bledsoe et al., essentials of paramedic care: division 1i 2006 by pearson education, inc. upper...

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Division 2Patient Assessment

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Chapter 10 History Taking

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Topics

History-Taking TechniquesActive ListeningThe Comprehensive Health History

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Components of a Patient History

Establishing rapportChief complaintHistory of the present illnessPast medical historyCurrent health status– Family history– Psychosocial history

Review of systems

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

The Interview

Differential field diagnosisHelps establish a bond

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Patient Rapport

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Patient Rapport – Setting the Stage

If a patient’s chart is available, review it before interviewing the patient.Use this information to gain clues about the patient.

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Patient Rapport – The First Impression

Present yourself as a caring, competent, and confident health care professional.

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Patient Rapport –Building Trust

When you introduce yourself to the patient, shaking hands or offering a comforting touch will help build trust.

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Patient Rapport – Asking Questions

Use a combination of open-ended and closed-ended questions.

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Patient Rapport – Language and Communication

Use appropriate language.Use an appropriate level of questioning, but do not appear condescending.When encountering communication barriers, try to enlist someone to help.Actively listen.

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Patient Rapport – Sensitive Topics

A paramedic must learn to become comfortable dealing with sensitive topics.It is important to earn a patient’s trust.

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

The Comprehensive Patient History

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Preliminary Data

Date and timeAgeSexRaceBirthplaceOccupation

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

The Chief Complaint

This is the pain, discomfort, and/or dysfunction that caused the patient to request help.

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

The Present Illness OPQRST-ASPN

Onset of the problemProvocative/ Palliative factorsQualityRegion/Radiation

SeverityTimeAssociated SymptomsPertinent Negatives

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Past History

General state of healthChildhood diseasesAdult diseasesPsychiatric illnessesAccidents or injuriesSurgeries or hospitalizations

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Current Health Status (1 of 2)

Current medicationsAllergiesTobaccoAlcohol, drugs, and related substancesDietScreening testsImmunizations

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Current Health Status (2 of 2)

Sleep patternsExercise and leisure activitiesEnvironmental hazardsUse of safety measuresFamily historyHome situation and significant othersDaily life

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

You should take your patient’s medications with you to the hospital,

when practical.

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Review of SystemsA 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

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Psychosocial HistoryChronic health conditionsJob– Work schedule– Stress

Family dynamicsSupportSafety issues – Car seat usage– Smoke and CO alarms

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Special Challenges (1 of 2)

SilenceOverly talkative patientsMultiple symptomsAnxiety

DepressionSexually attractive or seductive patientsConfusing behaviors or symptoms

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Special Challenges (2 of 2)

Patients needing reassuranceAnger and hostilityIntoxicationCrying

Limited intelligenceLanguage barriersHearing problemsBlindnessTalking with families or friends

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

If the patient cannot provide useful information, gather it from family

or bystanders.

Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Summary

History-Taking TechniquesActive ListeningThe Comprehensive Health History