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33 Cards in this Set

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Describe the purpose of effective history taking in prehospital patient care
Provides an account of medical, social, and environmental factors that may have a bearing on patient condition; provides structure to patient assessment; and are essential to establishing priorities in patient care
List components of the patient history as defined by the US DOT
Date, time, identifying data (age, sex, race, birthplace, occupation), source of referral (by self or by others), source of history (patient, family, friends, police, others) reliability, chief complaint, history of present illness, past history, current health status
Outline effective patient interviewing techniques to facilitate history taking
Establish a professional demeanor, ensure patient safety and comfort, greet patient by name and shake hands, avoid entering personal space, inquire about feelings, be sensitive to feelings and experiences, watch for signs of uneasiness, use appropriate and understandable language, ask direct, open-ended questions, use therapeutic communication techniques
Identify strategies to manage special challenges in history-taking (silence)
Stay alert to nonverbal clues of distress or anxiety and give patient time to ready self to answer
Identify strategies to manage special challenges in history-taking (overly talkative)
Accept a less comprehensive history, give patient free reins for a few minutes, ask yes or no questions, summarize comments frequently, refocus often
Identify strategies to manage special challenges in history-taking (patient with multiple symptoms)
Anticipate longer interview times, help patient focus on most relevant
Identify strategies to manage special challenges in history-taking (anxious patient)
Be sensitive to nonverbal clues of anxiety, remain supportive and calm, maintain caring and professional attitude
Identify strategies to manage special challenges in history-taking (false reassurance)
Avoid false reassurance. Instead reassure patient that there is hope, that the paramedic is listening, that care is available, that patient will be treated with dignity and respect, that patient’s condition is understood
Identify strategies to manage special challenges in history-taking (anger and hostility)
Maintain calm manner, demonstrate confidence, set limits on behavior, attempt to calm patient
Identify strategies to manage special challenges in history-taking (intoxication)
Ensure personal and scene safety, establish limits for acceptable behavior, request law enforcement
Identify strategies to manage special challenges in history-taking (crying)
If crying is uncontrollable, hold hand and use direct eye contact to reassure
Identify strategies to manage special challenges in history-taking (sexually attractive or seductive)
Set limits on behavior, reinforce fact that relationship is to stay professional, care provider should be same sex as patient, use an additional caregiver as a chaperone
Identify strategies to manage special challenges in history-taking (depression)
Identify the seriousness of the depression and be sensitive to nonverbal clues of depression, remain supportive and calm, maintain caring and professional attitude
Identify strategies to manage special challenges in history-taking (confusing behaviors or history)
Identify behavioral pattern and lead patient with directed questions
Identify strategies to manage special challenges in history-taking (developmental disabilities)
Don’t overlook patient’s ability to answer questions; but if the disability is severe, ask family or friends
Identify strategies to manage special challenges in history-taking (Communication barriers)
Find assistance
Identify strategies to manage special challenges in history-taking (talking with family and friends)
Consider them a resource to fill in missing information
Information gathered as part of the History of Present Illness
OPQRST, pertinent positives and negatives
Information gathered as part of the Past Medical History
Childhood illness, adult illness, accidents and injuries, surgeries and hospitalizations, psychiatric illness, family history
Information gathered as part of the Current Health Status
Allergies, medications, food allergies, environmental allergies, and look for medical ID devices
Information gathered as part of the Medications
What is taken regularly and why, how compliant are they, what nonprescriptions are taken, use of recreational drugs
Why is a patient’s last oral intake important to know
May affect potential airway problems if patient loses consciousness, may determine appropriateness of surgeries, may help rule out other problems
Determining the last menstrual period is important for all women presenting with abdominal pain. Which questions may you need to ask in follow-up
Contraceptive use, history of venereal disease, urinary tract infection, history of ectopic pregnancy
Information gathered as part of the last bowel movement
Determine history of diarrhea, constipation, bloody bowel movements and whether they would be considered normal or abnormal
Information gathered as part of the urinary function
Occurrence of: hematuria, discharge, pain or burning associated, frequency, inability to void
Information gathered as part of the environment
Home conditions, occupation, travel, military record
Information gathered as part of the personal habits
Tobacco and alcohol use, diet, screening, immunizations, sleep patterns, exercise, leisure, safety practices, home situation, physical abuse, sexual history, daily life, important experiences, patient outlook
Follow up questions to ask regarding alcohol use
Cutting down, annoyance by criticism, guilty about use, eye-opener(mornig use) CAGE
Tips to remember when questioning about abuse or violence
Gather clues about situation, girect questions are best, have a nonjudgmental attitude, avoid judgmental statements, avoid “why” questions, be supportive
Areas assessed in Review of Systems
General impression, skin, HEENT (head, eyes, ears, nose, and throat) respiratory, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, neurologic, hematologic, endocrine, psychiatric
Identify and explain therapeutic communication techniques for opening questions
Facilitation (words, actions, or psture should encourage patient to say more), reflection (repeat what patient said to encourage responses without bias or interruption), clarification (ask questions to to understand ambiguity), empathetic responses (interpret patient feelings), confrontation (tactfully confront patient about feelings), interpretation (make an inference from responses), ask about feelings
Define: Dysuria
Painful urination
Define: hematuria
Blood in urine