital signs

Step 3 of Medical Documentation

subjective section

Step 4 of Medical Documentation

objective section

Step 5 of Medical Documentation

assesment

Step 6 of Medical Documantation

plan

Step 7 of Medical Documentation

Sign