Components of a short report
- unit #
- pt age and sex
- chief complaint
- brief pertinent medical history
- pertinent treatment rendered
study of touching
thinking your way is the superior way
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
when do you automatically upgrade step 3 and 4 pts?
sections of the MIR
- patient data
- run data
- narrative section
Patient Data Elements of the MIR
- Insurance info
- nature of call
- Pertinent past history
- Last oral intake
- Events leading to 911 call
- 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
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
if the pt is unresponsive and has no spinal injury, how would you position them?
left side lateral recumbent
if the pt has chest pain or SOB, how would you position them?
Fowler's (sitting upright)
If the pt is in shock, how would you position them?
if the pt is pregnant + hypotensive, how would you position them?
elevate on right side of board with pillow
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