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Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Division 2Patient Assessment
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Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Chapter 10 History Taking
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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
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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
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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
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Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Patient Rapport
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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.
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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.
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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.
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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.
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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.
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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.
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Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
The Comprehensive Patient History
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Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Preliminary Data
Date and timeAgeSexRaceBirthplaceOccupation
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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.
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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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.
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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