Primary Medical Care Subject

Primary Medical Care Wanpen Waelveerakup, Dr.PH. Faculty of Nursing, Nakhon Pathom Rajabhat University Thailand

Primary Medical Care การรกั ษาโรคเบอื้ งตน้ Wanpen Waelveerakup, RN, DrPH (Public Health Nursing) Ruffel Joy C. Manalo, RN, MAN Faculty of Nursing Nakhon Pathom Rajabhat University

Course DesCription…1 • A study of a concept, principle and scope of primary medical care for nurses; health history interviewing, physical examination, problem- oriented medical record, laboratory test and interpretation, diagnosis, prescription and care of groups of medical signs and symptoms, basic surgical procedures and care, classification nursing care and referral regarding signs and symptoms of urgent and emergency, issue and trend in patient’s right, human’s right; related law, moral and ethics regarding primary medical care.

Course DesCription…2 1. Concept, principle and scope of primary medical care for nurses 2. Health history interviewing/taking, 3. Physical examination, 4. Problem-oriented & medical record, 5. Laboratory test and interpretation, 6. Rational drug use

Course DesCription…2 7. Diagnosis, prescription and care of groups of medical signs and symptoms, 8. Basic surgical care, 9. Classification signs and symptoms of urgent and emergency, 10. Patient’s right, human’s right; moral and ethics.



Topic 1 Concept, principle and scope of primary medical care for nurses

Learning Objectives OF THE TOPIC After studying this topic, students will be able to …. Describe the concept, principle and scope of primary medical care for nurses. Identify a rules, procedures and condition of primary medical care for nurses.

Concept principle Scope OF PRACTICE

The definition “ Primary Medical Care, (PMC) ” means an examination, diagnosis, and initial treatment to solve the problem of injury, illness, alleviate the severity of symptoms of the disease, to free the patient from illness or crisis, including the evaluation of the initial treatment. “Immunization” means vaccination to prevent disease.

Concept of PMC. for nurses • Initial treatment is a mission that is directly related to the responsibilities of medical and public health personnel. • Initial treatment is important because it helps people to be healthy, receive appropriate medical care and help reduce the severity of the illness. • Primary medical care is screening patients for treatment and referring patients with severe symptoms beyond the capacity to higher-caliber facilities. • A nursing practitioner provide preliminary treatment according to the requirements of the Nursing Council and the Ministry of Public Health to compensate for the shortage of doctors to perform this duty.

Requirements for PERFORM PMC. A nursing practitioner Registered nurse as a service provider must comply with the regulations of the Ministry - Level 1 Nursing or Level 1 Nursing and of Public Health regarding Midwifery Practitioner. the practice of nursing as - Have experience in nursing not less than 2 years. per the requirements of primary medical care and - Has completed the training as specified by immunization, 2002. the Nursing Council.. - Registered as a trained specialist in a nursing course in general practice (Primary Medical Care) with the Nursing Council.

Rules, procedures, and ConDitions…1 1.Diagnosis and treatment according to the standard of operation Nursing profession 2. Let the patient go to receive treatment from another professional if - symptoms do not relieve - Increased severe symptoms - It is a communicable disease that must be reported by the Communicable Disease Act. - have reasonable grounds for treatment, such as tools, equipment, or medical supplies

Rules, procedures, and ConDitions…2 3. The drug must be prescribed by the medicine manual prescribed protocol by the Nursing Council. 4. Must provide immunity as determined by the Ministry of Public Health 5. Must record a report about the patient's history or service recipients of the symptoms of the disease or the actual service provision and keep as evidence (at least 5 years)

Principle of primary medical care History Physical Primary Taking Examination Laboratory Test PMC1 Differential PMC2 Diagnosis PMC3 Initial PMC4 Treatment PMC5

scope of PRACTICE for nurses 1. History taking, physical examination, diagnosis, and treatment according to the preliminary treatment requirements of the nursing practitioner protocol or the Ministry of Public Health. 2. Provide assistance, referral to disease treatment, and perform specified procedures.

scope of PRACTICE for nurses 3. Give medication to relieve symptoms, treating the disease according to the prescribed guidelines and provided immunity by the MOPH. 4. Follow-up for treatment or caring. 5. Accepting patients to provide continuous care including additional medication as prescribed by a physician in refill treatment of chronic diseases patients.

topic Summary •It can conclude that… • PMC is a role of a physician doctor but nurses provide this tasks in Thailand according to the requirement of the Nursing Council and MOPH to replaced a doctor shorted.. • A nurse who provides PMC tasks must reached the requirements. • The scope of practices must follow the requirement of the Nursing Council and MOPH. • Must refer PT. for appropriate treatment and care if needed.

Thank you for your attentions! Email: [email protected] Email: [email protected]

Topic II Health history interviewing/taking Wanpen Waelveerakup, RN, PhD Ruffel Joy C. Manalo, RN, MAN Faculty of Nursing Nakhon Pathom Rajabhat University

OBJECTIVES OF THE LESSON After completing this lesson, the students will be able to: 1. Describe why a systematic approach to history taking is required. 2. Discuss how to prepare patient history taking. 3. Identify the eight (8) domains of health history requirements obtained from patient history taking. 4. Demonstrate patient history taking.

What is History Taking? • Asking questions of patients to obtain information and aid diagnosis. • Gathering both objective and subjective data for the purpose of generating differential diagnoses, evaluating progress following a specific treatment/procedure and evaluating change in the patient’s condition or the impact of a specific disease process.

Why a Systematic Approach to History Taking is Required • The value of the patient history will depend on the ability to elicit relevant information. • You are already in possession of the tools that will enable you to obtain a good history. • An ability to listen and ask common-sense questions that help define the nature of a particular problem. • Successful interviewing is for the most part dependent upon your already well developed communication skills.

Key Principles of Patient Assessment1 - It is estimated that 80% of diagnoses are based on history taking alone. - Use a systematic approach. - Establish a rapport with the patient. - Ensure the patient is as comfortable as possible. - Listen to what the patient says.

The eight (8) domains of health history 1. Initial data or data base 2. Chief complaint 3. Present Illness 4. Systemic review 5. Past illness or Past history 6. Personal history 7. Family history 8. History of illness in the neighborhood

1. Initial datA or data base It is also called biographical data. It is helpful to review patient’s health record such as: • Patient’s name (What’s your name?) • Gender • Age/Birthday/Birthplace (e.g., When is your birthday and birthplace?) • Marital status (e.g., single, married, divorced, widowed) • Religion (e.g.,Buddhist, Islam, Christian, Roman Catholic) • Educational background (undergraduate, graduate, post-graduate) • Occupation (What is your work and where) • Residence address (Where do you live?) • Contact in case of emergency (Who is the responsible person in case of emergency?)

2.Chief Complaint (CC.) • Initial Question(s): What brings your here? How can I help you? What seems to be the problem? ...... Push patient to be as descriptive as possible….. • Writing CC. with one sentence that covers the most important reason(s) and duration of the problems. (as stated or verbalized by the patient)

3. Present Illness (PI.)…1 Follow the questions to find out all the details of the patient’s problems: 1. Duration: How long has this condition lasted? Is it similar to the past problem? If so, what was done during that time? 2. Severity/Character: How bothersome is this problem? Does it interfere with your daily activities? Does it keep you up at night?

3. Present Illness (PI) ….2 • Follow-up Questions: 3. Location/Radiation: Does the symptom/s (e.g. pain) stay in a specific area? Has this changed over time? If the symptom is not focal, does it radiate to a specific area of the body? 4. Alternative Treatment/s Have they tried any therapeutic maneuvers? If so, what's made it better (or worse)?

3. Present Illness (PI) ….3 • Follow-up Questions: 5. Pace of illness: Does the problem gets better, worse, or stays the same? If it is changing, what was the frequency? 6. Are there any associated symptoms? Often times, the patient notices other unsualities that have popped up around at the same time as the main problem. These tend to be interrelated.

3. Present Illness (PI) ….4 • Follow-up Questions: 7. What does the patient think about the problem or what made them worried about? 8. Why today? Is there something new/different today unlike every other day when this problem has been present? Does this relate to a gradual worsening of the symptom/s itself?

THE 8 DIMENSIONS OF MEDICAL PROBLEM Chief complaint/s and present illnesses (PI) can be easily recalled using OLD CARTS. OLD CARTS Onset, Location/radiation, Duration Character, Aggravating factors Reliving factors, Timing Severity Goldberg C., (2018). Practical Guide to Clinical Medicine. Available from https://meded.ucsd.edu/clinicalmed/history.html

4. PAST HISTORY (PH)…1 Medical History •Have you ever received any medical care? •If so, what problems/issues were addressed? •Was there a continuous care given (i.e. provided on a regular basis by a single person) or episodic? •Have you ever undergone any diagnostic procedures, X-Rays, CT scans, MRIs or other special test/s? •Have you ever been hospitalized? If so, for what reason/s? Medications: Have you taken any prescribed medicines? If so, what is the dose and frequency? Do you know the reason/s why you are being treated?

4. PAST HISTORY (PH)…2 • Past Surgical History: Has the patient undergone any current operation, even at childhood? When was it? Was there any complication/s? ( If the patient doesn't know the name of the operation, try to at least determine why it was performed. Encourage them to be as specific as possible.) • Allergies/Reactions: Did the patient experienced any adverse reaction/s to medication/s?

5. PERSONAL HISTORY (PeH) • Smoking History: Does the patient smoke cigarettes? If so, how many packs per day and for how long? If they quit, when did this occur? • Alcohol: Does the patient drink alcohol? If so, how many bottle or glass per day and what type of drink? • Obstetric and Gynecology (if applicable): History of pregnancy? If so, how many times? What was the outcome of each pregnancy (e.g. full term delivery; spontaneous abortion; therapeutic abortion)?

6. FAMILY HISTORY (FH.) •In USA, coronary artery disease, diabetes and certain malignancies are the most common. •In Thailand, coronary artery disease, diabetes, hypertension and asthma are among the major health concerns.

7. REVIEW OF SYSTEMS (ROS.) • The review of systems (or symptoms) is a list of questions, arranged by organ system, from head-to-toe and is used by health care providers designed to identify body dysfunction/s or diseases. • The questions being asked reflects an array of common and important clinical conditions. • The disorders would go unrecognized if the patient’s bodily systems is not properly assessed.

8. History of illness in the neighborhood What are the current health problems of the people around the vicinity?: • Colleagues at work • Neighbors What kind of disease or illness are do they experience (e.g., TB, measles, chicken pox, DHF, Covid-19, etc.)? How are they treated? (e.g., herbal treatment & medical treatment)

CONCLUSION • A large percentage of the time, you will actually be able to make a diagnosis based on the history alone. • The eight (8) dimensions of medical problem can be easily recalled using the mnemonics OLD CARTS: Onset, Location or radiation, Duration, Character, Aggravating factors, Reliving factors, Timing and Severity • Patient history taking that aids in the diagnosis of diseases comprised of CC., PI., Past H., Personal H., FH., ROS. and history of illnesses in the neighborhood.

Thank You!

Wanpen Waelveerakup, RN, PhD Ruffel Joy C. Manalo, RN, MAN Faculty of Nursing Nakhon Pathom Rajabhat University

Learning Objectives OF THE TOPIC By the end of the topic students should be able to:- 1. Define of physical examination. 2. Describe how to perform the four techniques used in physical examination Define Physical examination techniques

Define of physical examination •Physical examination is a systematic data collection method that uses the senses of sight, hearing, smell and touch to detect health problems. • A medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. • Physical examination is defined as a complete assessment of a patient's physical and mental status.

KEY WORDS of physical examination • Data collection method • Examines a patient for any possible medical signs or symptoms of a medical condition. • Patient's physical and mental status • Physical examination means the data collection method for determining any possible medical signs or symptoms of a patient's physical and mental status.

Physical examination techniques 1. Inspection (การดู) Use your eye to see, 2. Palpation (การคลา) your finger to feel, 3. Percussion (การเคาะ) your ear to hear 4. Auscultation (การฟั ง) and your noses to smell To obtain valid information concerning the health of the patient อ.วนั เพ็ญ แวววีรคุปต์

Inspection involves using the senses of vision, smell, and hearing to observe and detect any normal or abnormal findings. • Using eyes to observe gestures and various parts of the body from head to toes.

Palpation consists of using parts of the hand to touch and feel for the following characteristics: • texture (rough/smooth), • temperature (warm/cold), • moisture (dry/wet), • mobility(fixed/movable/still/vibrating), • consistency (soft/hard/fluid filled), • strength of pulses (strong/ weak), • size (small/medium/large), • shape (well defined/irregular), and • degree of tenderness (no tender/mild/moderate/severe) อ.วนั เพ็ญ แวววรี คปุ ต์

2.1 Light palpation : gentle pressure, < 1 cm. deep Light palpation: To perform light palpation, place your dominant hand lightly on the surface of the structure. Photo by Wanpen

2.2 Deep palpation : increased pressure, >1 cm deep Deep palpation: With 1 hand With 2 hands: bimanual palpation To perform deep palpation, place your dominant hand on the skin surface and your non-dominant hand on top of your dominant hand to apply pressure. This allows you to feel very deep this organs or structures that are covered by thick muscle. Photo by Wanpen

2. Palpation • Ballottement : Used to assess the rebound of a floating object Picture from https://www.youtube.com/watch?v=opcQZgm6SSw