Comprehensive Patient Care and Communication Skills in Healthcare

Q: How should a healthcare professional engage in patient care?

A: Introduce yourself, identify the patient, explain care, obtain consent, protect privacy, show respect, and provide safe, compassionate care.

Q: What are important communication skills during a patient interview?

A: Active listening, open-ended questions, empathy, eye contact, clear language, and avoiding interruptions.

Q: What is an open-ended question?

A: A question that allows the patient to give a detailed answer, such as "Tell me about your breathing."

Q: What is a closed-ended question?

A: A question that usually requires a short or specific answer, such as "Are you having chest pain?"

Q: What is active listening?

A: Paying close attention to the patient and showing that you understand what they are saying.

Q: Why is empathy important in patient care?

A: It shows the patient that you understand and care about their feelings and concerns.

Q: How can healthcare professionals communicate effectively with an interdisciplinary team?

A: Communicate clearly, share important information, listen to others, document accurately, and ask questions when needed.

Q: What does SBAR stand for?

A: Situation, Background, Assessment, Recommendation.

Q: Why is SBAR useful?

A: It provides a clear and organized way to communicate patient information.

Q: Why should you review the medical record?

A: To understand the patient's condition, history, medications, treatments, and important safety concerns.

Q: Why is gathering a complete medical history important?

A: It helps identify the patient's health problems, risks, medications, and possible causes of their symptoms.

Q: What is the chief complaint?

A: The main reason the patient is seeking care.

Q: What is the history of present illness (HPI)?

A: Details about the patient's current illness or symptoms.

Q: What should you ask about when assessing a symptom?

A: Onset, location, duration, characteristics, severity, timing, what makes it better or worse, and associated symptoms.

Q: What should be included in a medication history?

A: Prescription medications, over-the-counter medications, and supplements.

Q: Why are allergies important to document?

A: To prevent harmful reactions to medications or other substances.

Q: What is included in social history?

A: Tobacco, alcohol, drugs, occupation, lifestyle, and living situation.

Q: What is a cough?

A: A protective reflex that clears the airways.

Q: What are common causes of cough?

A: Infection, asthma, COPD, allergies, smoking, GERD, and some medications.

Q: What is sputum?

A: Mucus or phlegm produced in the lower respiratory tract and coughed up.

Q: What should you assess about sputum?

A: Amount, color, consistency, odor, and presence of blood.

Q: What is hemoptysis?

A: Coughing up blood from the respiratory tract.

Q: What are common causes of hemoptysis?

A: Bronchitis, pneumonia, tuberculosis, pulmonary embolism, bronchiectasis, and lung cancer.

Q: What is dyspnea?

A: Difficult or uncomfortable breathing, also called shortness of breath.

Q: What are common causes of dyspnea?

A: Asthma, COPD, pneumonia, pulmonary embolism, heart failure, and anxiety.

Q: What is orthopnea?

A: Difficulty breathing when lying flat.

Q: What is paroxysmal nocturnal dyspnea (PND)?

A: Shortness of breath that suddenly wakes a person from sleep.

Q: What are common causes of chest pain?

A: Heart problems, lung problems, muscle problems, and gastrointestinal problems.

Q: What should you assess when a patient has chest pain?

A: Location, onset, duration, quality, severity, radiation, triggers, relief, and associated symptoms.

Q: What are the 4 classic vital signs?

A: Temperature, pulse, respiratory rate, and blood pressure.

Q: Why are vital signs important?

A: They provide information about a patient's basic body functions and can show changes in their condition.

Q: What is a normal adult heart rate?

A: 60-100 beats per minute.

Q: What is tachycardia?

A: A heart rate above 100 beats per minute in an adult.

Q: What is bradycardia?

A: A heart rate below 60 beats per minute in an adult.

Q: What can cause tachycardia?

A: Exercise, fever, pain, anxiety, dehydration, hypoxemia, and some medications.

Q: What can cause bradycardia?

A: Sleep, athletic conditioning, medications, or heart conduction problems.

Q: What is a normal adult respiratory rate?

A: About 12-20 breaths per minute.

Q: What is tachypnea?

A: Abnormally fast breathing.

Q: What is bradypnea?

A: Abnormally slow breathing.

Q: What is apnea?

A: Absence of breathing.

Q: What is dyspnea?

A: Difficult or uncomfortable breathing.

Q: What is a normal adult temperature?

A: Approximately 36-38°C (96.8-100.4°F), depending on the measurement site.

Q: What is fever?

A: An elevated body temperature, commonly caused by infection or inflammation.

Q: What is hypothermia?

A: An abnormally low body temperature.

Q: What does blood pressure measure?

A: The force of blood against the walls of the arteries.

Q: What is systolic blood pressure?

A: The pressure when the heart contracts.

Q: What is diastolic blood pressure?

A: The pressure when the heart relaxes.

Q: What is hypertension?

A: Abnormally high blood pressure.

Q: What is hypotension?

A: Abnormally low blood pressure.

Q: What bedside findings should you observe besides vital signs?

A: Level of consciousness, skin color, work of breathing, mental status, edema, breath sounds, and overall appearance.

Q: What does increased work of breathing mean?

A: The patient is working harder than normal to breathe.

Q: What are signs of increased work of breathing?

A: Rapid breathing, accessory muscle use, nasal flaring, retractions, and difficulty speaking.

Q: What is cyanosis?

A: A bluish discoloration of the skin or mucous membranes.

Q: What is edema?

A: Swelling caused by excess fluid in the tissues.

Q: What is hypoxemia?

A: Low oxygen levels in the blood.

Q: What is hypoxia?

A: Inadequate oxygen available to the body's tissues.

Q: How do you measure respiratory rate?

A: Observe the patient's breathing and count the number of breaths per minute.

Q: What should you assess when measuring respirations?

A: Rate, rhythm, depth, and effort.

Q: How do you measure blood pressure accurately?

A: Use the correct cuff size, position the patient and arm properly, and use the appropriate measurement technique.

Q: Why is the correct blood pressure cuff size important?

A: An incorrect cuff size can give an inaccurate blood pressure reading.

Q: What should you document when taking vital signs?

A: The measurement, time, and any relevant conditions or measurement site.

Action Plan:

A specific plan for what will be done to treat or manage a patient's problem.

Advance Directive:

A legal document that explains a person's wishes for medical care if they cannot speak for themselves.

Closed-loop Communication:

Communication where the receiver repeats or confirms the message to make sure it was understood correctly.

Culturally Competent Communication:

Communicating in a way that respects a patient's culture, beliefs, values, and language.

DNR/DNAR:

Do Not Resuscitate/Do Not Attempt Resuscitation; an order stating that CPR should not be performed if the patient's heart or breathing stops.

Electronic Medical Records (EMR):

A patient's medical information stored electronically.

Intimate Space:

The closest personal space, usually reserved for close relationships or physical care.

Nonverbal Communication:

Communicating without words, such as through facial expressions, gestures, posture, and eye contact.

Objective Data:

Information that can be seen, measured, or observed by a healthcare professional.

Pack-years:

A way to measure smoking history. Packs per day × years smoked.

Patient-centered Care:

Care that focuses on the patient's needs, preferences, values, and goals.

Personal Space:

The physical space a person prefers to have around themselves.

Pertinent Negatives:

Important symptoms or findings that the patient does not have.

Pertinent Positives:

Important symptoms or findings that the patient does have.

Protected Health Information (PHI):

Private health information that can identify a patient.

Return Demonstration:

When a patient or student performs a skill to show they understand how to do it.

SBAR:

A communication tool meaning Situation, Background, Assessment, Recommendation.

Sign:

An objective finding that can be observed or measured by someone else.

Subjective Data:

Information reported by the patient, such as pain, nausea, or feeling short of breath.

Social Space:

The space used when interacting with coworkers, acquaintances, or people you do not know closely.

Speak Up Initiatives:

Programs that encourage healthcare workers and patients to speak up about safety concerns.

Standard Precautions:

Basic infection-control practices used with all patients, such as hand hygiene and appropriate PPE.

Symptoms:

Problems or changes that are felt and reported by the patient, such as pain, nausea, or dizziness.

Teach-Back Method:

Asking the patient to explain or demonstrate what they were taught to make sure they understand.

Territoriality:

A person's sense of ownership or control over a particular space or area.

Angina:

Chest pain caused by reduced blood flow to the heart muscle.

Bradycardia:

A heart rate below 60 beats/minute in an adult.

Bradypnea:

Abnormally slow breathing.

Bronchorrhea:

Excessive production of watery mucus from the airways.

Daytime Somnolence:

Excessive sleepiness during the day.

Diaphoresis:

Abnormally heavy sweating.

Diastolic BP:

The pressure in the arteries when the heart relaxes between beats.

Dyspnea:

Difficult or uncomfortable breathing; shortness of breath.

Edema:

Swelling caused by excess fluid in the body's tissues.

Fetid:

Having a very unpleasant or foul smell.

Fever:

An abnormally elevated body temperature.

Gastroesophageal Reflux Disease (GERD):

A condition where stomach acid frequently flows back into the esophagus.

Hematemesis:

Vomiting blood from the gastrointestinal tract.

Hemoptysis:

Coughing up blood from the respiratory tract.