Unit 5: Clinical Skills and Management in Primary Health Care PDF

Okay, here is the converted text from the image into a structured markdown format. # UNIT 5: CLINICAL SKILLS AND MANAGEMENT IN PRIMARY HEALTH CARE * History taking: observation and interviewing * Physical Examination * Nutritional assessment: measurement of weight, height, upper arm circumfe...

Okay, here is the converted text from the image into a structured markdown format. # UNIT 5: CLINICAL SKILLS AND MANAGEMENT IN PRIMARY HEALTH CARE * History taking: observation and interviewing * Physical Examination * Nutritional assessment: measurement of weight, height, upper arm circumference strip, Socio-economic assessment * Diagnostic technique and skills * Recording and Reporting # CLINICAL SKILLS AND MANAGEMENT IN PRIMARY HEALTH CARE ## 5.0 Introduction Brief overview of clinical skills and management Primary healthcare is frequently the first point of contact for patients seeking medical care, so healthcare practitioners working in this setting need to have the clinical expertise needed to evaluate, diagnose and treat patients. Clinical skills and management in PHC are important in rendering effective, efficient, and high-quality treatment to patients. Clinical skills entail a broad range of activities including physical examinations, laboratory testing, medical procedures and the use of diagnostic technologies. It may also involve the ability to diagnose, manage, and treat both acute and chronic illnesses, give preventative care, offer counselling and health education, and carry out simple operations like wound care and immunization. They must also have management abilities to make sure the clinic runs smoothly and effectively. The ability to manage patient flow, plan appointments, handle patient records, manage drugs and supplies, and make sure the clinic complies with all regulatory requirements are all examples of management skill in primary healthcare. ### Importance of clinical skills and management in PHC * Early diagnosis and treatment: mean identifying a health condition and initiating treatment soon as possible which enhances wholistic, high-quality care. Healthcare providers with well-equipped skills can accurately assess, diagnosis, treatment and manage a patient in a timely manner. This will prevent a health condition from progressing and becoming worse, which can improve patient health outcome, reduce cost, increase satisfaction and ensure preventive measures. * Improved patient outcome: patient outcomes are the measurable results of interventions and treatments (improved health status). The skills enable them identify health issues early leading to instituting appropriate management and treatment as well as providing patient centred care. * Establishment of rapport and trust with patients: Health care providers with proper skills will listen and understand their patients. This will enhance patient's comfort and reassure the patient. * Reduced health care cost: Early diagnosis and treatment prevents cases from being worse. The less serious, the less cost. * Empowerment of patients: Clinically competent health care workers can give patients the information and tools they need to make wise decisions about their health and wellbeing and to effectively manage their diseases thus enabling them to take charge of their own health. * Patient satisfaction: When patient are treated early and the treatment is effective, they fell satisfied with the course of action and outcome. * Management of patient flow: Health care providers equipped with the necessary skills communicate effectively, ensures supplies and equipment are easy to find, improve the registration process as well as improve the hospital layout. These in-turn will reduce waiting time and optimize patient flow. ## 5.1 HISTORY TAKING: OBSERVATION AND INTERVIEWING ### Objectives By the completion of this topic, the student should be able to: * Demonstrate the ability to obtain a complete health history * Incorporate the different techniques of history taking * Document accurately the findings ### Introduction A major component of nursing care in PHC is the assessment of a client's health status. It covers two aspect - i) nursing health history and ii) – physical examination. ### 5.1 HISTORY TAKING: One of the most important clinical skills in primary healthcare is obtaining a patient's history. It entails asking the patient for a thorough medical history, including details about their present symptoms, past health, family history, medications, allergies, and social history. Health history is obtained through an interview between a nurse, the patient and significant others (where necessary). **Definition:** According to Hinkle and Cheever (2014), history taking is the collection of subjective data that provides an overview of the patient's current health status. ### Purpose of history taking: * To find out more about presenting symptoms and identify problems. * To establish rapport and foster therapeutic relationship with the patient * To direct necessary examination and investigations * To serve as a baseline data * To establish diagnoses ### Importance of history taking Gathering of information about patient's health: They enable health care provider to learn more about the patient's health, identify relevant risk factors, and discover underlying illnesses that might be causing some of the patient's symptoms. This information is essential for accurate diagnosis and treatment planning. Establishment of rapport and fostering of trust: By paying attention to their worries and taking the time to learn about their medical histories, healthcare providers can show empathy and build a deep therapeutic bond with patients. History-taking abilities are important for efficient communication and teamwork with other members of the healthcare team. Accurate and thorough documentation of the patient's history is crucial in order to guarantee continuity of treatment and to effectively share relevant information with other healthcare professionals who may be involved in the patient's care. Providing high-quality, patient-centred care: This is achieved by providing care that respects, responds to individual patient's preferences, needs and values. ### Types of health history There are a number of different types of health histories which may be collected from a patient: * A comprehensive health history. This collects detailed information about a patient and is usually completed on admission to a health care facility and during a general health check-up. * A rapid or focused health history. This collects specific information about a clear health-related issue with which a patient present. The information gathered is used to inform the immediate care of the patient. ### Components of the History Taking When a patient's first visit to the health facility and is seen by a health care team member, obtaining the baseline data is the first requirement. The nurse focuses on obtaining the following data: | S/N | Component | Data to collect | | --- | ------------------- | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | 1 | Biographical Data | Name, gender, date of birth.Address, contact telephone number.Details of contact person / next of kin.Patient's religion, ethnicity, occupation, marital status, educational status etc | | 2 | Chief Complaints | The patient's chief complaint or presenting problem.Should be recorded in the patient's own words.Record all of patient's complaints if it exceeds one.Suspend interview and provide care, if a patient's problem is urgent (e.g. pain, dyspnoea, injury, etc.), the interview should | | 3 | Present health history | It can be obtained by assessing the patient's symptoms. | Acronym `OLD CARTS` can be used to promote remembering. | | | | | :---- | :------------ | :------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ | | | O = onset | When did the symptoms start?Did they develop suddenly or gradually?Where was the patient / what was the patient doing when the symptoms started? | | | L =location | Are the symptoms located in a specific area?Is this area specific or generalised?Does the symptom radiate to another location? | | | D = duration | What is the duration of symptoms?Do they change over time?Are they persistent? If yes, does the severity fluctuate? (Describe).Are they irregular? If yes, how often do they occur, and what happens in between episodes? | | | C= Characteristics | What does the symptom look like - itching, tingling, colour, texture, composition, etc. | | | A= aggravating/alleviating factors | What makes the symptoms worse?What makes the symptoms better?(E.g. physical factors-activity, position, etc., psychological factors-anxiety, etc., environmental factors, etc.). | | | R= related symptoms | Is it associated with other symptoms (e.g. pain, nausea, fever, etc). | | | T=Treatment | Other treatments tried?How effective were these treatments? | | | S= severity | How severe is the symptom?Rate the symptom on a scale of 0 to 10.Does the symptom interrupt the person's activities of daily living? | | 4 | Present health status | Any pre-existing health conditions.Any current medications (prescription, over-the-counter).The patient's allergies. | | 5 | Past health history | Significant childhood illnesses.Previous hospitalisations for surgery, accidents, illnesses, etc.Any blood transfusionImmunisation status.Most recent physical examinations, and findings.Obstetric history, if relevant (gravidity, parity, etc.). | | 6 | Family history | Diseases and cause of death of biological relatives - parents, grandparents, aunts / uncles, siblings and children.Genetic conditions known to be present in the family. | | 7 | Review of systems | Includes abnormalities or concerns in each of the body systems.Questions should also be asked about any general or systematic symptoms they experience (e.g. fatigue, etc.).Instead of relying on memory, a checklist can be made and used. | | 8 | Patient profile | It is more biographical data and includes:Past event related to health: birth place, places lived, significant experiences while growing up,Edu/Occupation: past/current jobs, job satisfactionFinance: income, insuranceEnvironment: Physical- the environment in which the patient lives / works / learns, interpersonal-: The patient's important family / social relationshipsLifestyle patterns: sleep, exercise, nutrition, recreation, smoking, alcohol, drugsPhysical/mental disability: any disability, its effectSelf-concept: body image, view of selfSexuality: sexual functioning, sexual relationship, perception of self as a man or womanRisk for abuse: abusive relationshipStress and coping mechanism: daily hassles, coping patterns | | 8 | Recording and reporting | | ### Concept of Observation and Interview in History Taking #### 5.1a OBSERVATION According to Oxford dictionary, 'to observe' is 'to notice or perceive (something) and register it as being significant'. Observation is an essential part of history-taking in primary healthcare. It entails paying close attention to the patient's appearance, communication, and cognitive functions in order to obtain details that may be important to their past medical history and present health. Observation is the conscious and deliberate use of the five senses to gather data. Observation is a general term that refers to the careful use of one's senses to gain information. It is a skill that takes time and experience to perfect. ### Things to observe: Much can be learned by observing the patient. Observe the following: **Appearance** * Age - Does the patient appear to be his stated age, or does he look older or younger? * Physical condition: Does he look healthy? Is the weight appropriate for the height, underweight or overweight? Note the gait or any obvious limitations, such as an amputation, spinal cord injury, difficulty walking etc. Facial expression, hand movement, body language evidence of pain. * Dress: Is he/she dressed appropriately for the season? Note whether it is soiled or torn. Personal Hygiene: Is he clean and well groomed, or unshaven and unkempt, with dirty skin, hair or nails? Does he have a strong body odour or unusual breath odour? Can you smell alcohol, urine, or faeces? * Skin: Look for obvious scars, rashes, discolouration, bruising, swellings etc. Document any abnormalities. such as an unusually pale complexion, cyanosis, or jaundice. **Communication** * Speech: Document whether he speaks clearly in English or another language and note anything un usual doesn't respond when spoken to, speech is slurred, hoarse, loud, soft, incoherent, slow, fast. Indicate if he has trouble completing sentences because of shortness of breath or pain. * Hearing: If hearing is impaired, note whether he hears better through one or the other and whether he wears a hearing aid. If he's deaf, assess whether he reads lip or uses sign language. * Vision: Can he see well enough to read instructions in English or another language? Document whether he needs glasses to see or read, if he's blind, or if he can't read because he's illiterate. **Cognitive functions** * Awareness: Is he oriented and aware of his surroundings, or disoriented and unaware of time, place, and person? * Mood: Does he respond to questions appropriately? Is he talkative, or does he offer information only in response to questions? Does he seem hesitant, avoid eye contact, or look to a family member before answering? Does he seem angry? Thought processes: Note whether he can maintain a conversation. Does he make relevant statements and follow commands appropriately, or does his mind wander? Are their signs of mental disability like depression, eating disorders, obsessive-compulsive disorder etc. ### Importance of Observation The ability to observe is crucial for a number of reasons: * They can offer important hints about the patient's health status that might not be immediately obvious through other methods of assessment, such obtaining a history or performing a physical exam. For instance, a patient's skin tone or breathing pattern can reveal vital details about their cardiovascular health or oxygenation status. * It can help medical professional identify potential safety issues or environmental factors that might be causing the patient's symptoms. A patient's living arrangements, for instance, may reveal dangers like mould or clutter that could be aggravating their respiratory symptoms * It can enable health care workers to identify nonverbal clues. A patient's anxiety, depression, or pain, for instance, may be discernible from their body language or facial expression. * Observational skills demands careful attention to detail with the capacity to analyse and synthesize data from various sources, are necessary for effective observation skills. Healthcare providers in primary care can gain a more thorough understanding of the patient's health status and deliver more focused, efficient care by including observation into their history-taking process. #### 5.1b INTERVIEW It is an important concept in history taking. It entails asking the patient a series of questions in order to learn more about the patient's medical background, present symptoms, and other details that might be important to their health status. The nurse obtains a nursing history by interviewing the patient. An Interview is a planned communication with a purpose. In simple words, it is a conversation where somebody is trying to get information from another person. The person asking the question is the interviewer while the person answering is the interviewee. In this context, the nurse is the interviewer while the patient is the interviewee. * It focuses on: i) establishing rapport/ a trusting relationship to collect correct and useful information and ii) collecting information on client's health status to identify deviations. #### Types of interview questions There are different kinds of interview questions which can be grouped as open-ended or closed and leading or neutral. **Open-ended questions** These are questions that give the patient the option of giving more information. They are questions that cannot be answered with a simple 'yes' or 'no', rather require the patient to clarify or elaborate their feelings or thoughts. They allow for details and allow client to open up about their experiences. In responding to the questions, clients talk in sentences and may even tell stories. They provide opportunity for the nurse to probe further. patient the option of giving more information than just a yes or no response. Starts with words like "Tell me about" or "Can you describe". **Example:** "Can you describe the symptoms you are feeling, for instance? "Tell me about when you first started smoking" **Closed-ended questions** These are posed in a way that the answer come with a single word response (usually yes or no) That is direct questions asked when one wants exact information. Closed-ended questions can be helpful for quickly gathering precise information. The client can respond with one or two words. Does not provide ability to elaborate on the answer. Example: 'Is it 2 pm'?; when did the pain start?; Do you smoke?; Have you ever had surgery before? **Probing questions** Probing questions are means to get the patient to elaborate on their response or provide more details. Can you give me more details? and similar phrases are common openings for probing questions. or "Could you elaborate on that?" Example: Can you give me more details about when your symptoms first began? **Leading questions** Leading question is a type of closed-ended question where the asker is seeking a specific answer from the respondent, and it is often stated in a way as to confirm information. LQ is one that tends to suggest its own answer as well as directs the client's answer. The phrasing of the question assumes a fact that is yet to be established. Examples: "is it true that she was holding the knife in her hands? ‘Was she actually standing two kilometres away from you? Were you the one that was smoking? Effective interviewing techniques require nurses to use a combination of these question types depending on the circumstance and the information required. Nurses can obtain a more thorough understanding of the patient's health status and deliver more focused, efficient care by employing the right interviewing techniques. #### Phases of interview The nurse plans an interview before beginning it (paper, pen, data collection form or interview guide). There are typically several stages to an interview process which includes: introductory, working and summary/closing phases. **Introductory Phase:** * Introduce self to client, explain purpose of the interview and establishing rapport. * Keep client comfortable, assure client of confidentiality and provide privacy. **Working phase:** * Collect biographic data, reasons for seeking care and data on health status. * Listen attentively using all senses and observe cues * Use language the client understands and validate points not understood. * Questions should follow in a logical sequence. * Both client and nurse collaborate to identify client's problem * Show respect, concern, interest and acceptance. **Summary and closing phase** * Summarize information collected during the working phase. * Validate problems with patient * Discuss possible plan to resolve the problem. * Accurately document the information. A thorough interview allows the health care provider to collect the data required to create a personalized care plan that takes into account each patient's unique needs and concerns. Effective communication, active listening, and empathy are necessary interviewing skills. Nurses must be able to probe for more information, ask open-ended questions, and respond to the patient's emotional and physical needs with compassion. ## 5.2 PHYSICAL EXAMINATION Physical examination skills are yet another important facet of primary healthcare. These abilities entail a methodical and comprehensive examination of the patient's body to determine their physical state, spot any anomalies, and confirm or rule out a diagnosis. Healthcare practitioners in primary care need to be skilled in a number of essential physical examination techniques. They consist of: #### Importance * PES enable medical professionals to evaluate the patient's general health and spot any possible underlying issues that might need additional investigation. * Precise diagnosis and treatment planning: Healthcare practitioners can create a more individualized treatment plan that addresses the patient's unique needs and concerns by evaluating the patient's physical symptoms and sign. * Physical examination skills are crucial establishing trust and therapeutic relationship. During the physical examination, medical personnel can make patients feel more at ease and comfortable by showing empathy and compassion. Healthcare practitioners in primary healthcare must be skilled in a variety of physical examination techniques. They include: * **Inspection:** This entails purposeful and systematic observation of the patient's body from head to toe. * **Palpation:** entails a hands-on-assessment of the patient's body to locate any painful or abnormal areas. * **Percussion:** It involves tapping the body to elicit sounds and determine whether the sounds are appropriate for the underlying organs or tissues or area. The sound can tell one if the organ is: a) air filled (lungs), b) fluid filled (bladder and stomach), c) dense (liver). * **Auscultation:** involves using a stethoscope to listen to the patient's body sounds, such as heart and lung sounds. High pitched sounds like lungs, bowel and some heart sounds can be heard as well as Low - pitched sounds (some heart sounds etc). ## 5.3 NUTRITIONAL ASSESSMENT ### Objectives By the completion of this topic, the student should be able to: * Define and correctly use the key terms * Enumerate reasons for nutritional measurements. * Describe the different types of nutritional measurements for community level. ### Introduction Nutrition is the process of assessing an individual's nutritional status to determine if they are meeting up their nutritional requirements. Assessing nutritional state is important for early detection of deviation and prompt treatment. #### 5.3.1 Definition * Nutritional assessment is an in-depth evaluation of both objective and subjective data related to an individual's food and nutrient intake, lifestyle and medical history (Encyclopaedia,) * It can also be defined as the process of collecting and interpretating anthropometric, biomedical, clinical, dietary and economic (ABCDE) data to determine whether a person or groups of people are well nourished or malnourished (Ahmad, 2019). * Community Nutritional Assessment is an evaluation of the community in terms of its health and nutritional status, its needs and resources available to address those needs. #### 5.3.2 Purpose * To identify at risk individuals or groups for early intervention or referral before they become malnourished * To identify malnourished clients for treatment- malnourished people who are not treated early have longer hospital stays, slower recovery from infection and complications, and higher morbidity and mortality * Define nutritional status of community members. * To evaluate the effectiveness of nutritional intervention program. * To determine the patterns of growth and development * To detect practices that can increase the risk of malnutrition and infection #### 5.3.3 Factors/conditions that can prompt Nutritional Assessment * Disease conditions: this can lead to increased energy requirements, reduced energy intake or increased nutritional losses that may affect a person's nutritional status thus prompt NA. Examples are: cancer, burns, depression, G.I.T disorders -liver disease, malabsorption syndrome etc. * Age related changes: The aged may have reduced appetite, altered nutritional needs and poor dentition which may lead to malnutrition. * Polypharmacy: can interfere with nutrient absorption and use by the body leading to deficiencies * Weight problem: weight loss or gain that is unintentional may indicate an underlying problem hence call for NA. * Pregnancy and lactation: During these state, additional nutrients are required to ensure fetal growth and milk production. NA will ensure that they are meeting their nutritional need in certain conditions. * Unhealthy lifestyles: such alcoholism or excessive smoking may affect a person's nutritional status which may prompt NA. * Eating Disorders: Individuals with eating disorders such as anorexia or bulimia may require NA to determine their nutritional needs and monitor their progress. * Depression or chronic stress: it can affect appetite and nutrient absorption, leading to nutrient deficiencies. #### 5.3.4 Materials * Growth chart * Shakir strip or measuring tape * Weighing scale * Calipers * Infantometer/Stadiometer with weighing scale #### 5.3.5 Methods of Nutritional Assessment It can be done using these methods: **A. Anthropometry** Anthropometry is a method of nutritional assessment that assesses the body build and nutritional status of individuals (mostly children) using measurements such as weight, height, mid upper arm circumference (MUAC) and head circumference (for children less than 2 years) and skinfold thickness. They can determine an individual's growth. * **MUAC** * MUAC is taken for children less than five years and pregnant women using Shakir's tape. * Locate midpoint between acromial process of scapula (the bony projection on posterior of upper shoulder) and olecranon process of the elbow (bony point of elbow). * Place the Shakir tape or tape measure around upper arm at previously marked midpoint: Tighten (do not pinch) and note measurement in millimetres. **Normal Range** Children * 1-5 years = 12.5 – 18.5cm * 6-12 years= 17-22 cm * MUAC: < 12.5cm - malnutrition Adult: * males: >25-36cm, * females: >23-33cm (WHO 2011) **Shakir's Strip** * It is named after the man who first described it. * It is made of 3 colours: red- danger (below 12.5 cm), orange or yellow- (between 12.5cm & 13.5cm) and green (above 13.5cm) * **Head Circumference (HC) or Occipital - frontal circumference (OFC)** * It is the measurement of the head along the forehead anteriorly and the prominent area on the back part of the head posteriorly. * It measures the distance from above the eyebrows and ears and around the back of the head. It is measured to the nearest centimetre. * Wrap the flexible, non-stretchable measuring tape around the child's head at the largest part and read the tape. * HC is useful in assessing chronic nutritional problems in children under two years age. * Also, assesses brain growth as the brain grows faster during the first two years of life. But after two years the growth of the brain is more sluggish and HC is not useful. * HC is also measured at birth for all new-born babies. * Normal reading: At birth - 33cm - 36cm (± 1cm) * **Weight** The weight of a child or an adult can be weighed using a weighing scale. BMI is commonly used as tool for assessing weight status for adults aged 18 and above. * **Height** Height can be measured with the person standing erect on the stadiometer or Supine for infants using infantometer | Average heights for age | | weight | | :---------------------- | :-: | :----------- | | Birth | | 45-50 cm | | 1 mth | - | 50-60 cm | | 6mths | - | 65-70 cm | | 1yr | - | 75-82 cm | | 2yrs | - | 85-94 cm | | 5yrs | - | 105-120 cm | (WHO, 2006) * **Skinfold thickness** * Commonly used to assess malnutrition in children * Common sites are mid-triceps, subscapular skinfold, mid-thigh, mid-calf etc. * Calipers are used * The site is located and the mid-point identified * The skinfold is grasped by the thumb and index finger of the left hand and pulled away from the body about 1cm. * The caliper is then applied and the reading is taken. * Normal values: The normal varies based on age, sex, site * Children 6-11 years - 1.3 mm for boys, 1.2 mm for girls * Mid-triceps - women = 11.7, men = 8.7mm. (range=6-8mm) * Mid-thigh-women = 12.1mm men 15.7mm (range=10-15 mm) * **Body mass index (BMI)** * BMI is a n indicator for assessing weight of an individual in kilogramme/ the height in meter squared. $BMI = \frac{Weight (kg)}{Height^2(m)}$ * Normal = 18.5 - 24.9kg/m² * Less than 18.5 - underweight * More than 25kg/m² - overweight * \> 30kg/m² - obesity **B. Biochemical** Biochemical assessment means checking levels of nutrients in a person's blood, urine, or stools. * Blood: Haemoglobin estimation, PCV, Red cell count * Urine: albumin, sugar, blood * Stool: ova and * Intestinal parasites **C. Clinical Assessment** * It makes use of signs and symptoms that are known to be associated with nutritional deficiencies or excesses eg brittle nails. * General clinical examination with special attention to bilateral pitting oedema, emaciation (a sign of wasting, which is loss of muscle and fat tissue as a result of low energy intake and/or nutrient loss from infection), hair loss, and changes in hair colour. * It also includes taking a medical history to identify other existing diseases well as checking for or asking clients about symptoms of infection that can increase nutrient needs (e.g. fever) and nutrient loss (e.g. diarrhoea and vomiting), as well as medical conditions (e.g., HIV, celiac disease) that impair digestion and nutrient absorption and increase the risk of developing malnutrition. **D. Dietary** * Assessing food and fluid intake is an essential part of nutrition assessment. * Information about dietary quantity and quality, changes in appetite, food allergies and intolerance, and reasons for inadequate food intake during or after illness are provided. * The results are compared with recommended intake such as recommended dietary allowance (RDA) to detect normal or abnormal values. * Clients are counselled on how to improve their diets to prevent malnutrition or treat conditions affected by food intake and nutritional status (e.g., cardiovascular disease, cancer, obesity, diabetes, and hyperlipidaemia). Common ways to assess dietary intake are 24-hour recall, food frequency questionnaire and food group questionnaire. **E. Socio-economic assessment** It involves assessing social and economic factors that influence an individual's access to food, their food choices and dietary patterns. Socio-economic factors like income, culture, employment, budget, family size and social supports have impact on people's nutrition. It should also include details about the educational level, living conditions and kind of job Food availability, food insecurity (lack of access), and preparation. Once the assessment is complete, the information is compared to establish the nutritional status. In Nutritional assessment aids in assessing prevalence of nutritional disorders, planning corrective measures as well as evaluating the effectiveness of the implemented strategies. ## 5.4 COUNSELING SKILL Counseling is use of an interactive helping process focusing on the needs, problems or feelings of the patient to enhance coping and problem-solving or it refers to the process of providing the client with information and support to allow her make a decision regarding her health needs. Counselling skills/techniques refers to the ways and methods used by health care providers help individuals address their concerns and needs. They are important for PHC nurses as they enable them provide emotional support and guidance to patients. It requires nurses to be non-judgemental, empathic, active in listening and communication. ### Skills and Techniques: **Listening/attending:** Health care professionals must listen attentively and respond appropriately. They should give patient their undivided attention. It entails eye contact, body language, facial expression, nodding and tone of voice. **Empathy:** they must show understanding and compassion by putting themselves in their patient's shoes. **Communication:** use clear and simple language to explain information and treatment options. They should communicate effectively. **Non-judgement attitude:** Create a non-judgemental atmosphere to enhance the patient share their fears and concerns. **Questioning:** it is a technique of learning from the patient specific information and concerns. The different types of questions can be used. **Reflection/Paraphrasing:** it is restating what the patient said. It is an effective way of ensuring both of you understand each other. **Summarising:** it involves summarising what the patient said to validate what they are saying. ### Importance/roles of counselling skills * Identification of psychological and social factors: They make available safe and supportive environment for patient to discuss their concerns, emotions and experiences, allow for exploration and discovering as well as help to build trust and rapport which may make the patient to be more willing to discuss sensitive information that can help to identify these factors that may be impacting the patient's health. * Behavioural change: Active listening, empathy and non-judgemental attitude promote collaborative and supportive environment which empowers the patient to make a change. Barriers to change can also be identified, explored and then strategies can be instituted to overcame them. * Education and information: The skills can help providers educate patients on risks associated with certain lifestyles and the advantages of making positive changes. * Providing emotional support: counselling skills enable the nurse to show care and compassion. This can help the person to cope with their emotions and experiences and show them that they are not alone. * Patient Satisfaction: Effective counselling can lead to patient satisfaction with the care rendered to them. * Communication: it provides a safe and supportive environment for persons to express their concerns which can improve communication between the counsellor and counselee. ### Challenges that can arise when implementing counselling skills /techniques * Inadequate training and education: HC professionals may not have received sufficient training in these skills and this may lead to lack of confidence and competence. * Nurses should receive adequate training and education in CS. * Language barriers: patients who do not understand English may have problem communicating with the PHC nurse making it difficult for the nurse to implement. * In this situation, nurses should make available interpreters. * Improper time management: Due to nurses' busy schedule, they often have limited time to properly implement these skills. * They should manage their time effectively by prioritizing patients needs and allocating enough time for counselling. * Resistance to change: patients may not be ready to address their concerns making it challenging to counsel. * Get patient involved. ### Steps in Counselling The GATHER approach can be used – Greet, Ask, Tell, Help, Explain/Examine and Return visit. ## 5.5 DIAGNOSTIC TECHNIQUES and SKILLS Often times, further investigation n need to be carried out after the initial screening to arrive at a conclusive diagnosis. It is at this point that more diagnostic techniques are ordered and performed. The clinician can only prescribe an appropriate treatment plan when the diagnosis is made. Diagnostic techniques refers to a set of procedures, tests and tools that are used to identify and determine the cause of a particular problem or condition. Test like imaging, blood pressure, temperature test, etc are examples. They are used to diagnose conditions in patients that present symptoms or asymptomatic patients with a positive screening test. * They help the medical officer come up with a final diagnosis by limiting the possible options. * Many techniques are specialized for a particular disease or group of related diseases. * The technique is the method while the skill is the expertise. ### Purpose of Diagnostic technique The main purpose of diagnostic techniques is to gather information about or condition, and use that information to make informed decisions about the appropriate course of action. The general objectives are: * General screening * To diagnose a condition * To monitor the effect of treatment * To determine the stage of the disease or the severity * Rule out certain conditions ### Importance * Accurate Diagnosis: Diagnostic techniques allows for accurate identification of the cause of a condition. This is significant because proper treatment cannot be provided without accurate diagnosis. * Better Decision Making: They make available useful information that can be used to make decisions that are informed. This enables the nurse to arrive at the best solution leading to saving of resources. * Early detection: Screening test allows for early detection by catching signs of developing diseases early. * Improved Patient Outcomes: Accurate diagnosis leads to better patient outcomes because the right treatment plans will be created and this will enhance the patient wellbeing. ### Nursing responsibilities * Collecting patient data: Nurses are in charge of gathering patient data, including medical history and present symptoms, which can assist medical professionals in identifying potential health issues and scheduling the proper diagnostic tests. * Patient preparation: Nurses may be in charge of getting patients ready for diagnostic tests, which includes giving the patient instructions on how to get ready, explaining the procedure and possible outcome, relieving patient's anxiety by answering any questions they may have, verifying that informed consent has been obtained, giving pre-medication and care. They may also collect and send the specimen as the case may be. * Providing patient education: Nurses may be responsible for providing patient education related to the diagnostic tests, such as explaining why and how important it is for the test to be carried out, how the procedure will be, the potential risks and benefits, and what to expect during and after the test. * Assisting with the test and monitoring of the patient: such as obtaining blood samples, positioning patients for imaging tests, administering point-of-care tests, aadministering medication when needed, assessing physical condition and keeping an eye on any monitor if used. * Ensuring patient safety: Nurses are responsible for ensuring patient safety during diagnostic tests, such as monitoring vital signs, ensuring patient comfort, and addressing any adverse reactions and complications that may arise. * Documenting and reporting: In some cases