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Chapter 14

The Secondary Assessment

QuestionAnswer
closed-ended question a question requiring only a yes or no answer
crepitation the grating sound or feeling broken bones rubbing together
detailed physical exam assessment of the head, neck, chest, abdomen, pelvis, extremities, and posterior of the body to detect signs injury. It differs from the rapid trauma assessment only in that it also includes examination of the face, ears, eyes, nose, and mouth
diagnosis a description or label for a patient's condition that assists a clinician in further evaluation and treatment
differential diagnosis a list of potential diagnoses compiled early in the assessment of the patient
distention a condition of being stretched, inflated, or larger than normal
history of the present illness information gathered regarding the symptoms and nature of the patient's current concern
jugular vein distention bulging of the neck veins
medical patient a patient with one or more medical diseases or conditions
open-ended question a question requiring more than just a yes or no answer
OPQRST a memory aid in which the letters stand for questions asked to get a description of the present illness: onset, provocation, quality, radiation, severity, time
paradoxical motion movement of a part of the chest in the opposite direction to the rest of the chest during respiration
past medical history information gathered regarding the patient's health problems in the past
priapism persistent erection of the penis that may result from spinal injury and some medical problems
rapid trauma assessment a rapid assessment of the head, neck, chest, abdomen, pelvis, extremities, and posterior of the body to detect signs and and symptoms of injury
reassessment a procedure for detecting changes in a patient's condition. it involves four steps: repeating the primary assessment, repeating and recording vital signs, repeating the physical exam, and checking interventions
SAMPLE a memory aid in which the letters stand for elements of the past medical history: signs and symptoms, allergies, medications, pertinent past history, last oral intake, and events leading to the injury or illness
sign something regarding the patient's condition that you can see
stoma a permanent surgical opening in the neck through which the patient breathes
symptom something regarding the patient's condition that the patient tell you
tracheostomy a surgical incision held open by a metal or plastic tube
trauma patient a patient suffering from one or more physical injuries
trending changes in a patient's condition over time, such as slowing respirations or rising pulse rate, that may show improvement
What are the 3 basic components of the secondary assessment? physical examination, patient history, and vital signs
What may JVD indicate? heart failure or other obstructive conditions within the chest
What does DCAP-BTLS stand for? deformities, contusions, abrasions, punctures, burns, tenderness, lacerations, swelling
Created by: caitlyncrum
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