Paramedic Care: Principles & Practice. Volume 2 Patient Assessment
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1 Paramedic Care: Principles & Practice Volume 2 Patient Assessment
2 Chapter 1 The History
3 Topics Establishing Patient Rapport The Comprehensive Patient History Special Challenges
4 The Interview In the majority of medical interviews, field diagnosis is based on history. It is conducted simultaneously with the physical exam. It is a structured, flexible, tool with several components. Patient condition dictates length and completeness.
5 Establishing Patient Rapport
6 Establishing Patient Rapport Situation, the patient, and conditions will determine ability to establish rapport. Respond to the patient with empathy to gain trust. Patient s response to questions will guide the exam.
7 Establishing Patient Rapport Setting the Stage In a healthcare facility, if a patient s chart is available, review it before interviewing the patient. Gather information from the first responder personnel. Reconfirm information. Maintain an open mind!
8 If the patient cannot provide useful information, gather it from family or bystanders.
9 Establishing Patient Rapport The First Impression Your appearance should suggest neatness, cleanliness, pride, and professionalism. Present yourself as a caring, competent, and confident health care professional. Your voice, body language, gestures, and especially eye contact should communicate that you care about your patient s problems.
10 Establishing Patient Rapport Introductions Make eye contact with your patient and maintain it as you conduct the interview. Use your patient s name frequently during the interview. Avoid slang terms such as honey, chief, pops, or sweetie. Be aware of other forms of nonverbal communication.
11 Establishing Patient Rapport Asking Questions Ask questions in a way that elicits accurate information from your patient. Use a combination of open-ended and closedended questions. Open-ended questions allow patient to explain how he/she feels. Closed-ended questions elicit short answers.
12 Establishing Patient Rapport Language and Communication Effective communication means connecting with your patient. Barriers to communication include: Cultural differences Language differences Deafness Speech impediments Blindness When encountering communication barriers, try to enlist someone to help.
13 Establishing Patient Rapport Active listening techniques: Facilitation Reflection Clarification Empathy Confrontation Interpretation Asking about feelings
14 Establishing Patient Rapport Sensitive Topics A paramedic must learn to become comfortable dealing with sensitive topics. Sensitive topics may include sexual activities, death and dying, physical deformities, bodily functions, and domestic violence.
15 Establishing Patient Rapport Sensitive Topics Familiarize yourself with and practice some opening questions on sensitive topics. It is critical that you remain calm, objective, and nonjudgmental.
16 The Comprehensive Patient History
17 Preliminary Data Always record the date and time of the physical exam. Determine your patient s age, sex, race, birthplace, and occupation. These questions provide a starting point for the interview. After you have gathered the information, you should establish its reliability.
18 The Chief Complaint Begin with an open-ended question about your patient s chief complaint. The chief complaint is the pain, discomfort, or dysfunction that caused the patient to request help. When possible, report and record the chief complaint in the patient s own words.
19 The Present Illness OPQRST-ASPN Onset of the problem Provocative/ Palliative factors Quality Region/Radiation Severity Time Associated Symptoms Pertinent Negatives
20 Past History Ask questions about the patient s general state of health, childhood and adult diseases, psychiatric illnesses, accidents or injuries, surgeries, and hospitalizations. The patient s condition, the situation, and time constraints will determine how much information you can and should gather on the scene.
21 Current Health Status Current medications Allergies Tobacco Alcohol, drugs, and related substances Diet Screening tests Immunizations
22 Current Health Status Sleep patterns Exercise and leisure activities Environmental hazards Use of safety measures Family history Home situation and significant others Daily life
23 Current Health Status Important exercises Religious beliefs The patient s outlook
24 You should take your patient s medications with you to the hospital, when practical.
25 Review of Systems A system-by-system series of questions designed to identify problems your patient has not already identified: Skin Head Eyes Ears Nose Mouth/Throat Respiratory Cardiovascular Gastrointestinal Genitourinary Musculoskeletal Neurologic Psychologic Endocrine Hematologic
26 Special Challenges
27 Special Challenges Silence Overly talkative patients Multiple symptoms Anxiety Depression Sexually attractive or seductive patients Confusing behaviors or symptoms
28 Special Challenges Patients needing reassurance Anger and hostility Intoxication Crying Limited intelligence Language barriers Hearing problems Blindness Talking with families or friends
29 Summary Establishing Patient Rapport The Comprehensive Patient History Special Challenges
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