Assessing the patient:
- A comprehensive history is given to all new patients (who will receive ongoing care from the provider or primary care physician) and nonemergency patients. This kind of examination includes information about the patient’s life from multiple areas, including history of present illness, past medical history, family and social history, and chief complaint.
- A focused history is administered in emergency situations or when the patient is undergoing care of the clinician and presents with a specific complaint. A focused health history is specific to the system involved in the patient’s problem.
- There are many barriers that affect interpersonal communication. One barrier is cultural differences. It is the responsibility of the healthcare provider to be sensitive to patients who may have different cultural beliefs. Healthcare providers should avoid ethnocentrism, or believing that one’s own culture is better than anyone else’s. Another barrier to interpersonal communication is hostility. Hostility can impede communication by causing one or both participants to shut down.
The Examination:
The physical exam has certain procedures that meet a requirement and should be done in order.
- Inspection
- Palpation
- Percussion
- Auscultation
Pregnant Patients:
o The exam sequence is the same as for adults.
o These patients require a more inclusive assessment of the abdomen and pelvis.
o The preferred patient position is side-lying. Use the supine position only when necessary.
o The patient should void her bladder prior to examination.
Neonatal patients:
o Assessment techniques may vary related to age, wakefulness, and/or illness.
o Inspecting without disturbing the baby is the key.
o Assessment sequence for newborns should be head/fontanels, extremities, abdomen, and the rest of the body.
o Save invasive procedures for last.
Pediatric patients:
o Consider developmental stages while performing the assessment.
o The sequence of assessment is often altered to best suit the circumstances (e.g., sleeping vs. awake patient, cooperative vs. uncooperative child).
o Establish comfort before beginning the exam.
Geriatric patients:
o The assessment sequence is the same as for young adults.
o It is important to assist geriatric patients as needed throughout the exam. They may have difficulty with certain positions, limited sensory capabilities, and longer reaction times.
o It is key to remain patient to ensure accuracy of the exam.
o A functional assessment is needed.
Documentation:
Healthcare providers need to be able to document quickly. Some ways to help with this are:
- Use drawings, either drawn by the provider or as part of a preprinted form.
- Use abbreviations, but only standard abbreviations.
- Establish a routine.
- If using an electronic health record system:
- Learn to type.
- Learn keyboard commands and shortcuts.
SOAP includes subjective data, objective data, assessment, and plan. Subjective information refers to data that the patient presents, while objective data is information that is concluded through diagnostic tests and other assessment techniques. Assessment refers to the final evaluation, and the plan outlines treatment options.
Children:
Take a few minutes to establish a relaxed environment. Give a 1-year-old an object to hold in his hands. With a toddler, use a gentle pat, pleasing words, or interactive play. Allow children to touch the equipment used during the examination.
Family History:
The five broad categories usually explored in a patient’s family history are:
- cancer,
- diabetes,
- cerebrovascular accidents,
- myocardial infarctions,
- genetic defects
Cultural Competency – An interview with a Muslim man:
Q: Your background is of which culture?
A: I am Middle-Eastern, of Muslim faith.
Q: Is there something specific you practice for births?
A: We practice adhan (prayer) five times per day so that is the first thing our baby hears. We believe in a woman practitioner throughout the practitioner, but the father is present during the birth. Circumcision and breastfeeding are encouraged.
Q: Do you have special practices for weddings?
A: Oh yes, there are so many ceremonies throughout the period of engagement, wedding day rituals, and post-wedding rituals. Most marriages are arranged, and oftentimes, we do not meet each other until the engagement ceremonies.
Q: If someone is ill in your culture/religion, is there something special you do to cure the illness?
A: We view illness as an affliction of faith and it is very important for us to continue to pray during a hospital stay or home care. Certain medications are also prohibited during specific holidays, so when prescribing it is important to take those into consideration.
Q: Does your culture/religion have any beliefs regarding death?
A: Yes. When someone dies, they should be buried as quickly as possible. The body is turned to face the holy center of Islam. We almost never have an open casket. The body is covered and bathed in white cotton. Family typically stays with the family of the deceased for a week or longer.
Thank you for agreeing to allow me to interview you; I appreciate your time.
Nutrition:
To calculate BMI, convert the weight from pounds to kilograms. Divide this number by the individuals height in meters squared. A 24 hour dietary intake includes all food and beverages the individuals puts in their mouth. The practitioner then reviews the information to determine if the meals are balanced and if the individual is receiving an adequate amount of nutrients.
Three measures used to assess body composition and what they assess are mid-arm muscle circumference measures the distance around the biceps and other muscles of the arm, triceps skinfold measures with width of a fold of skin taken over the triceps muscle, bioelectrical impedance analysis/bioimpedance spectroscopy estimates body composition and body fat, BMI is a measure of weight and height.
