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RA 101 Midterm
History Taking
| Term | Definition |
|---|---|
| What are HAIs? | Healthcare Acquired Infection |
| Healthcare Acquired Infection are also known as: | Nosocomial Infections |
| Common Infections are: | MRSA, Influenza (Flu), Clostridium difficile (C.Diff) |
| Influenza (Flu) Transmission: | - Respiratory virus - Through droplet contact - Affects the nose, throat, bronchi, lungs - The portal of entry - through the nose or mouth |
| What is the chain of infection? | - infectious agent - reservoir -portal of exit - means of transmission - portal of entry - susceptible host |
| Patient Assessment: | any deviation from or interruption of the normal structure or function of any part, organ, or system of the body |
| Infection: | establishment and growth of a microorganism on or in a host, resulting in injury to the host Cause of infection Caused by pathogenic organisms |
| Types of Pathogens: | - Bacteria - Viruses - Fungi - Parasitic protozoa |
| Bacteria: | prokaryotic, ubiquitous single-celled organisms |
| Patient Assessment: | the radiographer collects pertinent data about the patient and the procedure |
| The radiographer’s Role: | collect a focused history - one that is related to the procedure |
| Qualities necessary for an open dialogue: | respectful, genuine, empathetic |
| Questioning Techniques: | - Open-ended - Facilitation - Silence - Probing questions - Repetition - Summarizati |
| Chief Complaint: | the single most important reason for the x-ray exam |
| Clinical History: | information about the patient’s condition; includes the “Sacred Seven” |
| Sacred Seven: | - Localization - Chronology - Quality - Severity - Onset - Aggravating or alleviating factors - Associated Manifestations |
| Localization: | - Helps to determining precise location of the patient’s complaint - Usually through gentle palpation or careful wording of questions - Ask patient to identify the area of pain/abnormality |
| Chronology: | - The time element of the history - Duration since onset, frequency, course of the symptoms - Described in seconds, minutes, hours, days, weeks, months, etc. |
| Quality: | Describes the character of the symptoms: - Color and consistency of body fluids/excretions - The presence of clots or sores - Size of lumps - Type of cough - Description of pain (sharp, dull, throbbing, radiating, cutting, crushing, pressure, etc.) |
| Severity: | - Describes the intensity, quantity, or extent of the symptom. - Intensity of the pain; the number of lumps, the size of the bruise; the extent of the burn. - Slight burning sensation vs. very intense burning sensation |
| Onset: | - Involves the patient explaining what he/she was doing when the illness/condition began - What the patient was doing at the time symptoms began |
| Aggravating and Alleviating Factors: | - Things that make the symptoms worse - Things that make the symptoms better |
| Associated Manifestations: | Other symptoms that accompany the main complaint |
| Symptoms can be objective: | can be seen, observed, heard and felt by radiographer or other medical staff, but not the patient |
| Symptoms can be subjective: | the patient’s own perception |
| The use of leading questions should be avoided whenever possible because: | they introduce biases into the history |
| A useful tool is to repeat information obtained as a part of the history for 2 reasons: | - to verify that the radiologic technologist has perceived the information correctly - to ensure that the patient has not changed his or her mind. |
| Open-ended questions (nondirected, nonleading): | lets the patient tell the story |
| Facilitation (nod or say yes, okay, go on ...): | encourages elaboration |
| Silence (to give the patient time to remember): | facilitates accuracy and elaboration |
| Probing questions (to focus the interview): | lets the patient provide more detail |
| Repetition (rewording): | clarifies information |
| Summarization (condensing): | verifies accuracy |
| Two types of touch that the technologist commonly uses in gathering a clinical history are: | - touching for emphasis: involves using touch to highlight or specify instructions or specify locations - touching for palpation: applying the fingers with light pressure to localize pain within that region |
Created by:
nycems
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