Assessing Patients and Managing Acute Situations



Assessing Patients and Managing Acute Situations




This chapter addresses basic principles involved in meeting patient needs, but before these needs can be met, they must be clearly identified. Observation, evaluation, and assessment are the skills needed to determine patient needs. When these skills are consciously practiced in the clinical area, they increase your value as a limited operator. They help you become more sensitive to the safety of the environment and the conditions of your patients.


The dictionary defines an emergency as a serious event that happens unexpectedly and demands immediate attention. Sudden deterioration in the status of any patient under your care is an acute situation requiring an appropriate response. Whether such a situation leads to a more serious problem may depend on whether you are prepared to act quickly and efficiently. Seen from this perspective, no patient problem can be considered trivial. Acute situations are bound to occur when you are dealing with patients who are ill or injured, and you must be prepared to cope in a way that will minimize the possibility of further injury or complication.



Assessing the Personal Concerns of Patients


Uncertainty about the coming procedure, fear of a possible diagnosis, or concern about the effect of illness on family members can cause varying reactions in patients. Sometimes these concerns are expressed as anger and demonstrated by inappropriate speech or rude behavior toward personnel. Other expressions of anxiety may be a need to talk constantly or, conversely, a tendency to become quiet and withdrawn. You may observe fidgeting or other nervous mannerisms.


Anxiety can also be caused by a concern over modesty, especially when patients must undress for examinations or treatments. Reassure patients by displaying a matter-of-fact attitude while providing ample cover and an explanation of the procedure.


Your presence is comforting to the anxious patient. Touch patients reassuringly and tell them what to expect. Let them know when you leave the area and when you expect to return. Escort ambulatory patients to the bathroom or back to the waiting area. It can be very distressing to patients if they must wander about in an examination gown wondering where to go. Once you start a procedure, try to remain near the patient. If patients must wait in an x-ray room or dressing room, let them know that you are within hearing distance and that they may call on you for help. If a call button is available, show patients how to use it and assure them that someone will assist them promptly if they call. If no call signal is available, check with patients frequently while they wait.


Physical discomfort adds to tension as well. Remember that most patients will find it hard to remain still during a long procedure on a hard surface. This is especially difficult for a thin patient or an elderly person with kyphosis. Note whether an obese patient has difficulty breathing when lying flat on the table. Note skin temperature when you touch the patient and inquire whether the patient is warm enough. If the patient feels chilled, provide a blanket and tuck it around the patient to provide both warmth and a sense of security. As you move briskly around the room the temperature may seem warm enough to you, but elderly or frail patients may not be active enough to keep warm. If the patient is coughing or sniffling, offer paper handkerchiefs and position a waste container within reach for the soiled tissues.


If dentures must be removed, provide a suitable disposable container and place it in a safe and visible location. Dentures slide in much more easily when wet, so add water to the container or direct the patient to a sink when dentures are replaced. Eyeglasses and hearing aids are also items essential to activities of daily living and are difficult and expensive to replace or repair. A bright-colored plastic box or basket is a useful container for these items and other small valuables (Fig. 22-1). Choose a safe location in view of the patient. Use the same place consistently and point out the location to the patient.




Physiologic Needs


Water


A dry mouth can be caused by thirst but can also result from anxiety or medication. A drink of water, offered with a straw if the patient is lying down, may be very comforting. Since some tests require that the patient have nothing by mouth, even water, it is wise to check that water is permitted.



Elimination


An urgent need to void can be very distressing to a patient. A full bladder may cause discomfort, irritability, and difficulty remaining still during the procedure. If this need is ignored in an older or debilitated patient, incontinence (loss of bladder control) may result, causing embarrassment for the patient and cleanup problems for you. Be especially sensitive to the need for bathroom facilities when procedures are prolonged.


Before a patient uses the bathroom, check to see if a specimen of urine or feces should be collected. If so, provide instructions and the correct container. Urine collection procedure is explained in Chapter 24. When a patient needs to defecate or urinate and is unable to walk or be taken to the bathroom in a wheelchair, a bedpan or urinal is used. This is not a common requirement in most outpatient facilities, but assisting patients with bedpans or urinals is a basic clinical skill.


When a bedpan is necessary, follow the procedure outlined in Box 22-1. Be sure that the patient is adequately covered for privacy. When a female patient is placed on the bedpan, the upper torso needs to be slightly elevated to prevent urine from running up her back. When a patient is restricted in mobility, two people may be needed to assist the patient onto the bedpan. If the patient is on the x-ray table, one person should stand on each side of the table to prevent the patient from falling.



When the patient is finished, you may have to assist with wiping. Wear gloves and have toilet tissue, a wet washcloth, and a dry towel conveniently placed. Assist the patient to lift the hips or roll away from you onto one side while you steady and remove the pan. Place it safely aside and, if necessary, help the patient by wiping from front to back with paper first, and then with a wet cloth before drying. Offer the patient a disposable moist towelette or a clean wet cloth and towel to cleanse the hands.


Male patients may need to use a urinal. Usually this is simply a matter of providing the urinal and removing it again when the patient is finished. If the patient is unable to use it himself, don protective gloves and spread the patient’s legs; lift the sheet with one hand and slide the penis into the urinal with the other. It may be advisable to hold the urinal in position until the patient is finished.


Patients may find it difficult to use a bedpan or urinal if they feel that they are under observation. If possible, you should remain out of the patient’s line of sight while staying close enough to ensure patient safety.


Empty the bedpan or urinal carefully into the toilet to avoid splashing. Remember to perform hand hygiene after removing your gloves.


Placing a patient on the bedpan or offering the urinal is not a complex task. Once you are familiar with this procedure, the chief obstacle to overcome is embarrassment. A cheerful, matter-of-fact attitude will make the process easier for you and for the patient.




Taking a History


It is important for you and the physician who interprets the images to know why an examination is being done. If the images are sent out to a radiologist, this information must accompany them. If the requisition does not provide complete and accurate information about the patient’s history and condition, you will need to obtain this information from the patient. The answers you receive may influence how the examination is conducted. The history also aids the radiologist in focusing the interpretation to meet the referring physician’s needs. This does not need to be a detailed medical history, but rather a thoughtful consideration of the patient’s current status and why this particular radiographic study is being done.


The process of taking a history presents an opportunity for you to give the patient individual attention and build rapport. In addition, your ability to gain the patient’s confidence will influence the amount of relevant information you obtain. Remember to introduce yourself, call the patient by name, and deal with immediate patient concerns as soon as possible.


Begin the history by asking a general question about the nature of the problem, such as, “Do you know why Dr. Chen wants you to have an x-ray of your chest?” Be realistic in the scope of your questions. Focus on expanding the information provided on the x-ray requisition. This is especially important when the request or order does not indicate the rationale for ordering the procedure. Most requisition forms have a place for this information, but in practice the history is often absent or is so limited that it does not seem relevant without further explanation. The information you obtain is most useful when recorded on the requisition form. You may also need to enter it into the computer record.


History requirements vary with the nature of the examination. Table 22-1 provides history questions and observations pertinent to many patient complaints. You can use it to become familiar with the types of information that will be most useful in specific situations. The history examples in this table use common abbreviations that are also used in charting and other medical recording.



TABLE 22-1


image Guidelines for Taking a History of a Patient’s Chief Complaint


















































Type of Examination Questions Observations Example of History*
Orthopedic, acute injury How did the injury occur? When? Can you show me exactly where it hurts? Swelling, deformity, discoloration, laceration, abrasion Twisting injury, L ankle, while skiing today; swelling & pain over lateral malleolus.
Orthopedic, not involving acute injury Where does it hurt? How long has it been bothering you? Were you ever injured there? How was the injury treated (cast, surgery)? Has there been any recent change? Deformity, scars, range of motion, weight bearing Chronic pain, R knee 2 yr, worse since building fence Sat. Prev Rx image cortisone inj. No known injury.
Neck Did you injure your neck? How? When? Where does it hurt? Do you have any pain, numbness, or tingling of the shoulder or arm? Which side? Range of motion MVC 10/12/08; lower neck pain & L shldr pain image numbness & tingling, L hand.
Spine Did you injure your back? How? When? Do you have pain, numbness, tingling, or weakness of the hip or leg? Which side? Any bowel or bladder problems? Gait, range of motion Lifting injury 2 wk ago. LBP radiating to R hip.
Head Were you injured? When? How? Do you have pain? Where? Did you lose consciousness? For how long? Speech: clarity, confusion; gait Severe HA, blurred vision, dizziness, & gen’l weakness, 24 hr. No known injury. Speech slurred.
Chest Do you know why your doctor ordered this examination? Are you short of breath? Do you have a cough? Do you cough up anything? Do you cough up blood? Have you had a fever? Do you have any heart problems? Respirations, cough SOB, wheezing, & R chest pain since resp flu 4 wk ago. Moderate, nonproductive cough.
Abdomen, gastrointestinal examinations Do you know why your doctor ordered this examination? Do you have pain? Where? Do you have nausea? Diarrhea? Have you had any other tests for this problem (lab tests, ultrasound)? Do you know the results? Have you ever had abdominal surgery? When? Why?   LLQ pain, incr over past mo. ? mass seen on US done here 10/21/11.
Urology Do you know why your doctor ordered this examination? Do you have any pain? Where? For how long? Do you have trouble passing urine? Pain? Urgency? Frequency? Have you ever had this problem before? Do you have high blood pressure?   2 prior episodes of UTI; current malaise, fever, & mid back pain.


image


*& = and; ? = question of; inj = injection; shldr = shoulder; gen’l = general; resp = respiratory; US = ultrasound. To identify other common abbreviations used in charting (e.g., MVC, motor vehicle crash), see Appendix L.


Patients may have been asked to complete a history questionnaire on their initial visit, but this information may be out of date. In facilities that perform procedures using contrast media, a special history questionnaire that includes questions about allergies and kidney function may need to be filled out and signed before each procedure that involves injection of a contrast medium.


Examinations for patients with chronic conditions or those receiving posttreatment follow-up may require a comparison with prior imaging studies. If these are not part of the current file, your history should contain information on previous relevant examinations, including when and where they were done.


Some medical assistants take preliminary histories before the physician sees the patient. Although the physician is responsible for taking the official medical history, a preliminary history can save time, allowing the physician to focus quickly on details of the patient’s problem. If taking patients’ preliminary histories is one of your accepted responsibilities, the standard format that follows can serve as a guide. Using this outline will allow you to elicit the greatest amount of information about the patient’s chief complaint in the least amount of time and will help you avoid missing relevant facts.



Onset: How did it start? What happened? When did it first trouble you? Was it sudden or a complaint that gradually got worse?


Duration: Have you ever had it before? If so, when? Has it been continuous? Does it bother you all the time? How long has this attack been bothering you?


Specific location: Where does it hurt (or where is the problem)? Can you put your finger on where it hurts the most? Does it hurt anywhere else?


Quality of pain: What does it feel like? Sharp, stabbing pain? Dull ache? Throbbing pain? How severe is it? Mild, moderate, severe? (Some like to use a pain scale of 0 to 5 or 0 to 10, with 0 being no pain at all and the highest number representing the worst pain the patient can imagine.) Does it wake you up at night?


What aggravates: When is it worse? What seems to aggravate it? Is it worse after meals (at night, when you walk)?


What alleviates: What has helped in the past? Does that still help? What seems to help now? Does the time of day (amount of rest or change in position) make a difference?


Tact and caution are required when obtaining a history. Anxious patients may read too much into your questions. Information regarding such serious matters as cancer, surgery, or heart attacks is best elicited in a general way rather than through blunt questions. “Do you know why your doctor ordered this examination?” is less threatening than “Is your doctor checking for cancer?” Victims of accidents for which legal liability is in question may be reluctant to provide information that could increase their liability or jeopardize a legal settlement. Minors may be hesitant to reveal personal information in the presence of their parents. When information is difficult to obtain, it is usually wise for the physician to take the complete history.


At this point the process of taking a history may seem complex and confusing. This is a skill that improves with practice. Role-playing with other students, including a critical observer, will improve your ability to take a history with sensitivity and confidence. As clinical practice provides additional knowledge and experience, you will find that your observation and history-taking skills become increasingly accurate and pertinent.



Assessing Current Physical Status


Establishing a Baseline


You may be the first and primary observer of a significant change in the patient’s current condition. To accurately assess change, you must first establish a baseline for your observations.


Before you start the procedure it is important to review the requisition. Unfortunately the requisition may not have enough specific information, and this is a place where your skill in history taking will prove valuable. If you have access to a chart, read the diagnosis and the most recent progress notes. An order for the radiographic procedure should be there. Some notations have special significance. Allergies are usually noted in red on the outside of the chart as well as in the history. A patient with a history of allergies is more likely to have an adverse reaction to medications, especially when administered by injection.



Physical Evaluation


In the context of this chapter, evaluation is an ongoing process of observation, assessment, and measurement to note and evaluate changes in patient condition. How do you know when the condition of a patient is changing for the worse? What do you look for?


The most important process is sometimes called eyeballing the patient, a skill of acute observation that compares the actions and appearance of this patient with those of similar patients you have seen. You also use this skill to compare the appearance of this patient now with the way he or she appeared earlier. Although this may seem intuitive, you are actually responding to subtle changes in the overall appearance of the patient.


One of the easiest signs to recognize is a change in skin color. Individual complexions vary, but when pale skin becomes cyanotic or olive skin becomes pale and waxen, the change is usually quite apparent. The term cyanotic denotes a bluish coloration in the skin and indicates a lack of sufficient oxygen (O2) in the tissues. This is most easily seen on the mucous membranes, such as the lips or the lining of the mouth. Nail beds may also show a bluish tinge. For some patients with heart or lung conditions this may be a chronic or usual state, but the patient who becomes cyanotic needs oxygen and immediate medical attention. Any patient who looks pale and anxious and does not feel well is subject to fainting and needs to sit or lie down immediately. Do not leave the patient! A patient who loses consciousness and falls to the floor may suffer injuries far more serious than the cause of the fainting.


We have discussed the importance of touch as a form of communication and reassurance, but contact with your hands also allows you to make physical observations. The acutely ill patient in pain may be pale, cool, and diaphoretic (perspiring) in what is frequently called a cold sweat. Hot, dry skin may indicate a fever, whereas warm, moist skin may only be a response to the weather or the room temperature. Cool, moist skin may indicate acute anxiety. Wet palms and shaking hands are typical of the apprehensive individual who will need an unusual amount of reassurance. These patients may find it difficult to concentrate. They often need more frequent instructions during the procedure and should receive written directions for any required follow-up care.


If you note any of these signs, it is important to determine whether this is a new symptom. Has the patient just received any new medication? If so, notify your supervisor or the physician immediately. You may be observing the first signs of an impending allergic reaction.



Vital Signs


The next four procedures used for assessment are usually referred to as vital signs. They involve the measurement of temperature, pulse rate, respiratory rate, and blood pressure. The ability to take vital signs is a valuable clinical skill. Even if taking vital signs is not a part of your usual job description, you may need to assess them in an emergency. If you do not take vital signs routinely, keep your skills sharp by reviewing your technique frequently. When time allows, check your co-workers. We should all be aware of our own baseline vital signs, so your practice will benefit you, the person on whom you practice, and the patient who may need your skill in an emergency. Know the location of a blood pressure cuff and gauge (sphygmomanometer), a stethoscope, and other equipment that might be needed in an emergency. Even before you are proficient in their use, you may be asked to obtain them for a nurse or physician. Table 22-2 provides a reference to normal vital signs by age.



Mar 7, 2016 | Posted by in GENERAL RADIOLOGY | Comments Off on Assessing Patients and Managing Acute Situations
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