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Components of a short report
- unit #
- pt age and sex
- chief complaint
- brief pertinent medical history
- vitals
- pertinent treatment rendered
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haptics
study of touching
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ethnocentrism
thinking your way is the superior way
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Trauma Triage Tool Components
- step 1: vitals and LOC
- step 2: anatomy of injury
- step 3: MOI & evidence of high energy impact
- step 4: special pt/system considerations
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when do you automatically upgrade step 3 and 4 pts?
when intoxicated
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sections of the MIR
- patient data
- run data
- narrative section
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Patient Data Elements of the MIR
- name
- address
- DOB
- Insurance info
- sex
- age
- nature of call
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SAMPLE
- Signs/symptoms
- Allergies
- Medications
- Pertinent past history
- Last oral intake
- Events leading to 911 call
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OPQRST
- Onset
- Provoker
- Quality
- Radiation
- Severity
- Time
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SOAP
- Subjective - what pt told me
- Objective - what I found
- Assessment - what I think the problem is
- Plan - treatment plan written out and whether or not it worked
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To meet the criteria for refusal of care, a pt must....
- be assessed thoroughly for any substance or intoxicant or medical condition
- have the lvl of care willing to accept determined
- have risks explained to them
- verbalize decisions/possible negative outcomes
- DOCUMENT discussion/sign AMA with witness
- encourage pt to seek medical attn if change in condition or decision
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if the pt is unresponsive and has no spinal injury, how would you position them?
left side lateral recumbent
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if the pt has chest pain or SOB, how would you position them?
Fowler's (sitting upright)
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If the pt is in shock, how would you position them?
lay flat
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if the pt is pregnant + hypotensive, how would you position them?
elevate on right side of board with pillow
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4 basic principals of lifting and moving
- keep weight as close to you possible
- when moving heavy object, use leg, hip and glut muscles + contracted ab muscles
- stack your body
- reduce the height or distance through which the object must be moved
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