Chapter 5 - Assessment

Question 1

Steps in the assessment model

Answer 1

Scene assessment
Primary assessment
Reassessment
Secondary Assessment
Treatment/Interventions
Documentation of findings
Ongoing Assessment

Question 2

The following are identified during what stage of the assessment model:

Hazards
MOI and CC
# of Patients
Additional resources
General impression of patient
PPE

Answer 2

Scene Assessment

Question 3

Rapid systematic check of the patient to identify conditions that pose an immediate threat to patients life

Answer 3

Primary Assessment

Question 4

Chief complaint

Answer 4

Injury or condition that patient verbally identifies and the most serious.
If patient is unresponsive, unresponsiveness is the chief complaint

Question 5

Measurement of the amount of oxygen actually bound to the hemoglobin compared to the carrying capacity

Answer 5

Oxygen saturation
SpO2 (pulse oximetry)

Question 6

Factors that reduce the reliability of pulse oximetry reading

Answer 6

Hypo perfusion
Hypotension
Decreased circulation
Cardiac arrest
Excessive motion of patient
Nail polish
CO poisoning
Hypothermia
Sickle cell disease or anemia (fewer red blood cells present to carry oxygen)
Smoking cigarettes (CO)
Edema

Question 7

Lateral position

Answer 7

Patient on their side

Question 8

Supine

Answer 8

Patient on back

Question 9

Lateral recumbent position

Answer 9

Recovery position - patient laying in semi prone, halfway between prone and lateral

Question 10

Prone position

Answer 10

Laying on stomach

Question 11

Fowler position

Answer 11

Laying on back with body elevated at 45-60 degrees

Question 12

Semi Fowler position

Answer 12

Laying on back elevated less than 45 degrees

Question 13

Trendelenburg position

Answer 13

Laying on back with legs elevated higher than head and body on inclined plane

Question 14

OPQRST

Answer 14

Onset - did it start suddenly, develop over time

Provocation - what provokes or causes it to get worse

Quality - what does it feel like (sharp, dull, stabbing)

Radiation/Region - where is it, does it radiate

Severity - scale of 1-10; rate pain

Time - when did it start

Question 15

Glasgow coma scale - rating for Eyes

Answer 15

4- spontaneous
3- to voice
2 - to pain
1 - no response

Question 16

Glasgow coma scale - rating for verbal

Answer 16

5 - oriented and converse
4 - disoriented and converse
3 - inappropriate words
2 - incomprehensible sounds
1 - no response

Question 17

Glasgow coma scale - rating for motor

Answer 17

6 - obeys verbal command
5 - to pain - localized
4 - withdrawal from pain
3 - abnormal flexion (decorticate)
2 - abnormal extension (degenerate)
1 - no response

Question 18

Average pulse, respirations and BP for neonate (<28 days)

Answer 18

120-160

40-60

80/40

Question 19

Average pulse, respirations, BP 1-12 months

Answer 19

100 - 120

30 - 40

80/40

Question 20

Average pulse, respirations, BP 1-8 years

Answer 20

80-120

16-24

90/50

Question 21

Average pulse, respirations, BP 8+ yrs

Answer 21

60 - 100

12 - 20

120/80

Question 22

Average time for capillary refill

Answer 22

Less than 2 seconds

Question 23

The force exerted by the blood against the blood vessel walls as it travels throughout the body.

Answer 23

Blood Pressure

Question 24

What does this measurement mean mmHg

Answer 24

Millimeters of mercury

Question 25

What does systolic pressure indicate?

Answer 25

Pressure in artery walls during contraction of the heart

Question 26

What does diastolic pressure indicate?

Answer 26

Pressure in artery walls during refilling (relaxing) of the heart

Question 27

Two methods of taking BP

Answer 27

Palpitation - using cuff to determine systolic by finding radial cuff Auscultation - uses cuff and stethoscope and involves listening for patients pulse. Determines both systolic and diastolic

Question 28

How do you express BP found by palpitation?

Answer 28

Only determines systolic and would be written as 120/P Record whether patient was sitting or lying down when it was taken

Question 29

BGL

Answer 29

Blood Glucose Level - refers to the glucose that is carried in the nlood

Question 31

What organ produces insulin

Answer 31

Pancreas

Question 32

What instrument is used to measure BGL

Answer 32

Glucometer

Question 33

Tool used to pierce finger when testing BGL

Answer 33

Lancet (sterile)

Question 34

What measurement is used to measure BGL

Answer 34

Millimoles per litre mole/L

Question 35

What is normal range for BGL

Answer 35

4-8mmol/L (“4-8 feeling great”) <4 - hypoglycemic >4 - hyperglycemic

Question 36

Normal BGL before and after a meal

Answer 36

4-6 mmol/L before 5-8 mmol/L after

Question 37

Chest auscultation is performed in which two areas

Answer 37

Bilaterally below clavicle below mid clavicular line Bilaterally at the 4th and 5th intercostal space below the armpit