Chapter 11 – Therapeutic Communications And Patient History Flashcards
Discuss the basic elements of the communication process
Six basic elements:
A source: Communication starts with an information source. The source of verbal communication is written or spoken words
Encoding: the act of placing a message into words or images so that it is understood by the receiver in the sender
The message: the information to be communicated
The channel: the past at the center selects for transmitting the message to the receiver
A receiver: the receiver must interpret the message
Feedback: the response from the receiver that allows the sender to know how the message is being received
Identify nonverbal behaviors that are used in patient interviewing
Examples of nonverbal behavior include actions, body language, and active listening. This means posture, gestures, and physical appearance. Always reflect interest in the patient, active listening requires complete attention and verbal engagement
Discuss common patient responses to illness or injury
A patient can have a variety of responses, regression is a return to an earlier developmental state such as acting like a child because the adult is depending on Cara from someone else. Also fear, embarrassment, frustration, sorrow, feeling of helplessness, guilt, anxiety or anger
Discuss the communication skills that should be used to interact with the patient
When communicating with the patient, begin by identifying yourself and establishing your role. “My name is so-and-so and I am a trained EMR” Address the patient by their name, “mr. or mrs.” then asked for a preferred name. Be aware of personal space, look at the patient while they are talking, and explain what you need to do if you have to invade their personal space. Speak confidently yet calmly, and use common terms and always tell the truth. Do not give false hope
Discussed developmental considerations of various age groups that influence patient interviewing
Young infants are not afraid from 0 to 6 months, older infants from 6 to 12 months can have separation anxiety. Try to have a caregiver near, and don’t be startled, speak smoothly. Toddlers respond to tone of voice, have high separation anxiety, can answer simple questions and cannot be reasoned with. Give them a comfort item, they do not like strangers or being touched. Gain the cooperation of a caregiver. Approach preschoolers slowly and talk at I level, use simple words and reassure that they are not bad or being punished. Try to assess them when they are up bright and have a caregiver near. Do not use missed leading terms with school aged children, try to talk directly to them about what happened. Be honest and straightforward, and if you need to do something that will cause pain, briefly explain it and don’t leave much time for process. Treat adolescents like adults, and explain to them about what you are doing and ask them what happened
Discuss techniques that may be necessary when interviewing patients who have special needs
Non-English-speaking patients may require an interpreter, if one isn’t present, contact dispatch or medical direction. Hearing impaired patients: don’t change the way you speak, use normal tone at normal speed just like a normal patient. A gentle touch on the shoulder may be needed, eliminate background noise and keep questions short and simple and be in proper lighting and try to ask yes or no questions
Discuss the communication skills that should be used to interact with family members and bystanders
Identify yourself and take control of the situation, briefly explain your intentions, avoid medical terms, speak at normal rate and clarify unclear information, maintain good posture and do not get distracted, but allow emotions to be let out and do not give false hope
Identify and explain each of the components of the patient history
Patient history: The part of the patients assessment that provides facts about the medical problem or medical history. Components include the current medical problem, history of the present problem, and past medical history is, and current health status.
History of the present illness: chronological record of the reason the patient is seeking medical attention. It includes a detailed evaluation of the problem and signs and symptoms that lead up to the problem. Ask patient to tell you what happened, this could provide clues of the patient’s current situation
Provide examples of open ended and closed or directed questions
Open ended questions: require that the patient answers with more than a yes or no. These questions give the patient opportunity to express feelings and thoughts and it encourages them to explain what’s wrong. For example, “what’s troubling you?”
Closed or direct questions: a simple yes or no answer, for example asking about high blood pressure diabetes or another illness
Discuss the need to search for additional medical identification.
In some situations, a person situation can be so critical that you need to ask the important questions while providing care. If a patient loses consciousness, knowing what his symptoms were before he lost consciousness can help identify causes. It’s important to search for medical tags or ask friends or family about health conditions
Explain the standardized approach to history taking using the OPQRST and SAMPLE acronyms
Onset: how long ago did the problem begin? What were you doing? Was it sudden or gradual?
Provocation (position) what makes it better or worse? In what position was the patient found? Should they remain there?
Quality: what does the pain feel like?
Region: where is the pain?
Severity: rate the pain from 0 to 10
Time: how long have you felt this way? Have you ever felt this before? How long did it last?
SAMPLE: a memory aid used to standardize the approach to history taking
Signs and symptoms
Allergies
Medications
Past medical history
Last oral intake
Events leading to the injury or illness
Give examples of pertinent positive and pertinent negative findings
Pertinent positive: a yes answer regarding illness or injury. For example, when caring for an asthma patient, pertinent positive findings would include shortness of breath and feeling of tightness in her throat or chest
Pertinent negative: a no answer regarding illness or injury. For example, if a woman has abdominal pain, pertinent negative findings would include no recent abdominal trauma, no stomach surgery, or vaginal infection
Differentiate between a sign and a symptom
Sign: something that can be measured, felt, heard, smell, or seen by a care assistant
Symptom: something that the patient describes they are feeling
