PRELIM Flashcards
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6:37PM Wed Feb 19
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..•
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@ cdn.fbsbx.com
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1 of 6
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TOPIC 1
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KEY TERMS
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Chief Complaint- Primary medical problem
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Chronology- Time element of history (duration, frequency, etc.)
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Clinical History- info of patient’s condition
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Leading Questions- Provides info direct answers for symptoms
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Localization- determine precise area of pain (gentle palpation)
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Objective- perceptible to external senses
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signs
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Subjective- felt by patient
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not visible
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Quality- Descr. of character of senses
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4 PRINCIPLES OF ETHICS
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1) Autonomy - A person’s right to make own decisions
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2) Beneficence- duty to act in best interest
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prevent harm
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help people achieve full potential
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3) Non- Maleficence- duty to avoid causing harm
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do no more
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harm
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4) Justice- duty to treat people fairly & equally
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Reasons for repeated exposure
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-Motion
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-Position
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-Technical Factors
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PATIENT INTERVIEW
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Clinical History Acquisition- acquire clinical info to contribute in
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diagnostic process
job of Radtechs to obtain clinical history and
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give special attention to the area of pain
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Qualities of interviewer: Respect, Genuineness, Empathy
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DATA COLLECTION PROCESS
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Important for good history taking:
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• Objective Data - signs
can be seen, heard, or felt
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(Includes Lab reports)
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Subjective Data - symptoms
felt by patient
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Questioning Skills
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• Open- ended: non-direct/leading
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• Facilitation: (nodding) encourages elaboration
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• Silence: accuracy & elaboration
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• Probing questions: provides more detail (Localization &
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Chronology)
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• Repetition: clarify info
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• Summarization: verify accuracy
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ELEMENTS OF CLINICAL HISTORY
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Determine Chief Complaint:
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- Indication for examination
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- Trauma
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- Previous surgery
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Include Sacred 7:
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1) Localization- area of pain
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2) Chronology- when
how long
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3) Quality-Characteristics
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4) Severity- how severe the pain
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5) Onset- start of pain
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6) Aggravating/ Alleviating factors-factors worsening pain
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7) Associated Manifestations- happenings during pain
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episodes
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PRELIM
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RULES FOR SUCCESSFUL COMPLETE PATIENT HISTORY
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1) Private atmosphere
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2) Establish rapport using nice manners
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3) Ask their preferred addressed (Mr., Mrs., Ms.)
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4) Inform patient the importance of information
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5) Assure confidentiality
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6) Using open-ended & closed-ended questions
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Privacy- gives you right to control how personal info is used
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Confidentiality- sensitive info is not shared with unauthorized
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people (for medical records, research, data, etc.)
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PATIENT ASSESMENT & COMMUNICATION
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KEY TERMS
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INPATIENT
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Patient admitted to hospital for
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diagnostic studies/ treatment
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(24 hrs)
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OUTPATIENT
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COMMUNICATION
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GERONTOLOGY
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GERIATICS
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PALPATION
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PARALANGUAGE
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Application of light pressure
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Non-verbal elements of speech:
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vocal features (tone, pitch, rate,
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AUTONOMY
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Communication process - exchange of info between send &
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receiver
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Sender - Message - Encoding - Channel - receiver - decoding-
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Method on Effective Communication
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Verbal Skills
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1) Speech & Grammar: vocabulary, voice clarity, sentence
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organization, cultural difference must be appropriate
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2) Humor: used to relax patient
avoid cultural slurs &
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inappropriate references (age, sex, disease, etc.)
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Non-Verbal Skills
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1) Paralanguage: music of language
ex. Intonation, tempo
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2) Body Language: avoid confusing signals
actions = words
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3) Touch: for emotional support, emphasis, palpation only
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4) Professional Appearance: for patient's comfort &
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confidence in technologist's abilities
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5) Personal Hygiene: hygiene reflects professional behavior
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unkempt = less desire in communication & close contact
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6) Physical Presence: posture is perceived as confidence &
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self esteem
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7) Visual Contact: ensures questions,
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TYPES OF PATIENTS
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1) Seriously ill & traumatized patient
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May act differently due to stress, pain, or anxiety
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- Work efficiently & quickly with communication to
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determine coherent level
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1 Vianal mimnaired nationte
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