COPR EMR flashcards
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32 cards. Read the term and the definition here. The deck at the top of this page is optional.
- Expressed consent
- Consent given verbally or through a clear gesture by a competent patient after being informed of the assessment, treatment, and risks.
- Implied consent
- Consent assumed for a life-threatening emergency when the patient cannot respond, based on the reasonable assumption that a person would want life-saving care.
- Four elements of negligence
- A duty to act, a breach of the standard of care, causation linking the breach to harm, and actual damages suffered by the patient.
- Abandonment
- Discontinuing care without ensuring an equal or higher level of care continues, such as leaving a patient without a proper handover.
- AVPU scale
- A consciousness scale: Alert, responds to Verbal stimulus, responds to Painful stimulus, Unresponsive. Used during the primary assessment.
- Glasgow Coma Scale
- A score combining eye (1-4), verbal (1-5), and motor (1-6) responses, with a total ranging from 3 to 15.
- SAMPLE history
- Signs and symptoms, Allergies, Medications, Past medical history, Last oral intake, and Events leading to the illness or injury.
- OPQRST
- A pain assessment tool: Onset, Provocation and Palliation, Quality, Region and Radiation, Severity, and Time.
- Reassessment intervals
- Unstable patients are reassessed at least every 5 minutes, stable patients at least every 15 minutes, and after every intervention.
- Head-tilt chin-lift
- An airway-opening manoeuvre used for a medical patient without suspected spinal injury, lifting the chin and tilting the head back.
- Jaw-thrust manoeuvre
- An airway-opening technique used when spinal injury is suspected, displacing the jaw forward without tilting the head.
- Oropharyngeal airway
- An airway adjunct inserted only in patients without a gag reflex, holding the tongue away from the posterior pharynx.
- Bag-valve-mask rate
- For adults, deliver about one breath every 5-6 seconds (10-12 per minute), watching for visible chest rise.
- Oxygen titration target
- For most patients, adjust oxygen to keep SpO2 at about 94-98%, using a nasal cannula or mask based on the needed flow.
- Adult compression depth
- Compress the adult chest at least 5 cm (2 inches) deep at 100-120 per minute, allowing full recoil between compressions.
- Compression-ventilation ratio
- Adult single-rescuer CPR uses 30 compressions to 2 ventilations; two-rescuer pediatric CPR uses 15 to 2.
- AED pad placement
- One pad below the right clavicle and one on the left lateral chest; the chest must be dry and clear of medication patches.
- Tourniquet use
- Applied proximal to a limb wound when direct pressure fails to control severe bleeding; note the application time and do not loosen it.
- Hypoglycemia care
- Altered mental status with sweating and tremor; give oral glucose if the patient can swallow safely, otherwise follow protocol.
- FAST stroke screen
- Face droop, Arm drift, Speech difficulty, and Time of onset; record the time symptoms began for reperfusion decisions.
- Anaphylaxis treatment
- Give epinephrine by auto-injector, adult dose 0.3 mg intramuscularly in the anterolateral thigh, then oxygen and transport.
- Five medication rights
- Right patient, right medication, right dose, right route, and right time; document the effect after giving the medication.
- Spinal motion restriction
- Considered for significant mechanism with altered mental status, midline tenderness, neurologic deficit, or a distracting injury.
- Rule of nines
- Adult burn extent estimate: each arm 9%, each leg 18%, anterior trunk 18%, posterior trunk 18%, head 9%, perineum 1%.
- Heat stroke
- Core temperature above about 40°C with altered mental status; begin active cooling immediately and transport rapidly.
- Sucking chest wound
- An open chest injury covered with an occlusive dressing, with oxygen and monitoring for worsening respiratory distress.
- Newborn delivery care
- Support the head, check for a nuchal cord, dry and warm the infant, stimulate breathing, and assess APGAR at 1 and 5 minutes.
- Pediatric compression depth
- About one-third of the chest diameter, with a 30:2 ratio for a single rescuer and 15:2 for two rescuers.
- Supine hypotensive syndrome
- In late pregnancy, the uterus compresses the inferior vena cava; relieve it by left lateral positioning or manual uterine displacement.
- Radio report elements
- Identify the unit, state the situation clearly and briefly, and confirm receipt of orders from medical oversight.
- Mass casualty triage
- Sorting patients by priority: immediate, delayed, minimal, and expectant, under a single incident commander.
- Therapeutic communication
- Using open-ended questions, active listening, and reflection to build rapport and gather accurate information from the patient.