Transcript Focused History & Physical Exam - Behavioral Patient

Principles of Patient Assessment
in EMS
Focused History & Physical Exam:
Behavioral Emergencies
Introduction
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Every type of illness/injury will come with
some type of emotional or psychological
element.
Behavioral emergencies occur when a
person with/without a psychiatric hx
becomes stressed & overwhelmed or feels
they are “loosing control.”
Introduction (continued)
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A crisis occurs when a person’s perception
of an acute distressing event results in an
abnormal behavioral response.
Crisis is an internal response that can
create reactions such as:
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Severe anxiety
Panic
Paranoia
Other psychotic events
The EMS Provider’s Role
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You must be able to take an active role in
controlling the situation without being
threatening:
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Upon arrival make a clear, short and calm statement
of who you are and why you are there.
Determine the problem and how many people are
involved.
Get a description of any unusual activities, risk
factors, prior episodes.
Remember scene safety! Is this a crime scene?
Common Psychiatric Disorder
Classifications
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Mental
Emotional
Behavioral
Effect an estimated 20% of the U.S.
population
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Psychological Disorders
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Features:
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Observe the patient’s body language and
verbal responses for clues
Various disorders have distinctive
characteristics
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Psychological Disorders (continued)
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General Appearance:
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Neglect in personal hygiene, grooming
Inappropriate dress
Excessive attention to details (obsessivecompulsive)
Unilateral neglect (brain lesion)
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Psychological Disorders (continued)
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Intellectual Function:
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Assess memory, concentration, judgment and
orientation
Psychiatric disorders may affect short, long
and recall memory
Assessment is done in the patient interview
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Psychological Disorders
(continued)
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Thought Content:
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Thought content and perceptions should be
logical, consistent and connected with the
current situation
Delusions – a false personal belief or idea is
portrayed as true
Hallucination – a perception of something that
is not present
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Psychological Disorders (continued)
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Physical Complaints:
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Often vague – headache, muscle ache, weight
loss, lack of energy
Consider medical causes first
Motor Activity:
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Tense, restlessness, pacing, crying, fidgeting
or slow moving
Consider drug intoxication, pain, abnormal
blood sugar or hypoxia first
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Psychological Disorders (continued)
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Speech & Language:
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Consider word choice, quality, pace and
articulation of speech and language
Consider other causes for alterations such as
stroke, tumors or trauma.
Body Language:
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Body language is the expression of thoughts
or emotions by means of posture or gestures
Stay alert to non-verbal cues for potential
violence
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Psychological Disorders (continued)
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Mood:
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Assess mood and affect through facial
expressions, body language and responses to
questions
Should be appropriate for the current
situation and transitions according with topics
in conversation
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Assessment
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Scene Safety:
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A major misconception “all mental patients
are unstable and dangerous”
Many behavioral emergencies begin as
medical calls. ALWAYS assess scene safety in
every call.
Respect a patient’s personal space.
Limit the number of people and avoid
overwhelming the patient.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Assessment (continued)
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Focused History:
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Obtaining a history may be difficult, these
patients are often unreliable, poor historians
or uncooperative
Family or caretakers may not be available or
may distort the information
Assess predisposing risk factors such as
depression or major life event
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Assessment (continued)
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O – Where, when and how did the event begin?
P – What is the problem today? Did the patient
intend on harming him/herself?
Q – What type of crisis is the patient
experiencing?
R – Are there any concomitant medical factors?
S – Is this event similar to previous episodes?
T – How long has this been going on?
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Assessment (continued)
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S – What type of crisis is the patient
having? Any associated symptoms?
A – Are there any allergies to meds?
M – What meds and any recent changes
to medication schedule?
P – What is the patient’s behavioral
history? Any substance abuse?
L – meds, meals, alcohol?
E – new stress, changes in social status?
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Mental Status Exam
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Obtain baseline assessment and verify
finding with family/caretaker, MD
Appearance – note physical position and
posture, personal hygiene, appropriate
dress, age and gender
Affect – what feelings is the patient
exhibiting
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Mental Status Exam (continued)
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Behavior – what is the patient doing?
Cognitive function – assess level of
consciousness, memory, mood and affect.
Speech – assess word choice, content,
intonation, clarity and pace.
Thought process – assess if judgment is
reasonable for the current situation.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Behavioral Emergencies
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Depression is a common reaction to major
life stress:
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Feelings of sadness, discouragement, and
hopelessness
Reduced activity levels, inability to function,
and sleep disturbances
Severe depression is a risk factor for suicide
May present as symptoms of disease (organic
illness, cardiac or respiratory conditions)
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Mental Illness
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There are many pathologies for behavioral
and psychiatric disorders:
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Genetic
Chemical imbalance
Organic illness
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Substance Abuse
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Dependence, abuse and intoxication.
True addiction is both psychological and
physical.
Alcoholism is particularly insidious among
the elderly.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Suicide Attempts
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Occur when a patient has a true desire to
die.
Gestures are pleas for help.
Whether “attempt” or “gesture” do not
discount the patient’s emotional state in
any way.
Be direct and ask:
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“Where you trying to kill yourself?”
“Do you want to die?”
Clearly report and document your findings.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Attention/Pleas for Help
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Some behavior calls are related to a
patient’s cry for attention:
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Suicide gesture
Hypochondriac
Lonely person calling repeatedly for no
apparent medical reason
Safest approach is to assume something is
seriously wrong until proven otherwise.
Often people who want help are unaware
of available resources and they call 9-1-1.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Assisting a Transportation
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Mental health evaluation order.
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The police should have an order and be on
the scene
Inmates feigning illness.
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Complete a thorough assessment
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Assisting a Transportation
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Patients who are a danger to themselves
or another.
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Major concern is safety for EMS providers and
the patient
Do not use excessive force and be aware of
the dangers of restraint
Never restrain a patient in a prone position!
Review the NAEMSP policy on patient restraint
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Medical Conditions that Mimic
Behavioral Disorders
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Stroke, tumors, or trauma can affect
speech.
Medications, severe infections, hypoxia,
hypo or hyperglycemia can cause altered
mental status, depression or psychosis.
Psychotropic meds can have powerful side
effects and severe interactions with other
medications.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Stress and the EMS Provider
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Emergency responders are routinely
subjected to both positive and negative
stress.
Stress disorders may be acute or develop
into chronic conditions if not recognized
and managed.
Be watchful and recognize
signs/symptoms of stress in yourself and
coworkers.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Stress and EMS Providers
(continued)
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Signs and symptoms of ineffective or failing
coping mechanisms include:
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Increased absenteeism
Withdrawal
Depression
Hyperactivity
Irritability
Increased smoking or alcohol use
Sleep disturbances
Headaches
Poor concentration and decision making
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Conclusion
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Response to crisis varies by person.
Inability to cope or failing mechanisms can
cause impaired functionality.
Some become withdrawn/depressed,
others overactive/violent.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Conclusion (continued)
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Many factors can alter a patient’s behavior
(regardless of any mental health history).
Personal safety comes first! Take an
active role in controlling the situation and
supporting the patient’s emotional and
physical needs.
Whenever possible obtain a complete
history!