Chapter 4 Case Study: Communications and Documentation PDF

CHAPTER 4 Case Study Communications and Documentation Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com. Part 1 Copyright © 2021 by Jones & Bartlett...

CHAPTER 4 Case Study Communications and Documentation Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com. Part 1 Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com. Your BLS unit is dispatched to a home for an older woman who has fallen. You arrive on scene and are greeted by a hospice worker who found the patient in the bathtub. As you enter the bathroom, the 86-year-old patient is sitting in the bathtub without water; her back is resting on the faucet. She is pale and cold to the touch and complains of having hip and back pain and of being very cold. Part 1 Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com. She said she had gotten up around 3 AM to use the restroom, tripped, and fell into the bathtub. She worked herself into the current sitting position and couldn’t move after that. She rates her back pain an “8” and her hip pain a “10” of a scale of 1 to 10. Part 1 Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com. 1. What are the primary reasons that a prearrival radio report is given to the receiving hospital? 2. Why is it important to document in a narrative format rather than just completing check boxes on a prehospital care report? Part 2 Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com. Many different forms of communication must be employed when working in the field. Your responsibility as the “sender” of information must take into consideration that many of those who receive information may have difficulty understanding your instructions and/or requests. The woman you are caring for has been able to understand directions to rate her pain. Part 2 Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com. 3. What are some therapeutic communication techniques that you can use when interacting with a patient? 4. What can you do to minimize the potential for miscommunication? Part 3 Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com. You provide the following report to the hospital: “Columbus Fire, Columbus Community Hospital. We are en route to your facility with an 86-year-old woman who fell into her bathtub at 3 this morning, where she remained until 10 this morning. Patient is conscious and alert and complains of being severely cold and of having hip pain and mid-back pain where she was leaning back on the faucet in the bathtub.” Part 3 Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com. “The patient is alert and oriented; her skin is pale and cold to the touch. We noted crepitus in the pelvic girdle. Her blood pressure is 112 over 84, pulse is 72, and respirations 14. We have immobilized her with a c-collar on the gurney. She still has pulse, motor, and sensory function distally in all four extremities. She has a history of diabetes. Our ETA is 10 minutes. Do you have any questions or orders for us?” Part 3 Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com. 5. What questions do you anticipate emergency department personnel to ask? 6. With the patient’s history of diabetes, what else might play a role in your care? How does this disease affect the patient’s perception of pain? Part 4 Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com. Although the patient is in extreme pain, you carefully explain all the procedures you perform during her care, which helps lower her anxiety. You also offer reassurance, knowing that her anxiety is to be expected. You make direct eye contact when addressing her claustrophobia about being immobilized and her expressed fear of falling off the gurney. Part 4 Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com. When you are not performing medical procedures, you take the time to hold her hand, let her know how far away you are from the hospital, and explain to her what to expect from the doctors and nurses when you arrive. She tells you that she cannot stand the collar and asks you how long she needs to have it on and lie supine. You are unsure. Part 4 Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com. 7. How should you answer her? 8. Is it ever justifiable to misinform a patient to reduce the patient’s anxiety temporarily? Summary Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com. You feel that you aided in this patient’s care by addressing her pain and fears during the call. Ignoring or failing to validate a patient’s feelings can have a negative impact on the overall success of your care. Understanding how pain and fear can cloud a patient’s thinking can help you know when to adjust your tone of voice for reassurance, to slow down your speaking, and to simplify your sentences to communicate effectively. Summary Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com. Do not lie to patients or fabricate answers to their questions when you honestly do not know the answer. Remember patient trust is essential!