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Table of Contents PARAMEDIC CARE: PRINCIPLES & PRACTICE ? 2ND EDITION VOLUME 2 ? PATIENT ASSESSMENT CHAPTER 1 ? THE HISTORY Heading Level Heading Chapter Opening Key Terms Objectives Case Study 1 INTRODUCTION 1 ESTABLISHING PATIENT RAPPORT 2 Setting the Stage 2 The First Impression 2 Introductions 2 Asking Questions 2 Language and Communication 4 Facilitation 4 Reflection 4 Clarification 4 Empathy 4 Confrontation 4 Interpretation 4 Asking about Feelings 2 Taking a History on Sensitive Topics 1 THE COMPREHENSIVE PATIENT HISTORY 2 Preliminary Data 2 The Chief Complaint 2 The Present Illness 4 Onset 4 Provocation/Palliation 4 Region/Radiation 4 Severity 4 Time 4 Associated Symptoms 4 Pertinent Negatives 2 The Past History 4 General State of Health 4 Childhood Diseases 4 Adult Diseases 4 Psychiatric Illnesses 4 Accidents or Injuries 4 Surgeries or Hospitalizations 2 Current Health Status 4 Current Medications 4 Allergies 4 Tobacco 4 Alcohol, Drugs, and Related Substances 4 Diet 4 Screening Tests 4 Immunizations 4 Sleep Patterns 4 Exercise and Leisure Activities 4 Environmental Hazards 4 Use of Safety Measures 4 Family History 4 Home Situation and SignificantOthers 4 Daily Life 4 Important Experiences 4 Religious Beliefs 4 The Patient?s Outlook 2 Review of Systems 4 General 4 Skin 4 Head, Eyes, Ears, Nose, and Throat (HEENT) 4 Respiratory 4 Cardiac 4 Gastrointestinal 4 Urinary 4 Male Genital 4 Female Genital 4 Peripheral Vascular 4 Musculoskeletal 4 Neurologic 4 Hematologic 4 Endocrine 4 Psychiatric 1 SPECIAL CHALLENGES 2 Silence 2 Overly Talkative Patients 2 Patients with Multiple Symptoms 2 Anxious Patients 2 Patients Needing Reassurance 2 Anger and Hostility 2 Intoxication 2 Crying 2 Depression 2 Sexually Attractive or Seductive Patients 2 Confusing Behaviors or Histories 2 Limited Intelligence 2 Language Barriers 2 Hearing Problems 2 Blindness 2 Talking with Families or Friends End of Chapter Summary You Make the Call Review Questions Further Reading On the Web Marginalia Margin Glossary Content Review Key Ideas Special Features ? Within Chapter Patho Pearls PARAMEDIC CARE: PRINCIPLES & PRACTICE ? 2ND EDITION VOLUME 2 ? PATIENT ASSESSMENT CHAPTER 2 ? PHYSICAL EXAM TECHNIQUES Heading Level Heading Chapter Opening Key Terms Objectives Case Study 1 PHYSICAL EXAMINATION APPROACH AND OVERVIEW 2 Examination Techniques 3 Inspection 3 Palpation 3 Percussion 3 Auscultation 3 Measurement of Vital Signs 4 Pulse 4 Respiration 4 Blood Pressure 4 Body Temperature 2 Equipment 4 Stethoscope 4 Sphygmomanometer 4 Ophthalmoscope 4 Otoscope 4 Scale 4 Additional Equipment 2 The General Approach 1 OVERVIEW OF A COMPREHENSIVE EXAMINATION 2 The General Survey 3 Appearance 4 Level of Consciousness 4 Signs of Distress 4 Apparent State of Health 4 Vital Statistics 4 Sexual Development 4 Skin Color and Obvious Lesions 4 Posture, Gait, and Motor Activity 4 Dress, Grooming, and Personal Hygiene 4 Odors of Breath or Body 4 Facial Expression 3 Vital Signs 4 Pulse 4 Respiration 4 Blood Pressure 4 Temperature 3 Additional Assessment Techniques 4 Pulse Oximetry 4 Capnography 4 Cardiac Monitoring 4 Blood Glucose Determination 1 ANATOMICAL REGIONS 2 The Skin 4 Color 4 Moisture 4 Temperature 4 Texture 4 Mobility and Turgor 4 Lesions 2 The Hair 2 The Nails 2 The Head 2 The Eyes 2 The Ears 2 The Nose 2 The Mouth 2 The Neck 2 The Chest and Lungs 3 Posterior Chest Examination 3 Anterior Chest Examination 2 The Cardiovascular System 2 The Abdomen 3 Abdominal Organs 4 Digestive 4 Urinary 4 Female Reproductive 4 Male Reproductive 4 Cardiovascular 4 Lymphatic 3 Abdominal Examination 2 The Female Genitalia 2 The Male Genitalia 2 The Anus 2 The Musculoskeletal System 3 The Extremities 4 Wrists and Hands 4 Elbows 4 Shoulders 4 Ankles and Feet 4 Knees 4 Hips 3 The Spine 2 The Peripheral Vascular System 2 The Nervous System 3 Mental Status and Speech 4 Appearance and Behavior 4 Speech and Language 4 Mood 4 Thought and Perception 4 Insight and Judgment 4 Memory and Attention 3 The Cranial Nerves 4 CN-I 4 CN-II 4 CN-III 4 CN-IV, V, VI 4 CN-VIII 4 CN-IX, X 4 CN XI 4 CN-XII 3 The Motor System 3 The Sensory System 3 Reflexes 4 Biceps 4 Triceps 4 Brachioradialis 4 Quadriceps 4 Achilles 4 Abdominal/Plantar 1 PHYSICAL EXAMINATION OF INFANTS AND CHILDREN 2 Building Patient and Family Rapport 2 General Appearance and Behavior 4 Infants (Newborn?1 Year) 4 Toddlers (1?3 Years) 4 Preschoolers (3?6 Years) 4 School-age (6?12 Years) 4 Adolescents (13?18 Years) 2 Anatomy and the Physical Exam 3 General Appearance 3 Head and Neck 3 Chest and Lungs 3 Cardiovascular 3 Abdomen 3 Musculoskeletal 3 Nervous System 1 RECORDING EXAMINATION FINDINGS End of Chapter Summary You Make the Call Review Questions Further Reading On the Web Marginalia Margin Glossary Content Review Key Ideas Special Features ? Within Chapter Cultural Considerations PARAMEDIC CARE: PRINCIPLES & PRACTICE ? 2ND EDITION VOLUME 2 ? PATIENT ASSESSMENT CHAPTER 3 ? PATIENT ASSESSMENT IN THE FIELD Heading Level Heading Chapter Opening Key Terms Objectives Case Study 1 INTRODUCTION 1 SCENE SIZE-UP 2 Body Substance Isolation 2 Scene Safety 2 Location of All Patients 2 Mechanism of Injury 2 Nature of the Illness 1 THE INITIAL ASSESSMENT 2 Forming a General Impression 2 Mental Status 3 AVPU Levels 4 Alert 4 Verbal 4 Pain 4 Unresponsive 2 Airway Assessment 2 Breathing Assessment 2 Circulation Assessment 2 Priority Determination 1 THE FOCUSED HISTORY AND PHYSICAL EXAM 2 The Major Trauma Patient 3 Mechanism of Injury 3 Rapid Trauma Assessment 4 Head 4 Neck 4 Chest 4 Abdomen 4 Pelvis 4 Extremities 4 Posterior Body 3 Vital Signs 3 History 2 The Isolated-Injury Trauma Patient 2 The Responsive Medical Patient 3 The History 4 The Chief Complaint 4 History of the Present Illness 4 Past Medical History 4 Current Health Status 3 Focused Physical Exam 4 Chest Pain/Respiratory Distress 5 HEENT (head, eyes, ears, nose, and throat) 5 Neck 5 Chest 5 Cardiovascular 5 Abdomen 5 Extremities 4 Altered Mental Status 5 HEENT 5 Chest 5 Abdomen 5 Pelvis 5 Extremities 5 Posterior Body 5 Neuro 4 Acute Abdomen 5 HEENT 5 Chest 5 Abdomen 5 Posterior Body 3 Baseline Vital Signs 3 Additional Assessment Techniques 4 Pulse Oximetry 4 Capnography 4 Cardiac Monitoring 4 Blood Glucose Determination 3 Emergency Medical Care 2 The Unresponsive Medical Patient 1 THE DETAILED PHYSICAL EXAM 2 Components of the Comprehensive Exam 4 Head 4 Eyes 4 Ears 4 Nose and Sinuses 4 Mouth and Pharynx 4 Neck 4 Chest and Lungs 4 Cardiovascular System 4 Abdomen 4 Pelvis 4 Genitalia 4 Anus and Rectum 4 Peripheral Vascular System 4 Musculoskeletal System 4 Nervous System 5 Mental Status and Speech 5 Cranial Nerves 5 Motor System 5 Reflexes 5 Sensory System 2 Vital Signs 2 Recording ExamFindings 1 ONGOING ASSESSMENT 2 Mental Status 2 Airway Patency 2 Breathing Rate and Quality 2 Pulse Rate and Quality 2 Skin Condition 2 Transport Priorities 2 Vital Signs 2 Focused Assessment 2 Effects of Interventions 2 Management Plans End of Chapter Summary You Make the Call Review Questions Further Reading On the Web Marginalia Margin Glossary Content Review Key Ideas Special Features ? Within Chapter Patho Pearls PARAMEDIC CARE: PRINCIPLES & PRACTICE ? 2ND EDITION VOLUME 2 ? PATIENT ASSESSMENT CHAPTER 4 ? CLINICAL DECISION MAKING Heading Level Heading Chapter Opening Key Terms Objectives Case Study 1 INTRODUCTION TO CRITICAL THINKING 1 PARAMEDIC PRACTICE 2 Patient Acuity 2 Protocols and Algorithms 1 CRITICAL THINKING SKILLS 2 Fundamental Knowledge and Abilities 2 Useful Thinking Styles 4 Reflective vs. Impulsive 4 Divergent vs. Convergent 4 Anticipatory vs. Reactive 1 THINKING UNDER PRESSURE 2 Mental Checklist 4 Scan the Situation 4 Stop and Think 4 Decide and Act 4 Maintain Control 4 Reevaluate 1 THE CRITICAL DECISION PROCESS 2 Form a Concept 2 Interpret the Data 2 Apply the Principles 2 Evaluate 2 Reflect 2 Putting It All Together End of Chapter Summary You Make the Call Review Questions Further Reading On the Web Marginalia Margin Glossary Content Review Key Ideas Special Features ? Within Chapter Patho Pearls PARAMEDIC CARE: PRINCIPLES & PRACTICE ? 2ND EDITION VOLUME 2 ? PATIENT ASSESSMENT CHAPTER 5 ? COMMUNICATIONS Heading Level Heading Chapter Opening Key Terms Objectives Case Study 1 INTRODUCTION TO COMMUNICATION 1 BASIC COMMUNICATION MODEL 1 VERBAL COMMUNICATION 1 WRITTEN COMMUNICATION 2 Terminology 1 THE EMS RESPONSE 4 Detection and Citizen Access 4 Automatic Collision Notification 4 Call Taking and Emergency Response 4 Prearrival Instructions 4 Call Coordination and Incident Recording 4 Discussion with the Medical Direction Physician 4 Transfer Communicaitons 1 COMMUNICATION TECHNOLOGY 2 Radio Communication 4 Simplex 4 Duplex 4 Multiplex 4 Trunking 4 Digital Communications 2 Alternative Technologies 4 Cellular Telephone 4 Facsimile 4 Computer 2 New Technology 1 REPORTING PROCEDURES 2 Standard Format 2 General Radio Procedures 2 Model Verbal Reports 3 Medical Patient 3 Trauma Patient 1 REGULATION End of Chapter Summary You Make the Call Review Questions Further Reading On the Web Marginalia Margin Glossary Content Review Key Ideas Special Features ? Within Chapter Patho Pearls Legal Notes PARAMEDIC CARE: PRINCIPLES & PRACTICE ? 2ND EDITION VOLUME 2 ? PATIENT ASSESSMENT CHAPTER 6 ? DOCUMENTATION Heading Level Heading Chapter Opening Key Terms Objectives Case Study 1 INTRODUCTION 1 USES FOR DOCUMENTATION 2 Medical 2 Administrative 2 Research 2 Legal 1 GENERAL CONSIDERATIONS 2 Medical Terminology 2 Abbreviations and Acronyms 2 Times 2 Communications 2 Pertinent Negatives 2 Oral Statements 2 Additional Resources 1 ELEMENTS OF GOOD DOCUMENTATION 2 Completeness and Accuracy 2 Legibility 2 Timeliness 2 Absence of Alterations 2 Professionalism 1 NARRATIVE WRITING 2 Narrative Sections 3 Subjective Narrative 3 Objective Narrative 4 Head-to-Toe 4 Body Systems 3 Assessment/Management 2 General Formats 3 SOAP Format 3 CHART Format 3 Other Formats 4 Patient Management 4 Call Incident 1 SPECIAL CONSIDERATIONS 2 Patient Refusals 2 Services Not Needed 2 Mass Casualty Incidents 1 CONSEQUENCES OF INAPPROPRIATE DOCUMENTATION 1 CLOSING End of Chapter Summary You Make the Call Review Questions Further Reading On the Web Marginalia Margin Glossary Content Review Key Ideas Special Features ? Within Chapter Legal Note
Library of Congress Subject Headings for this publication:
Emergency medicine.
Emergency medical technicians.
Emergencies.
Emergency Medical Technicians.
Emergency Treatment.