PARAMEDIC CARE: PRINCIPLES & PRACTICE

Patient Assessment

The History

The ability to elicit a good history lays the foundation for good patient care.

Topics  History Taking Techniques  Active Listening  The Comprehensive Health History

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.

The First Impression  Present yourself as a caring, competent, and confident health care professional.

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

Asking Questions  Use a combination of open- ended and close-ended questions.

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.

Active Listening  Facilitation  Reflection  Clarification  Empathy  Confrontation  Interpretation  Asking about feelings

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

The Comprehensive Patient History

Elements of the Patient History

Preliminary Data  Date and time  Age  Sex  Race  Birthplace  Occupation

The Chief Complaint  This is the pain, discomfort, dysfunction that caused the patient to request help.

The Present Illness OPQRST-ASPN  Onset of the problem  Provocative/ Palliative factors  Quality  Region/Radiation  Severity  Time  Associated Symptoms  Pertinent Negatives

Past History  General state of health  Childhood diseases  Adult diseases  Psychiatric illnesses  Accidents or injuries  Surgeries or hospitalizations

Current Health Status (1 of 3)  Current medications  Allergies  Tobacco  Alcohol, drugs, and related substances  Diet  Screening tests  Immunizations

Current Health Status (2 of 3)  Sleep patterns  Exercise and leisure activities  Environmental hazards  Use of safety measures  Family history  Home situation and significant others  Daily life

Current Health Status (3 of 3)  Important exercises  Religious beliefs  The patient’s outlook

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

Review of Systems  A system-by-system series of questions designed to identify problems your patient has not already identified.

Special Challenges (1 of 2)  Silence  Overly talkative patients  Multiple symptoms  Anxiety  Depression  Sexually attractive or seductive patients  Confusing behaviors or symptoms

Special Challenges (2 of 2)  Patients needing reassurance  Anger and hostility  Intoxication  Crying  Limited intelligence  Language Barriers  Hearing problems  Blindness  Talking with families or friends

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

Summary  History taking techniques  Active listening  The comprehensive health history