Patient care

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Chapter 4 Patient care

Sarah Fearn

CHAPTER CONTENTS

Introduction 41
Assessing the patient 42
Paediatrics 42
The elderly patient 46
Mental health problems 49
The trauma or emergency patient 50

KEY POINTS

image Every patient is individual; no two persons react in the same way to a given situation.
image Prescriptive guidance with regards to patient care is not appropriate. There is no magic formula when caring for patients and skill must be developed in assessing and adapting to the needs of patients on an individual basis.
image In addition to caring for the patient, it is important to consider the needs of those accompanying the patient, such as friends, relatives or carers.

INTRODUCTION

Patients, no matter who they are or why they are attending hospital, are affected emotionally and physically by illness and pain. Whilst every patient is unique and will cope in their own way, this chapter examines aspects of patient care for a variety of patient groups from paediatrics and the elderly to those involved with trauma or with mental health problems.

When reading the chapter consider that issues discussed in the context of a specific patient group may also be relevant to other patients. For example, visual impairment is most common amongst the elderly population; however, the guidance given regarding this can equally be applied to all visually impaired patients, regardless of age.

ASSESSING THE PATIENT

It is difficult to care for a patient appropriately without first assessing their needs, and anticipating these as early as possible ensures a more pleasant patient experience. When assessing a patient’s needs, the following questions may be helpful:

Who is the patient?

• What is his age? (This will often affect the approach taken to his care.)
• Does he have special needs, such as a hearing impairment or a learning disability?
• What is his level of understanding?
• What is his level of mobility?
• Are there any cultural or religious issues to consider?

Why is he here?

• Is the examination routine or is the patient symptomatic? (This may influence the patient’s feelings and anxiety levels and also his behaviour.)

What examination is being undertaken?

• How long is the patient likely to be in the department?
• How invasive is the procedure?
• Are detailed explanations required?
• What aftercare will be needed?

PAEDIATRICS

Paediatrics range from the neonate to the young adult and each age presents a different challenge. A child in the hospital environment is faced with strange sights, smells and sounds which can be very frightening. The experience of visiting or staying in hospital may affect subsequent visits, and fears may be carried into adult life. Ensuring a child is as comfortable as possible is therefore essential. Before examining each age group, there are several general points to consider.

GENERAL ISSUES

Preparation

Prior to the child attending for examination:

• Preparation of the child and parent or guardian is extremely important.
• Play has an important role in helping a child relax and, although not always available, the use of a play specialist can help in preparing a child for a potentially distressing situation.1
• Child friendly leaflets (Fig. 4.1) can help explain information to a child using simple language and pictures.
• Remember that in order for the parents to prepare a child for an examination, they also need to understand clearly what is involved.
image

Figure 4.1 Child friendly leaflets.

Once the child has arrived in the department:

• Ensure the waiting area and examination room are a pleasant temperature.
• Ensure all equipment is ready and a preliminary exposure is set to minimise the time the child spends in the room.
• Ensure help is readily available before bringing the child into the room.
• Think carefully how the examination will be carried out, having age-appropriate toys and distractions ready.

Is it our turn next Mummy?

It is inevitable that children will sometimes have to wait before an examination; however a child- friendly environment is likely to encourage a child to feel at ease.2

• Where possible a separate waiting area for paediatrics can have several benefits:

– It is less stressful for parents who do not have to worry about other patients.
– The child can be more easily distracted with toys and books whilst waiting.
– A quieter area, avoiding the hustle and bustle of a busy waiting area, can help calm the child prior to his examination.

• Keep waiting times to a minimum to avoid children becoming restless.
• Keep time spent in the examination room to a minimum.

Dealing with parents and guardians

Parents are often extremely anxious and it can be as much of a challenge caring for them as for the child. Remember that anxiety can result in an overprotective parent who may be more irritable and less patient than usual. When dealing with the parent:

• Plenty of reassurance is often needed, although be careful not to falsely reassure.
• Remain patient and calm at all times and ensure you are firm yet polite.
• Do not separate the parent and child unless absolutely necessary; use discretion with the older child.
• Involve parents in the care of the child, informing them what you are doing and why. This helps to make them feel more in control.
• Remember that parents know their children extremely well and will often be able to communicate with them more effectively than a stranger. Utilise this when providing explanations or instructions or if a child needs distraction.

In the past there have been many approaches to keeping children still for radiographic examinations, some of which today are considered inappropriate. Restraining a child should be the last resort. It is preferable to take time to build a rapport with the child in order to gain his trust. If the child is unable to keep still on his own, consider that the presence of a familiar face may be comforting enough to achieve this; for example sitting the child on a parent’s lap.

Lastly, it may seem obvious but never leave a baby or toddler unattended, not even for a second. Even if a baby does not appear to be on the move, it only takes a moment for a him to roll over when your back is turned and this could result in serious injury, especially if he falls from a height.

AGE-SPECIFIC ISSUES

Having considered the general issues, paediatrics have been grouped into the following five age ranges:

• Neonate
• Older baby or toddler
• Pre-school child
• Primary school child
• Older child and young adult

Guidance is provided on how to deal with the issues and challenges associated with each age group, although it must be remembered that each child is unique and will develop at his own pace.

The neonate

Babies up to the age of one month are termed neonates (Fig. 4.2). These babies are most commonly encountered on the Special Care Baby Unit (SCBU), although remember that not all neonates requiring imaging are admitted to hospital.

• The neonate will be more likely to remain settled if they are warm and comfortable. Maintaining warmth is important as the neonate loses heat very quickly; therefore, if he must be undressed, ensure that this is for as short a time as possible
• Always minimise movement of the baby, as this is unsettling
• Ensure all examinations are performed quickly and efficiently
image

Figure 4.2 The neonate.

Consider that parents of the neonate:

• may be shocked at the early arrival or the poor health of their baby and may need time to adjust
• are likely to be extremely anxious and this may cause changes in behaviour
• are likely to be protective of their child.

With regards to the mother, she may have had a traumatic birth and hormone levels are likely to affect her behaviour.

When dealing with the neonate on SCBU:

• Always seek permission from SCBU staff and wait for their assistance before beginning any examination.
• The neonate will often have numerous lines and tubes connected to him and care should be taken not to dislodge these.
• Minimise handling of the neonate as this can affect oxygen saturation levels.
• Avoid leaving the incubator open for any length of time so as to maintain warmth, and use hand holes where possible.
• Infection control is important:

– Disposable gloves and apron should be worn and changed between patients.
– X-ray equipment such as cassettes should be covered and cleaned.
– Hands should be washed before and after contact with each baby.

The older baby or toddler

Although young babies tend not to mind who picks them up, as they become more aware of the world around them they begin to become upset if separated from their parent (Fig. 4.3). It is important, therefore, to ensure a familiar person remains with them throughout their examination.

image

Figure 4.3 The older baby.

Although restraint should be considered a last resort, it is vital to remember that babies are unlikely to keep still unless they are sleeping. Holding of the baby by the parent or guardian is preferable to the use of restraining devices such as Bucky bands. In such a scenario, radiation safety is essential and the appropriate guidelines for holding patients should be followed. Older toddlers understand a significant amount and so techniques other than physical restraint may prove effective.

• If the child is old enough to understand then take time to build a rapport with the child in order to gain his trust.
• The presence of a familiar face may be comforting enough to achieve cooperation; for example sitting the child on a parent’s lap.3
• Distracting a child with a toy, or playing a game may be all that is needed to keep a child still.4

Keeping a baby or toddler as comfortable as possible prior to and during the examination is essential.

• A dummy or favourite toy may comfort the child and provide familiarity.
• Do not place baby on a cold surface; instead cover with a sheet.
• Do not undress a child unnecessarily as he can feel vulnerable when undressed and may also become cold.
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