Patient-Focused Care

The most important facet of being a sonographer is seeing the patient as the primary focus of your efforts. Despite personal or philosophic concerns, you must be considerate of your patient’s age, cultural traditions, personal values, and lifestyle. Good patient care goes beyond procedural skills. It includes communicating with patients and allowing them to express their individual problems, fears, and frustrations. Good patient care also requires you to cooperate with other departments and facilities and health care professionals to deliver the best and most complete patient care through a team effort.

Patient-focused care (PFC) represents a national movement to recapture the respect and goodwill of the American public. It is the beginning of a larger objective to ensure that every patient receives the best possible medical care. The patient-focused approach encourages sonographers to relate to patients as people with needs, who are to be respected and cared for in a mature and dignified manner.

The Affordable Care Act

On March 23, 2010, the Affordable Care Act was signed into law as a way of putting consumers back in charge of their health coverage and care. The goal of the act was to crack down on some of the most egregious practices of the insurance industry while providing stability and flexibility to families and businesses. The Departments of Health and Human Services, Labor, and Treasury issued regulations to implement a new Patient’s Bill of Rights under the Affordable Care Act to help patients with pre-existing conditions gain coverage and keep it, to protect patients’ choice of doctors, and to end lifetime limits on the care consumers may receive. Other benefits of the Act are to strengthen review of insurance premiums; to get the most from premium dollars; to keep young adults covered; and to provide affordable coverage to consumers without insurance, because of pre-existing conditions. The new Patient’s Bill of Rights regulations now include the following stipulations:

More detailed information can be obtained by accessing http://www.healthcare.gov/.

Health Insurance Portability and Accountability Act (HIPAA)

The HIPAA Privacy Act was first signed into law in 1996 and created national standards to protect individuals’ medical records and other personal health information. In April 2001 the Department of Health and Human Services enacted the Health Insurance Portability and Accountability Act (HIPAA). The HIPAA Privacy Rule became effective April 14, 2003, marking the first comprehensive federal protection for the privacy of health information. Pursuant to this act, all segments of the health care industry (including sonography) are charged with promoting enhanced patient privacy in the health care system. The HIPAA Security Rule, which required full compliance by April 21, 2005, is a federal law, and anyone not in compliance can face up to $250,000 in fines and jail time of up to 10 years.

The Privacy Rule was created to achieve the following:

Sonographers must understand the privacy procedures of their practice or hospital to be able to provide patients with information and answers to questions about how their information can be used. Sonographers also are tasked with securing patient records containing individually identifiable health information so that they are not readily available to those who do not need them. Any communications necessary for quick, effective, high-quality health care are considered allowable communications. These include communicating verbally with pertinent physicians and family members and using patient names to locate them in waiting areas. In compliance with HIPAA, sonographers must be careful to do the following:

Patients may request that students, other observers, medical personnel, and families leave the room during the sonography examination. If any patients elect to have friends or family members present during their examination, inform them of the hospital rules and any policies that govern such requests. Some sonographers say they feel uncomfortable having “outsiders” looking on while they are scanning, even though no regulations may prohibit their presence. If this situation arises, give a truthful explanation to the patient if inadequate space exists for viewing or if the presence of observers hinders your concentration and abilities. Explain that you need time alone with the patient to prepare for the examination and to take a series of scans for evaluation purposes. This may ease the situation. In return for such cooperation, you could offer to call the observers into the examination room for their own “viewing.” By following these suggestions, you can control the discovery of unexpected pathologic findings without causing anxiety to patients or their support group.

Another patient right involves the expectation of pleasant physical and emotional surroundings that ensure the person’s comfort, safety, and respect as an individual.

Emotional Surroundings

An ultrasound facility should offer a climate in which the patient is treated as an individual. Staff members should introduce themselves to patients and explain what they will be doing for them. Patients should be oriented to any procedures such as filling out admission or consent forms. Patient privacy should be respected at all times, particularly during dressing and undressing, during performance of ultrasound scans, and during use of bathroom facilities. If patients require assistance at any of these times, the sonographer should provide it in a mature and completely professional manner.

Comforting patients is at least 80% nonverbal and involves giving the patient undivided attention, using facial expressions, eye contact, gestures, and voice intonations that convey empathy.

A sonographer should allow patients to freely express their thoughts, opinions, or beliefs. Be a good listener and do not impose beliefs on the patient. In the event that the examination performed reveals serious illness or the threat of imminent death, patients may want to engage in spiritual practices or rituals. Show respect for their wishes and provide assistance or privacy as indicated.

Denial

Although shock may be the first reaction to injury or chronic illness, denial is common. Refusing to accept the diagnosis right away gives patients a chance to “regroup” and gather the strength to confront what they have to face. Very similar to denial is confusion; even though a physician tries to explain a patient’s illness, it is hard to retain it all. Some patients avoid thinking of their illness until it must be faced by having imaging studies, lab work, or treatments.

Anger

Anger toward others may be expressed verbally or physically and may manifest as crying and blaming. Once patients realize that anger is not doing them any good, they usually make the choice to accept their diagnosis and get to work at getting better.

Anxiety and Fear

Feelings of apprehension may cause patients to be unwilling to adjust to their new situation. They may cry, fear being alone, or act suspicious, hostile, or withdrawn. Anxiety also can produce physical changes such as a rapid pulse, increased blood pressure and respiration, headaches, nervousness, excessive perspiration, or rapid speech. Some patients fantasize about the worst outcome and become depressed.

Frustration and Helplessness

The longer it takes to diagnose and treat an illness, the more frustrated the patient can become. In American society, men are especially vulnerable to feelings of loss of control and independence because strength may be an extremely important part of their self-image.

Grief

Grieving is the process of adjusting to the reality of a loss. Whether it is a loss of health or the loss of a pregnancy, patients are flooded with emotions. Shock, denial, anger, bargaining, guilt, and depression are common feelings that grieving patients must work through before they are able to accept their losses.

Guilt

Patients who feel that they are unable to perform their accustomed roles in life (such as mother or breadwinner) usually respond with anger (“Why me?”) or view their loss as a punishment. Particularly in the area of loss resulting from pregnancy interruption, a woman tends to examine critically every aspect of her life to discover where she was at fault. The response to guilt can take many forms: withdrawal, blame, fault finding, or physical complaints.

Depression

Feelings of helplessness, sadness, or lack of vitality are characteristic of the depressed person. Severely depressed patients often complain of insomnia, early morning fatigue, loss of appetite, and numerous physical complaints.

Dependency

Some patients are highly demanding, whereas others show their dependency by an inability to follow directions or by attempting tasks beyond their capabilities.

Suspicion

Feelings of mistrust may overcome some patients, making them fearful and feeling that everyone and everything is against them. Often, the one-on-one environment of the sonography laboratory encourages patients to talk about their feelings. Patients who finally reach the stage of acceptance understand that they have a right to be emotional but that that behavior ultimately robs them of taking control through knowledge, problem solving, and cooperating with their health care team. Emotional relapses may occur, but they will learn to recognize and move past them.

Although sonographers are not responsible for evaluating and treating patients’ emotional reactions, they should share observations and concerns with the referring physician or charge nurse. By all means, try to be a good listener. If a patient responds negatively to being scanned and becomes upset, do not also get upset. Instead, try to be patient, understanding, and secure enough to let patients know you care.

Helping Patients Understand How to Cope with Their Illness

When dealing with illness—especially chronic illness—patients find strength they never thought they had. Acceptance of their condition is essential, along with finding ways to feel more in control. Sonographers can play a part in helping their patients take control by discussing how knowledge can help them understand what is being done to them, make better decisions, and be proactive. Working with the health care team by being cooperative ultimately will help them find answers. Learning how and when to relinquish some control can only speed the quest for answers and recovery. Sonographers who spend extended time with such patients can gauge the level of their concern. They have the opportunity to discuss how patients may gain hope and understanding through support networks, through sharing concerns and fears, and through learning to ask for and accept help.

Pulse

The pulse is the beat of the heart that can be felt as a vibration within the walls of the arteries. With each heartbeat, blood forced into the arteries causes them to swell or expand, producing arterial pulses that can be felt with the fingers. The most convenient site for taking the pulse is the radial artery, located on the thumb side of the wrist. However, other arteries close to the skin also provide pulse sites (e.g., temporal, carotid, mandibular, femoral, and popliteal).

Pulse rate refers to the number of beats per minute (bpm), whereas rhythm refers to the time interval between beats. The sonographer should evaluate whether the pulse has a smooth and regular rhythm as opposed to irregular rhythms with skipped beats. The strength of a pulse refers to its force and usually is described as either bounding or weak and thready. Substances such as coffee, tea, tobacco, or certain drugs can cause rhythm irregularities. Shock and hemorrhage can cause a weak, thready pulse, whereas fever can produce a bounding pulse. The normal adult pulse rate is 60 to 65 beats per minute (bpm). Newborn infants have a pulse rate of 120 to 140 bpm, and women, children, and elderly patients usually have a slightly faster than normal pulse rate (Table 5-1). Athletes in good condition generally have a slower pulse: below 60 bpm.

Any variation of the normal rhythm of the heart is termed arrhythmia and includes premature beats or palpitations. Such irregularities may simply be a normal physical response or a sign of disease. Abnormally rapid pulse rates (> 100 bpm) are termed tachycardia. Abnormally slow pulse rates (< 60 bpm) are termed bradycardia. Exercise, strong emotions, fever, pain, and shock can elevate the pulse. In contrast, resting, depression, and certain drugs (such as digitalis) can lower the pulse.

The pulse is felt by gently compressing the artery over a bony prominence in the area. Never feel the pulse with the thumb, because the thumb has a pulse of its own that interferes with obtaining an accurate reading of the patient’s pulse. An arterial pulse should be obtained as follows (Figure 5-1):

Respiration

The oxygen and carbon dioxide exchange that occurs in the lungs is referred to as respiration. The respiratory process begins with the delivery of oxygen to body cells via blood that has passed through the lungs. The cells give off accumulated carbon dioxide to the blood, which returns it to the lungs. There the potentially dangerous carbon dioxide wastes are exhaled out of the body in the act of breathing.

Breathing can be defined as the expansion (inspiration) and contraction (expiration) of the lungs. Normal breathing is quiet, effortless, and regular in rhythm; it occurs at a rate of 16 to 20 breaths per minute in the normal adult.

Note the rate, rhythm, and the depth and character of the respiration. The rate refers to the number of respirations per minute. Rhythm refers to the regular rate of breathing and a symmetric movement of the chest. Depth refers to the amount of air taken in with each respiration (normal, shallow, or deep). Character refers to the quality of respiration (e.g., quiet, labored, wheezing, and coughing).

Any injuries to the lungs, chest muscles, or diaphragm affect breathing. Note any positions the patient may need to assume to breathe easily (e.g., sitting up or standing as opposed to lying down). Also note any difficulty in breathing (dyspnea) or changes in the patient’s color (cyanosis or pallor).

Count respiration without the patient being aware of this task. Watch the patient’s breathing and count a breathing sequence (in and out) as one respiration. Start the count at zero and continue counting respirations for at least 30 seconds. Multiply the number by 2 to produce the respirations per minute. If irregularities are observed (rate, rhythm, patient appearance, or behavior), count the respirations for 1 full minute and report the findings.

Blood Pressure

Blood pressure is the pressure that circulating blood exerts against arterial walls. It is produced by the pumping action of the heart. The pressure of blood within the arteries is highest whenever the heart contracts (called systolic pressure). Between beats, when the heart rests, arterial pressure is at its lowest (called diastolic pressure).

Heart activity can be heard as “thumping” sounds in the large arteries of the limbs. These sounds can be translated into numbers representing millimeters of mercury (mm Hg) on a manometer. When taking a blood pressure reading, the sonographer listens with a stethoscope and watches the numbers on a manometer.

The optimal adult blood pressure is less than 120/80 (120 indicating systolic pressure; 80 indicating diastolic pressure). High blood pressure, or hypertension, is known as “the silent killer,” because most individuals have no symptoms. It causes wear and tear of the delicate inner lining of the blood vessels. Heredity and aging are the greatest risk factors. The risk begins to increase from pressures of 115/70 mm Hg and doubles for each 10 mm Hg increase in the systolic reading and 5 mm Hg increase in the diastolic reading. Although variations exist even in normal patients, the average values for arterial pressure are as follows:

Even if only one reading (either the systolic or the diastolic reading) is in the high range, it signifies high blood pressure. Strong emotions, pain, exercise, and some disease conditions are factors that can increase blood pressure. Resting, depression, hemorrhage, and shock are factors that can lower blood pressure. Blood pressure readings also can vary from minute to minute and day to day because of changes in a patient’s physical, mental, or emotional activity.

The volume of blood in the body and any resistance to the flow of blood through blood vessels also affect blood pressure. For example, hemorrhaging decreases blood volume, causing the blood pressure to fall. In contrast, fatty deposits develop within the blood vessels of patients with arteriosclerosis, causing resistance to blood flow and producing higher blood pressure readings.

The site for taking blood pressures is usually over a large artery in the arm or leg. The brachial artery of the upper arm is selected often, but arteries of the lower arm, thigh, and calf also may be used, depending on the accessibility of the limb and the patient’s condition.

When the arm is used, the patient should either sit or lie down on his or her back, with the arm and blood pressure cuff at the level of the heart.

A wide variety of blood pressure monitors are available: mercury/aneroid, digital, and multipurpose vital sign monitors. The most familiar of these is the sphygmomanometer (either mercury or aneroid), used with a cuff and a stethoscope (Figure 5-2). Mercury manometers, which provide the most accurate measurements, show increments of 10 points, from 0 to 300. Aneroid manometers show units of 20, ranging from 20 to 300. Raising the silver column of mercury or the aneroid needle to 200 begins the procedure. A properly calibrated manometer will show the needle and mercury column at the zero mark on the mercury manometer (20 on the aneroid manometer) when not in use.

The cuff contains an inflatable rubber bladder; center this over the brachial artery, 1 inch above the elbow (Figure 5-3). Wrap the cuff snugly but not tightly. If the cuff is too loose, systolic and diastolic readings will be heard higher than their actual values.

A stethoscope with a flat diaphragm is best for taking blood pressure. After using your fingers to locate the brachial artery in the shallow depression where the elbow bends, place the diaphragm of the stethoscope over the artery without touching the cuff or the patient’s clothing (Figure 5-4). Use gentle application, because too much pressure can cause abnormally low diastolic sounds.

Patients with Tubes or Tubing

IV infusion tubing, nasogastric suction, urinary catheters, and nasal catheters and cannulae for oxygen administration are the most common types of tubing a sonographer will encounter when working with hospital patients. Although you may not be responsible for starting any of the procedures associated with such equipment, knowing how to handle and care for patients who have such tubes in place is important. If the patient has tubings or drains, you should take special care to avoid pulling them out or disconnecting them.

Intravenous Equipment

IV tubing connected to a plastic bag or bottle is used to infuse fluids into the patient’s body. A needle or plastic catheter attached to the container is inserted into a vein. The flow of fluid is measured by a drip meter, and a clamp on the tubing is used to regulate the flow of the prescribed fluid (Figure 5-6).

Some institutions may use computerized infusion pumps to regulate drip rate. This device delivers a measured amount of fluid over a period of time. An alarm sounds if a problem occurs, such as drops falling at an improper rate, the bag emptying, infiltration within the patient’s tissues, or patient’s arm position obstructing flow.

Unless specifically authorized, you should not change or regulate the amount of flow of a solution, although you may have to move some patients to and from the scanning table or bed or remove their clothing. The following guidelines should help in working with such patients:

Nasogastric Tubes

Hospital patients commonly have a tube inserted into one nostril. Depending on the length of the tube, it may terminate in the patient’s stomach or intestine. Such tubes can be used for feeding, to obtain specimens, to treat intestinal obstructions, to prevent or treat distention after surgery, or to drain fluids from the patient’s stomach by suction (Figure 5-7).

When a nasogastric (NG) tube is being used to drain substances out of the stomach or to collect a specimen, the patient is given nothing by mouth (NPO), because food would only be drawn back out through the tube. In caring for patients with NG tubes, never pull on the tube when moving these patients or changing their positions. If the patient begins to gag or vomit while the tube is in place, report it immediately.

Fluids can be removed from the patient’s body through the tubes by gravity or suction. The outer end of the tube may have a clamp attached, or a plastic connection may link it to longer tubing attached to an electrical suction machine. Suction (by use of either a syringe or a machine) often is used to remove thick secretions that cannot be drawn out easily by gravity.

Here are some rules for working with patients connected to mechanical suction machines:

Oxygen Therapy

Oxygen may be administered to any patient experiencing respiratory difficulty (oxygen deficiency). The goal of such therapy is to lessen a low-oxygen concentration in the blood and to decrease the workload of the respiratory system.

The use of oxygen is associated with some hazards. Oxygen should be considered a drug and its dosage or concentration should be evaluated and ordered by a physician. Although oxygen by itself cannot burn, contact with any combustible material (even a spark) causes it to ignite and burn or, in high concentrations, to explode.

Delivery systems for oxygen therapy include in-room piping systems and oxygen tanks, or cylinders. If a laboratory is equipped with an in-room piping system, oxygen and suction usually are provided through wall outlets. Outlet connectors, which vary in shape, color, and connection methods used, are keyed to a specific gas or function (Figure 5-8).

Oxygen also may be contained in large tanks or small cylinders. Large cylinders usually are used for patients requiring high flow rates or oxygen use over extended periods. These can be identified by size and the presence of a metal cap screwed onto the top of the cylinder to protect the valve from damage. Small cylinders can be identified by their size and a rectangular valve (without a handle), which has three holes on one side. Small cylinders are used during patient transportation or for short duration needs. Some ambulatory patients need continuous oxygen and may use over-the-shoulder slings or rolling stands to hold the tank when ambulating.

Because the gas contained within a cylinder is under extremely high pressure, sonographers should never do the following when gas cylinders are in use:

The delivery of oxygen to the patient may involve the use of either high- or low-flow devices. Among the low-flow devices are the nasal cannula or nasal prongs, nasal catheter, or simple oxygen masks. The nasal cannula is used when a patient needs extra oxygen rather than a total supply of oxygen (Figure 5-9, A). The prongs are inserted into the patient’s nostrils and held in place by an elastic band around the patient’s head. They are connected to the oxygen source by a length of plastic tubing.

A nasal catheter is a piece of tubing that is longer than a cannula. It is inserted through the nostril into the back of the patient’s mouth. This method provides more effective oxygen delivery and is used when the patient must have additional oxygen at all times. The nasal catheter is fastened to the patient’s forehead or cheek by a piece of adhesive tape to hold it steady.

Several different types of oxygen masks may be used. Among the most common types of masks are the following:

All oxygen masks, except the Venturi mask, require humidification, which is generally achieved by means of a humidifier (usually disposable) filled with water. The humidifier is connected to a threaded outlet at the bottom of the flowmeter or regulator. A small universal connector extends from the front or top of the humidifier for connection to the oxygen device. The following precautions should be observed in working with patients receiving oxygen therapy:

Catheters

The most common kind of catheter used for removing fluids from the body is the urinary catheter. The catheter (made of plastic tubing) is inserted through the patient’s urethra and into the bladder (Figure 5-10). Catheters may be used to obtain sterile specimens when patients are unable to urinate naturally or to determine how much residual urine remains in a patient’s bladder after urination.

A retention, or indwelling, catheter is a system used to provide temporary or permanent drainage of urine. A Foley catheter commonly is used. Foley catheters are specially designed as two tubes, one inside the other. The inner of the two tubes is connected at one end to a small balloon. After the catheter has been inserted, the balloon is filled with water or air so that the catheter will not pass out through the patient’s urethra. Urine drains from the bladder through the outer tube and collects in a container attached to the patient’s bed or table. Clamping or unclamping the tubing can control the flow of urine. Importantly, the catheter bag must always be positioned at a level lower than the patient’s urinary bladder. Catheterization is a sterile technique, and the catheter drainage system should consist of a closed sterile system. As with other patient tubing, the catheter should be taped to the patient (inner thigh in this case) at all times and should be checked periodically for kinking and to ensure that the patient is not lying on the tubing and obstructing the flow of urine out of the body.

Another use of the urinary catheter involves patients scheduled for obstetric or gynecologic sonography. Some of these patients are unable to fill the bladder naturally or maintain a full bladder for the duration of the examination. As a result, they must be catheterized to instill fluid into the bladder, with the tubing clamped off until the end of the sonography study. Bladder filling is not required for transvaginal examinations.

Because of the short length of the female urethra, the risk of urinary tract infection is increased with catheterization. For this reason, it is unwise to use catheterization as a routine method of filling the bladder of patients scheduled for pelvic sonography, unless a clinical indication exists to do so. Only trained and authorized personnel should perform any catheterization procedure.

Wound Drains

After surgery, a patient may have a drain or wick placed within a wound to allow for drainage. Wound drains are plastic tubes that provide a way for fluid, blood, or air to drain out of the body and aid the healing process. One end of a wound drain is placed within the wound and the other may be connected to a suction collection device. The fluid may be collected in a drainage bag, plastic bulb, or onto a dressing. Wound drains are evaluated daily and emptied as needed. The drain remains until the surgeon decides that it is safe for the drain to be removed. Sonographers must anticipate and avoid the possibility of pulling or dislodging such drains during patient positioning or transfer.

Colostomies and Ileostomies

Surgical treatment of patients with disorders of the intestinal tract may result in the construction of a colostomy (an opening into the colon) or an ileostomy (an opening into the ileum). In such patients, a loop of intestine is brought out of the body through a surgical incision on the abdominal wall; the opening allows drainage of feces. The colostomy or ileostomy opening (stoma) is covered by plastic disposable bags or pouches held in place by double-faced adhesive tape or special glue. These appliances may require frequent changing because of the constant flow of liquid feces that is especially prevalent during the immediate postoperative period.

When performing abdominal sonography on such patients, have a small supply of appliances on hand. It may be necessary to remove and later replace the devices to gain unobstructed access to the surface of the abdominal wall. Follow these procedures:

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