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MA114 Chapter 21 physcial examination
- 2. 2 Physical Examination 1. Describe the components of the patient’s medical history and how to collect the history information. 2. understanding and communicating with patients: • communicate with patients and display sensitivity to diverse populations. • Demonstrate therapeutic communication • Obtain and document patient information. • Respond to nonverbal communication • Compare open-ended and close-ended questions.
- 3. 3 Physical Examination 3. Do the following related to the patient interview: • Identify barriers to communication and their impact on the patient assessment. • Detect a patient’s use of defense mechanisms and the resultant barriers to therapeutic communication. • Demonstrate professional patient interviewing techniques. 4. Discuss the use of therapeutic communication techniques with patients across the life span. 5. Compare and contrast signs and symptoms.
- 4. 4 Physical Examination 6. the physical examination: • Outline the medical assistant’s role in preparing for the physical examination. • Summarize the instruments and equipment the provider typically uses during a physical examination. 7. Identify the principles of body mechanics and demonstrate proper body mechanics. 8. Outline the basic principles of gowning, positioning, and draping a patient for examination.
- 5. 5 10. Describe the methods of examination and give an example of each one. 11. Outline the sequence of a routine physical examination. Also, prepare for and assist in the physical examination of a patient, correctly completing each step of the procedure in the proper sequence.
- 6. 6 We must communicate effectively with patient and provide a warm, caring environment Medical care is extremely personal; remember that each patient is an individual with certain anxieties Understanding and Communicating with Patients
- 7. 7 Sensitivity to Diverse Patient Groups Respect the individuality of patient and attempt to see person’s health problem through his or her eyes Examine your own values, beliefs, and actions to develop empathetic sensitivity to others
- 8. 8 Patients of Asian backgrounds may have been raised in a culture that considers it extremely rude to establish eye contact Personal space may be an issue for patients from diverse backgrounds Older people face unique communications problems in the healthcare environment Patients may use religious beliefs and values to understand and cope with health problems Treating Diverse Patients
- 9. 9 To be sure patients understand what you explain, have them explain it back to you Therapeutic Techniques
- 10. 10 Restatement, reflection, and clarification Concentrate, understand, and listen Pay attention to nonverbal cues Active Listening Techniques
- 11. 11 Includes gestures, facial expressions, and mannerisms Be aware of the cues your body language sends to patient Get feedback from patient to ensure you are understood Observe patient’s nonverbal communication cues Nonverbal Communication
- 12. 12 Observation of Nonverbal Communication in Patients
- 15. Sensitivity to Diverse Patient Groups Diversity could be based on race, age, culture, religion, or physical qualities Practice respectful patient care Empathy: key to creating a caring, therapeutic environment Value systems begin as learned beliefs and behaviors Personal biases or prejudices are huge barriers to development of therapeutic relationships 15
- 17. 17 Lean toward the patient to show interest Face patient squarely and at eye level Eye contact is essential A closed posture (crossed arms or legs) may indicate disinterest Be sensitive to the patient’s personal space Be careful with body gestures such as hand and arm movements Tone of voice should reflect interest in patient Observe patient’s body language Nonverbal Language Behaviors
- 18. Understanding and Communicating with Patients To provide high-quality patient care, we must communicate effectively Healthcare professionals accept the responsibility of developing relationships with patients Be aware of self-boundaries Keep focus on the patient 18
- 19. 19 Ask for general information or to state topic to be discussed in general terms Used to begin interview or introduce a new section of questions Effective method of gathering details from patient Open-Ended Questions or Statements
- 20. 20 Ask for specific information Limits the answer to one or two words (usually yes or no) Use these when you need confirmation of specific facts Closed Questions
- 21. 21 First and most important part of data collection Three stages: Initiation or introduction Body Closing Interviewing the Patient
- 22. 22 Ensure privacy Prevent interruptions Prepare comfortable surroundings Take judicious notes Preparing the Appropriate Environment
- 23. 23 Providing unwarranted assurance Giving advice Using medical terminology Leading questions Talking too much Defense mechanisms Interview Barriers
- 24. Collecting the History Information Documentation should include: Purpose of patient’s visit, written as chief complaint (CC) Patient’s vital signs (VS) Height and weight Pain; documented using a scale of 1 to 10 24
- 25. Assessing Pain Where is the pain located? Is it associated with any particular movement? Can you describe how it feels? Is it constant or intermittent? Does anything relieve pain? When was the onset of the pain? Did something cause the pain to start? Are you taking any medication to relieve the pain? What is it and how often are you taking it? Is it effective? When was your last dose? Does pain affect your daily activities? On a scale of 1 to 10, with 10 being the highest level of pain, where would you rate your pain? 25
- 26. 26
- 27. Components of the Medical History Database Chief complaint (CC) History of present illness (HPI) Past history (PH) or past medical history (PMH) Usual childhood diseases Major illnesses Surgeries Allergies Accidents Immunization record 27
- 28. Therapeutic Techniques Feedback is crucial Message can be sent via: Face-to-face communication Telephone Email Letter Must become effective communicator Play vital role in collecting and documenting patient information 28
- 29. Active Listening Techniques Restatement Paraphrasing patient’s statements Reflection Repeating main idea of conversation while also identifying sender’s feelings Clarification Summarizes or simplifies the sender’s thoughts and feelings; resolves any confusion 29
- 30. Nonverbal Communication More than 90% of communication is nonverbal Nonverbal actions: Gestures Facial expressions Mannerisms Observe nonverbal communication to become aware of message being conveyed 30
- 31. Nonverbal Language Behaviors Lean toward patient to show interest Face patient squarely and at eye level Eye contact Be careful with body gestures Watch your tone of voice Continually observe patient’s body language Documenting in an EHR can be distracting 31
- 32. Open-Ended Questions or Statements Asks for general information or states topic to be discussed Effective method of gathering more details from patient about chief complaint or health history Used: To begin an interview To introduce a new section of questions Whenever person introduces a new topic 32
- 33. Closed Questions Direct, or closed, questions Limits the answers to one or two words Use closed questions when you need confirmation of specific facts 33
- 34. Interviewing the Patient Interview skills help to collect necessary information and build rapport with patient Consider the interview a type of contract between you and patient Three stages of patient interview: Initiation or introduction Body Closing 34
- 35. Preparing the Appropriate Environment Ensure privacy Prevent interruptions Prepare comfortable surroundings *****Take judicious notes 35
- 36. Therapeutic Communication Techniques Open-ended questions and statements Direct or closed questions Active listening Silence Establishing guidelines Acknowledgment Restating Reflecting Summarizing 36
- 37. Interview Barriers Providing unwarranted assurance Giving advice Using medical terminology Leading questions Talking too much Defense mechanisms 37
- 38. Defense Mechanisms Denial Suppression Reaction formation Projection Rationalization Undoing Regression Sublimation 38
- 39. Communication Across the Life Span Interact appropriately with the age and developmental level of patient Children Make sure environment is safe/attractive Don’t offer a choice unless they can truly make one Praise the child; reduce anxiety Older children Privacy Adults Patient education 39
- 40. Assessing the Patient Signs and symptoms Symptoms: Subjective findings Cardinal symptoms: symptoms of greatest significance Signs: Objective findings Can be observed or measured by provider or medical assistant 40
- 41. Documentation Guidelines Check name on record; confirm identity Month, day, and year must precede entry All unusual complaints, symptoms, or reactions must be noted in detail Describe objective data If patient reports pain, record quality and intensity of pain using a pain scale of 1-10 Document complete medication history Record details about previous history Learn to be observant 41
- 42. Physical Examination The medical assistant’s roles include: Preparing the examination room Assisting the patient Assisting the provider 42
- 43. Preparing the Examination Room Stock with all equipment and supplies Check expiration dates, and discard expired materials Ensure the room is private, well lit, and a good temperature Clean and disinfect room between patients to avoid infection Be sure drapes, sheets, and gowns are ready to use Arrange equipment for easy access Observe Standard Precautions 43
- 44. Assisting the Patient Ensure medical record is complete and consent forms are signed Introduce yourself and address patient by preferred name Verify accuracy of insurance information by office policy Obtain any preordered specimens Measure height, body mass index, and vital signs 44
- 45. Assisting the Provider Hand out equipment and supplies as needed Alter position of lamp and turn lights on/off as needed Position the drape during phases of the examination Collect and properly label all specimens Perform follow-up diagnostic procedures as needed 45
- 46. Supplies and Instruments Needed for Examination Gauze Antiseptic wipe Specimen collection system Lubricant Tape measure Clean nonsterile gloves Fecal occult blood testing supplies Percussion hammer Tuning forks ***you will be setting up for a physical exam 46
- 47. Supplies and Instruments Needed for Examination Ophthalmoscope For inspection of inner eye structures Tongue depressor Holds tongue down during throat examination Otoscope For examination of the external auditory canal and tympanic membrane 47
- 48. Principles of Body Mechanics Used consistently in work environment Proper alignment begins with good posture When reaching for object: Don’t twist or turn Turn feet toward object Don’t sit with legs crossed 48
- 49. Transferring a Patient Focus on correct body mechanics Provide support on the patient’s strong side Keep one hand under the axillary region and one on forearm Always bend at the knees Ensure the patient is safely positioned 49
- 50. Draping the Patient Drape the patient to protect privacy and keep the patient warm Position the sheet so that it allows complete visibility for examiner to conduct examination Expose one portion of body at a time during examination 50
- 51. Positioning the Patient Fowler position Semi-Fowler position Supine (horizontal recumbent) position Dorsal recumbent position Lithotomy position Sims position 51
- 52. Positioning the Patient Prone position Face down on ventral surface of the body Knee-chest position Difficult to maintain Rarely used in ambulatory care setting 52
- 53. Trendelenburg Position Rarely used in ambulatory setting Can be achieved only if examination table separates so that legs can be elevated higher than the head 53
- 54. Methods of Examination Inspection Palpation Percussion Auscultation Mensuration Manipulation ***very important to know 54
- 55. Examination Sequence General appearance Disorientation, gait, posture, nourishment Speech Could reveal pathologic condition Skin Note fingernails and toenails Head How patient handles stress and illness Eyes and ears PERRLA 55
- 56. Examination Sequence Nose and sinuses Mucosa examined for color/texture Mouth and throat Oral hygiene and dental care Neck Examined for range of motion (ROM) Chest Examine heart, chest, lungs Abdomen Relaxation of abdominal muscles Reflexes Checked in sitting, Fowler, and supine positions 56
- 57. Examination Sequence Breasts and testicles Examined visually and by palpation Testicular examination Rectum Maintain comfort and dignity Examination gloves and lubricating jelly needed 57
- 58. The Role of the Medical Assistant Aid provider in examination of patient by preparing patient and necessary equipment Ensure patient’s safety and comfort during examination 58
- 59. Patient Coaching Consider the following: What information the patient needs to know How to convey the information so that the patient understands it How the patient will use the information Whether any community resources are available that might help Whether the patient understands and will learn more about health problems or treatment protocols 59
- 60. Legal and Ethical Issues HIPAA applications Guard patient confidentiality during all parts of a visit If paper records are used, place medical records facing the door If EHRs are used, safeguard patient information by closing patient files and locking computers when you are out of the room Place physician’s schedule away from patient areas 60
- 61. Patient-Centered Care Effective communication includes used of all therapeutic tools Watch for nonverbal behaviors to verify congruence between what patient states and demonstrates via body language Modify communication methods as needed Use restatement, reflection, and clarification Use electronic communication appropriately and effectively 61
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