Exam 2 Study Guide
Exam 2 Study Guide HSC 464
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HSC 464 Notes Chapter 8 Effective Communication of Health Advice to Enhance Patient Compliance 393 What is patient communication gt gt gt gt gt A two way process of imparting or exchanging of information or news between a patient and a healthcare professional Based on the needs of the patient Make patients carry out health recommendations Healthcare professionals require interviewing skills to accomplish this task Skills required by a health professional Skills that would promote trust with the patient encourage them to express their concerns freely and enable the health professional to identify misconceptions and clarify them Ability to recognize patients verbal and nonverbal cues Ability to respond accurately and appropriately to those cues Ability to provide support and feedback Problem solving skills Interpersonal skills 393 Skills for Building a Rapport Relationship gt Important for developing a patient s ability and willingness to carry out recommendations Ability to make patients feel cared for and respected autonomy Health professional s ability to communicate information effectiver Ability to make patients feel comfortable sharing their health information with you Acceptance equal powers and understanding Empathy Trust oz Acceptance and Understanding gt gt gt V The rst step to building rapport Entails respect for people regardless of their circumstances or value It is not blind acceptance of their behavior nor approval 0 Continuing to respect and value the patient as a person Feeling respected builds relationships facilitates communication and trust gt gt Health professionals who show acceptance of patients views do not exhibit a judgmental attitude towards the patients Lack of acceptance can lead to the patient withholding information Communicating Empathy gt Empathy the ability to view feelings from patient s perspectives and to communicate acceptance and understanding to the patient in a nonjudgmental way lnvolves the health professional putting aside their own feelings and values and putting themselves in the patient s shoes and seeing the feelings from the patient s point of view Empathy must be an accurate understanding of the patient s perspective Empathetic response does not involve giving advice or coming up with solutions Fundamentals for empathy are acceptance honesty and understanding Building Trust gt gt Facilitates rapport and establishes credibility Fundamentals to building trust are taking the best interest of the patient in mind health professional s ability to communicate genuine concerns for patients and the patient s belief in the competence of the health professional Trust can be built based on the health professional s expertise Role title and academic degrees Physician nurse pharmacist etc Health professionals who seem unsure of the information they re presenting risk losing credibility and trust The patient will begin to cast doubts on their credibility Building trust requires effective communication con dence and accuracy in information being given amp up to date with information Nonverbal Behavior gt gt gt Consists of more than just verbal exchange alone Nonverbal behaviors communicate the attitudes beliefs and emotions of both patients and health professionals Examples of nonverbal communication Body movements Facial expressions Touch Eye contact Tone of voice oz Patient Cues gt A health professional must be aware of nonverbal cues in order to receive and interpret messages the way they were intended gt A patient s cue may be suggestive of the patient s emotional state a lack of understanding possible discomfort with the recommended solution orjust a need for additional information Linking the patient s behavior to their words A health professional is able to better understand a patient s statements Look for nonverbal cues throughout the interaction Nonverbal communication must be correctly interpreted Ex a patient who is dgeting may be uncomfortable physically or with the information being given disinterest Interpreting nonverbal cues without clari cation may lead to ineffective patient education Failure to correctly interpret a patient s nonverbal cues may be construed by the patient that the health professional is insensitive to their needs leading to failure to build rapport A patient s nonverbal communication matches their verbal responses Always seek additional information by probing whenever a patient s nonverbal response appears to con ict with the verbal response Asking questions may open additional dialogue on nonverbal cues The nonverbal cue may also just be noted for further followup or future investigations Common Patient Cues and Their Interpretations VVVV Not answering questions Shrugging shoulders Being absentminded Frowning lack of understanding of instructions Patient disagrees with the treatment prescribed or health recommendation Patient will have difficulty carrying out the health recommendation HdgeUng Patient is uncomfortable physically Patient uncomfortable with the content of information being given Interpretations About Reacting to a Patient s Nonverbal Cues gt Health professional s lack of knowledge of how to approach the patient gt May establish further barrier to patienthealth worker interaction O 90 gt Varies depending on the relationship between the patient and the health professional gt May depend on the clinical worker s judgment of the teaching situation gt Continuing a patient education session without noting or clarifying nonverbal messages leads to ineffective patient teaching I echniques for Probing a Nonverbal Patient Cue Be nonthreatening Be nonaccusing Communicate your observation concisely Ex for a patient who is dgeting quotYou seem to be uncomfortable Is there anything I can do to help youquot Ask a question Take appropriate action based on the additional information received Stopping the session Clarifying issues Noting the nonverbal cue for future followup VVV VV Cues From Health Professionals gt Health professionals may convey unintentional cues and messages to a patient through their nonverbal messages gt Health professionals need to understand their own nonverbal messages as well as those of the patient What to Consider Before Touching a Patient Number of previous interactions with the patient Age difference between the patient and the health professional Gender of both Cultural differences between the two The circumstances rst encounter handshake may suffice a terminal condition a hand around the shoulders may be comforting VVVVV Effects of Health Professional s Nonverbal Messages gt Health professional is accepting and interested in the patient gt Patient may interpret the message and believe the health professional is not interested in them gt Health professional has not considered their special problems and concerns End result may be patient s failure to follow recommendations Responding to Patient Verbal Cues Probing gt Probe an open ended statement that attempts to obtain additional information from the patient gt A health professional s responses to a patient s verbal statements can facilitate or hinder the degree to which teaching goals are reached gt The statement is meant to encourage the patient to express their views Tell me your understanding of your condition Do you know anyone else with this condition Do you know your condition Responding to Patient Verbal Cues Clarifying Responses gt Purpose is to facilitate correct understanding and help health workers interpret patients verbal responses the way they were intended gt Important for ensuring accurate perception of the patient s verbal statements Responding to Patient Verbal Cues Re ecting Responses gt Encourages a patient to elaborate on a statement already made gt Helps the health professional gain more understanding and perspective for effective patient education gt Helps in accurately identifying and addressing patient s fears and concerns Responding to Patient Verbal Cues Confronting Responses gt lnvolves giving honest feedback to the patient and not taking an argumentative role with the patient gt Should not make inference about the patient s motive for the observed behavior gt An opportunity for a patient to elaborate on or deny an observation brought to their attention gt Confrontation should not communicate hostility but re ect sympathetic interests gt A confrontation statement consists of an observation than an accusation statement lnitiating Patient Teaching gt Either during informal interactions or during formal interactions patient education is the major purpose of the meeting gt The main drive of patient education is to gather data make an educational diagnosis and build a rapport gt For formal interaction Introduce yourself to the patient De ne your professional role De ne the purpose of the interaction Put patient at ease through touch or asking how they feel Ask the patient the name shehe prefers to be called Ensure a conducive environment 0 ex quiet room 393 Establishing Goals for Communication gt The content of patient education depends on the needs and interests of the patient the prevailing circumstances and the goals to be achieved Ask yourself quotWhat do I want the patient to be able to do as a result of my instructions todayquot quotWhat information does the patient need to carry out the instructionsquot These questions help you to establish realistic goals and assess the feasibility of meeting those goals Ex patient who smokes two packets of cigarettesa day but has no insight would have a goal of increasing his awareness of the hazards of smoking and cutting down on the packets smoked but not of quitting smoking in the immediate term Then identify longterm goals and be explicit in the way you set the goal Ex rendering a diabetic patient independently able to manage their own insulin injection accurately at home on a daily basis Establish priorities for the sequence of information to be given Information that is necessary for a patient to function safely and adequately should be covered rst Communicating Information VVVVV V Interpersonal skills are required for effectiveness of information The needs of the patient are important Be direct in giving information Avoid medical jargons Clarify perceptions Take note of social background culture etc Be speci c when giving patients information emphasize the most important instructions Helping Patients Remember Instructions gt gt gt Organize the material well Clarify and specify instructions Repeat important points and emphasize them to the patient Chapter 9 Making the Patient a Partner in Patient Education 393 The Art of Negotiation gt gt Negotiation the process in which there is conferring discussing or bargaining to reach an agreement Health professionalpatient interactions should be a negotiation otherwise the two parties would be at odds because of invalid assumptions about the patient s ability or willingness to follow advice Negotiation identi es areas of agreement and disagreements and provides a forum for discussion of possible solutions Should not be assumed that health professionals know what is best for the patient and their health but the two must agree on what is best for the patient Health professionals should understand patients feelings or identify barriers to compliance before advising them to follow instructions Blindly advising patients to follow instructions leads to con icts Negotiation can increase the likelihood that patients will be helped to find solutions to problems that may interfere with them following health advice Change in Patient Status gt gt gt Patients are no longer passive recipients of healthcare Health professionals are no longer the ultimate authority on what is best for the patient Patients are no longer looked at as troublesome when they ask for additional information or challenge information given to them Patients are now expected to play an active role in their own healthcare decisionmaking Not the passive type who offer no criticism or merely asking few queonns No more paternalism from health professionals patients are now equal partners in decisionmaking Health professionals should come to the patient s level with no attitudes Selfhelp and patient information has increased patients involvement in their own care Patients now want more information about their condition and treatment Patients who are given more information have more respect for the health professional gt Patients now need to know that they are not mere recipients of information but rather that they can play an active part in their own heath 393 Model of Professional Relationships and Negotiations gt There are three models of interaction gt 1 Activitypassivity model Health professionals take an active role assuming full responsibility for determining goals Patients assumed a passive role being recipients of care and having little input into the treatment or the care being received Agreement with the patient is taken for granted gt 2 Guidancecooperation model Most of the responsibility for goal setting still belong to the health professional That by virtue of the health professional s training they have special knowledge and expertise that patients seek to receive help for their needs That patients are seeking help and therefore willing to cooperate The major goal of this model is to give information to patients so that they follow the recommendations given Health professionals are in a paternalistic role Patients are expected to comply with the recommendations Little opportunity for patient input or disagreement with the recommendations made Agreement with the patient is taken for granted gt 3 Mutual participation model AKA the model of negotiation Patients and health professionals work together sharing information to reach common goals 0 Patient and health professional are equal members of the interaction Characterized by a high degree of empathy and recognition of patient s individual needs Health professionals play the role of facilitator and educator Patient s own experiences provide clues for the most effective plan to follow oz Special Circumstances gt Education to a child gt Patient education in emergency gt Cosmetic surgery gt When negotiations fai 0 Shared Responsibility in Patient EducationMutual Participation Model gt Patients personal responsibility is the central theme of negotiation gt The responsibility of the health professional is in no way lessened gt Health professionals have the responsibility to communicate instructions as well as well as assessing whether patient can follow the regimen offering help and support gt To what extent is the patient able to incorporate instructions into their daily lives 393 Boundaries of Patient Education gt Patient s beliefs values and social in uences may have signi cant impact on the extent to which they follow health recommendations gt Recommendations that seem simple to health professionals may be overwhelming to the patients gt Cost the degree to which patients are willing to follow recommendations are related to cost associated with the instruction Cost in terms of discomfort pain loss of selfesteem 393 When Negotiations Fail gt Pressure by the patient but may be rejected by the health professional gt Health professional accepts that the patient is not following the regimen as expected but this should not be construed as condoning an undesired behavior Ignore the problem Be open and honest about areas of disagreement Avoid confrontation Continue to exhibit an attitude of cooperation and respect VVVV o3 Facilitating Patient Decision Making gt Be realistic in relaying the consequences of following or not following a health professionals recommendation gt Don t use threats or fear in an attempt to motivate the patient to follow a health recommendation Fear can raise the patient s anxiety levels to a degree that they deny that the threat exists gt Help patients increase their awareness of their use of excuses and rationalization and how these are interfering with following instructions gt Prepare the patient realistically for what they might expect from following or not following the recommendation 393 Patient Contracting gt Patient contracting is important for helping patients follow through with the recommendations given in order to reach mutually accepted goals gt Based on the theory of learning that behavior can be increased when there are positive consequences that closely follow performance of that behavior gt Patient s strengths than weaknesses should be emphasized through reinforcement at each level of attainment gt To be effective contracting must be based on patient s needs Framework for Patient Contracting Help patients identify goals Make those goals observable Reinforce positive patient behavior Decrease undesired patient behavior Help patient remember recommendations with contracting Make several considerations in the use of contracting by focusing on future actions translating problems into speci c behaviors and by focusing on the patient s environment VVVVVV Chapter 10 Notes llliteracy in Patient Education and Patient Compliance Literacy De ned gt Literacy an individual s ability to read write and speak English and compute and solve problems at levels of pro ciency necessary to function on the job and in society to achieve one s goals and develop one s knowledge and potential gt Literacy involves more than just being able to read and write Entails thinking organizing interpreting and analyzing information Causes of llliteracy gt Biological factors Learning disability ADHD Genetics Injury to the CNS 0 birth injury stroke meningitis dementia gt Other causes Inadequate educational preparations Cultural factors 0 Immigrants are functionally illiterate by virtue of inability to speak the language of the host country Societies where culturally education preference is given to boys than to girls o3 llliteracy as a Disability gt As a functional disability illiteracy can have far reaching impact on one s ability to work and enjoy many leisure activities Ex reading a newspaper magazine etc llliteracy can also be in the form of inability to read signs directions or written materials 20 of the adult population of America cannot read above the fth grade level A patient s ability to understand health information is a prerequisite to patient compliance through their own informed choice Health professionals shouldn t depend on patient education materials alone at the expense of explaining to the patient Always check a patient s ability to read and understand materials given Never use patient education material as a substitute for direct information Myths about llliteracy gt gt Preconceived views of illiteracy can interfere with the interaction with the patient Stereotyping that illiterates are from low socioeconomic status uneducated or unemployed Misconceptions that illiteracy doesn t exist in the USA yet almost half of the United States adult population has de ciencies in reading or computational skills The belief that a patient is unable to read will let the health professional know but this is not often the case Existing social stigma attached to the inability to read yet the health professional is regarded as education elite A view by health professionals that illiteracy is directly related to intelligence Assessing Patient s Literacy Skills gt gt It is important for the health professional to recognize that illiteracy can be a potential problem in patient compliance Recognize that some patients will not volunteer information about their illiteracy Do the literacy assessment of a patient before conducting patient educann Don t assume you will be able to recognize patients with poor literacy skills as you educate them gt Don t feel uncomfortable delving into patient illiteracy issues unless the problem goes unresolved gt Direct questioning of patients alone about their reading ability has been found to be ineffective Many patients will hide their reading difficulty Others often underreport their difficulties gt Observing the patient being alert to cues and conducting sensitive and timely direct questioning have been found to be the best method of assessment of patient illiteracy gt Ability of patients to comprehend the content and concepts within written materials are more important than just mere reading Assessing Proper Rapid Estimate of Adult Literacy in Medicine REALM gt A word recognition test gt Designed to assess a patient s ability to read common medical words gt Takes about three minutes to administer Assessing Proper WideRange Achievement TestRevised gt Also a word recognition test gt Provides an approximate grade level of reading ability Assessing Readability of Materials gt Assesses a patient s grade reading level of written materials before giving any materials to them gt Make sure the readability level matches the patient s ability gt Both vocabulary and sentence structure in uence readability of materials gt The health professional needs to have knowledge of how to assess readability of materials using the SMOG formula Ten consecutive sentence near beginning Ten consecutive sentences in the middle and ten at the end of the material Count number of words containing three or more syllables Teaching Patients with Low Literacy Skills gt Patient education should be altered to suit whether a patient is able to read but also understand gt Patients with low literacy skills may not bene t from written materials you have to teach them all that you want them to learn gt Health professionals should assess readability of written materials and match the reading level with the patient s needs gt The material should be well organized Only essential information gt List items most important for the patient to know rst gt Use headings to focus on key concepts of the message gt Underline or highlight important points for the patient to remember gt Arrange materials in a logical sequence of presentation gt You may have to develop your own education materials other than using already prepared one gt Use large print for ease of reading gt Avoid the use of medical jargons gt Provide the reading material in advance of the teaching session gt Visual presentation can add to a patient s ability to comprehend gt Repeat the most important information throughout the session gt Ask the patient to summarize what has been discussed to test understanding gt If the patient has not understood reframe the issue using the patient s frame of reference Chapter 11 Complementary and Alternative Medicine What is Complementary and Alternative Medicine CAM gt A group of practices focusing on Wellness PromotionIllness Prevention Incorporates a holistic approach to medicine that focuses on treating the whole person including the mind body and spirit rather than just isolated parts of the body The goal is to promote harmony of mind body and spirit Treatment of illness but not trauma or organbody part replacement Terms complementary and 39alternative are often used interchangeably when referring to therapies but there is a distinction Complementary Medicine is used together with conventional medicine as part of a modern integrativemedicine approach 0 Ex A patient with chronic headache who uses biofeedback in addition to conventional medications Alternative medicine has traditionally been used in place ofto replace conventional medicine Few use this 0 Ex use of a herb to remove a wart instead of surgical excision Complementary and alternative medicine describes diverse products or practices that are outside of mainstream Western medical practice for promoting health and preventing or treating disease A philosophy common to all complementary medicine is that healing comes from within The basic principle of CAM is that the body possesses an intrinsic healing capacity and that medical practice should exploit the body s own ability to ght disease and promote healing from within 393 As Patient Educators You Need to Know gt Health involves keeping patients happy energetic engaged having fun and feeling great gt Can be achieved through not just the prevention or treatment of diseases but also through CAM gt Patients can take more control over their health no matter what type of medicines they employ in their lives They are the ultimate decision makers in terms of their own health gt Who Uses CAM and Why CAM users often seek what they perceive as a more natural gentle approach to healing You need this knowledge to approach such patients with an informed mind Other CAM patients distrust the traditional medical approach and believe that alternative practices will give them greater control over their own health care A survey conducted by the National Center for Complementary and Alternative Medicine revealed that 38 of adults use some form of CAM oz Common CAM PracticesPractitioners Chiropractors Naturopaths Massage therapists Spiritual healers Folk healers Biologicallybased therapies such as Herbal therapies Megavitamin therapies Special diets Homeopathy Mindbody or behavioral interventions Ex yoga Energy therapies Ex bio elds therapies pulsed eld alternating current direct current VVVVVVVVVV V oz How Widely Used are CAM O O 90 90 gt Eisenberg 1998 found that 42 of adults had used at least one alternative therapy in the previous year gt Myth that only the poorly educated na39ive gullible and low SES patients use CAM gt Another myth That patients using conventional care do not use CAM gt Terminally ill patients are more likely to use CAM as desperation measure is inaccurate They use it for general health maintenance Complementary and Alternative Medicine CAM gt Who Can Provide CAM Treatment Various forms of CAM are increasingly being taught in US medical schools and are available to patients in some clinics and hospitals 0 Some such as acupuncture are even covered under many health insurance policies Complementary and alternative therapies vary widely in terms of the nature of treatment extent of therapy and types of problems for which they offer help 5 Domains of Complementary and Alternative Medicine Domain 1 Whole Medical Systems gt Built on complete systems of theory and practice earlier than and apart from western medicine gt Considered Alternative in the United States gt Examples Traditional Chinese Medicine 5000 yrs old Ayurveda Medicine Indian 6000 yrs old Naturopathic Medicine Traditional American Indian Med Tibetan Homeopathic Medicine gt Whole Medical Systems Focus on Balance Complete systems of theory and practice evolved over time in cultures amp apart from conventional or Western medicine Treat Whole Person vs Disease of Person Methods based on indigenous theories beliefs and experiences handed down based on various theories of Balance of energy that is responsible for life chiqi yinyang Belief that the mind is critical for treatment of illnesspromotion of heath Traditional Chinese Medicine Emphasizes the proper balance or disturbances of qi or vital energy in health and disease respectively Traditional Native American Medicine Combines religion herbal medicine spirituality and rituals that are used to treat emotional and medical conditions Ayurveda Medicine Indian 0 An alternative medical system that began and evolved over thousands of years in India Focuses on balance of mindbodyspirit Theory Based on Five elements 9 Waterfireairspaceearth o Developed along with yoga and meditation 9 Belief in universal life energy force 9 Similar to qi in TCM Chinese Medicine Naturopathic Medicine Western Version 0 Prevention treatment and optimal health through therapeutic methods and substances 0 Views disease as a manifestation of an alteration in the processes by which the body naturally heals itself Homeopathic medicine 0 An unconventional Western system based on the principle that quotlike cures likequot Sees pathogens as symptom instead of cause of disease 0 Empirical research is lacking Acupuncture 0 Among oldest healing practices in the world China and other Asian countries for 1000 s of years 0 One of oldest forms of traditional Chinese medicine used for musculoskeletal dysfunction mood enhancement and wellness promotion The placement and manipulation of acupuncture needles is based on traditional Chinese theories of lifeforce energy qi ow through meridians or energy pathways in the body Acupressure similar to acupuncture but no needles Pressure applied to points critical to balancing yin and yang the two Chinese principles that interact to in uence overall harmony of the body 0 Premise is that disease results from disruption in ow of qi amp imbalance in forces of yin amp yang Stimulation of speci c points on body via insertion of thin metal needles though the skin 0 2007 NIH survey 31 mi US adults and 150000 child had used it in 2006 oz Domain 2 MindBody Medicine gt Techniques used to enhance the mind s capacity to affect bodily gt symptoms and functions Examples Meditation Deep Breathing Guided ImageryRelaxation thru Imagery Laughter Therapy Prayer Art Therapy Music Therapy Dance Therapy Yoga Hypnosis Laughter amp Health Shuts off ow of quotfight or ight hormonesquot experienced from stressangerhostility Stress hormones suppress immune system 0 Increase number of blood platelets 9 Can cause obstructions in arteries amp raise blood pressure Bolsters Immune System by Increasing o KILLER T amp B cells a major part of immune response in attacking cancer cells amp diseasedestroying antibodies Salivary immunoglobulin A defends against infectious organisms entering through respiratory tract Gammainterferon disease ghting protein quotRelax Rhythmic Breath Technique Bene ts Natural tranquilizer for the NS Sends instant message to autonomic NS no threats body can return to homeostasis Use it whenever aware of internal tension Use to fall asleep Short circuits negative reactions to upsetting events MindBody Medicine Meditation Use the mind to reach state of consciousness for some bene t 0 May have ties to religions including but not limited to o Buddhism 9 Hinduism o Taoism Breath Techniques Counting Deceptively Simple Zen Meditation Practice Sit in a comfortable position with spine straight amp head inclined slightly forward Gently close eyes amp take a few deep breaths Let breath come naturally without trying to in uence it To begin the exercise count quot1quot to yourself as you exhale The next time you exhale count and so on up to quot5 One Complete Cycle Then begin a new cycle counting quotonequot on the next exhalation Never count higher than quot5quot and count only when exhaling Know your attention has wandered when you nd yourself up to quot12quot even quot19quot Try to do 10 minutes of this form of meditation and see if you wander gt Hypnosis Hypnotherapy quotA trancelike state in which you have heightened focus concentration and inner absorption When you39re under hypnosis you usually fee calm and relaxed and you can concentrate intensely on a speci c thought memory feeling or sensation while blocking out distractionsquot oz Domain 3 Natural Products gt Use of Substances found in nature herbs other plants special diets or vitamin supplements in doses outside those used in conventional medicine gt Examples CannabE St John s Wort Gingko Biloba Ginseng Shark Cartilage Fish Oil with Omega3 Fatty Acids CleO Aromatherapy gt Natural Products and Herbs Super juices Natural products many of which overlap with conventional medicine39s use of dietary supplements Commonly involve intake of 39functional foods 39oatmeal green tea super juices designed to improve speci c aspects of physical or mental functioning Herbal remedies used for thousands of years Dietary supplements sh oil whey powder protein powder Minerals and daily vitamins gt History of Modern Medicine Up till mid 1800 s whole plants used as medicine Mid 1800 s Scientists began extractingmodifying active plant ingredients then making own versions of plant compounds Modern Medicine arises In time only licensed practitioners permitted to use the new medicines 1847 American Medical Association founded replaced 39remedies from nature with new drugs partly from nature partly from the laboratory By 1910 rmly established amp ends herbal medicine in US for next 60 years until beginnings of revival in 1970 s as 39CAM gt Forms of Herbal Remedies and Supplements Herbal remedies come in several different forms 0 Tinctures extracts of fresh or dried plants usually contain a high percentage of grain alcohol to prevent spoilage and are among the best herbal options Freezedried extracts are very stable and offer good value for your money Standardized extracts often available in pill or capsule form are also among the more reliable forms of herbal preparations Herbal supplements and functional foods can currently be sold without FDA approval 0 The lack of standard regulation means that some unskilled and untrained people may be treating patients without fully understanding the potential chemical interactions of their preparations As a result the FDA has instituted new regulations to oversee the manufacture of dietary supplements including herbal supplements gt Aromatherapy Oils These essential oils tend to produce slower frequency brain waves to slow brain to more relaxed state Always dilute with carrier oil Almond Apricot Avocado Jojoba Olive Sesame etc Research it before using gt Marijuana and Cannabinoid Medicines Chronic Pain Management Cannabinoid receptor system most widespread receptor system in the human body Body produces speci c molecules endocannabinoids that interact with receptors to help lessen pain as shown by numerous studies CBl receptors found primarily in the brain spinal cord and periphery CBZ receptors are on the immune tissues Classi ed into three types endocannabinoids produced by the body phytocannabinoids produced by the cannabis plant synthetic cannabinoids produced in the laboratory Cannabinoids Some unstable many insoluble in H20 making them hard to research and turn into medicines Various reactions to cannabinoids Data from recent clinical trials encouraging but mixed Composition and delivery route ie how a medicine is administered are extremely important to the viability of cannabinoid medicines Both FDA and Institute of Medicine have stated that there is no future for herbal cannabis as a prescription medicine Yet 22 states plus Washington DC have legalized it for medical use Most common illegal drug used in the US At least onethird of Americans have used marijuana sometime in their lives People smoke marijuana because it elevates their mood and relaxes them Depending on the level of THC users may also experience euphoria hallucinations and paranoia Some call it a 39gateway drug because it tends to be the rst illegal drug teens use oz Domain 4 ManipulatingMoving Body Parts Focus on body structures amp systems of the body bones and joints soft tissues and circulatory and lymphatic systems Techniques that use manipulation to one or more body parts Feldenkrais Alexander Technique Examples gt gt gt gt Massage Progressive Relaxation ChiropracticOsteopathic Manipulation Body Awareness Feldenkrais Alexander Acupuncture Biofeedback Osteopathy and Chiropractic Spinal manipulation has been used since the time of the ancient Greeks and was incorporated into chiropractic and osteopathic medicine in the late 19th century Massage Hippocrates de ned medicine as quotthe art of rubbingquot Therapies that press rub manipulate muscles and other soft tissues Used for pain relief sports injuries reduce stress increase relaxation address anxiety and depression general wellbeing Dates back 1000 s yrs in writings of ancient China japan lndia Arabic nations Egypt Greece Rome Types of Massage Therapy 0 Deep tissue massage Swedish massage Trigger point massage Shiatsu massage o Trager bodywork employs gentle shaking motion of limbs to induce states of deep pleasant relaxation Manipulative and BodyBased Practices Using Muscular Skeletal Manipulation Rol ng Structural Integration aims to restructure the musculoskeletal system by working on tension held in deep Acupuncture The placement and manipulation of acupuncture needles is based on traditional Chinese theories of lifeforce energy Qi that ows through meridians in the body Acupuncturists in the United States are licensed 0 Most participants report high levels of satisfaction Acupressure Similar to acupuncture but uses pressure instead of needles Focuses on balancing the yin and yang Movement Therapies Feldenkrais system of movements oor exercises and bodywork to retrain central nervous system Alexander Technique Yoga Domain 5 Energy Medicine gt gt gt Use of energy elds based on the belief that these surround and penetrate the human body Techniques that affect the energy elds that are thought to surround and penetrate the body Examples Qigong Tai Chi China Yoga India Reiki Therapeutic Touch Energy Medicine Focuses on energy elds thought to originate within body bio elds or on elds from other sources electromagnetic elds Qigong ancient system of Chinese energy medicine healing Using breathing techniques gentle movement and meditation to cleanse strengthen and circulate the life energy qi Reiki Rei God s Wisdom Ki life force energy 0 Japanese technique for stress reduction and relaxation promotes heaHng quotLaying on handsquot to promote ow of Ki and feelings of well being Therapeutic touch detect and manipulate the person s energy eld by placing their hands on or near a patient 393 CAM in Patient Education gt Before recommending utilization of CAM resources for your patient Consult the most reliable resources NIH site for a good start Evaluate risks scienti c basis of claimed bene ts and contraindications if any to using CAM for your patient s issue Don t promote your treatments as a cureall for every health problem Tell your colleagues in conventional health care about CAM you plan to use on the patient Give them a full picture of what you do to manage the patient s health This will help ensure coordinated and safe care and prevent negative interactions between drugs and CAM Most patients don t consult nor inform health professionals about their CAM practices This is attributed to fear of being ridiculed or their questions being dismissed or censured Attitude of health professionals about CAM vary some are skeptical or hostile to it while others accept it Some health professionals may avoid discussion of CAM with patients because they lack adequate knowledge of these practices Patients are using CAM so health professionals need to learn how to talk with patients about it 393 What Motivates a Patient to Use CAM VVVVVV Beliefs and expectations Perceived vulnerability to disease Personal or family history Acquired knowledge from friends or the media Patients own experience with the disease Emotions rather than logic What Makes Herbs Medicine gt 1000 s of Chemicals in the plants gt Ex anthocyanin39s in lavender violet and blue shades gt carotenoids in primrose bright red yellow and orange shades gt These chemicals create value as medicines Antioxidant cancer aging diuretic release excess bodily uids mucilaginous soothe digestion nervines sooth nervous system bitters aid in digestion NO difference in principle between the toxicity of medicinal plants and that of synthetic chemicals Some plants are virtually nontoxic while others become poisonous in normal doses AopathicConventiona quotModernquot Medicine gt gt A quotDisease Modelquot Disease seen as biological condition 3iness is a result of exposure to pathogens Aside from vaccination programs focuses on getting well once sick Treats acute nesses amp chronic conditions Mainly concerned with identifying and curing conditions Problem solution based approach Also great at xing physical issues trauma hip knee replacement plastic and other corrective surgeries Types of WesternAllopathic Health Care Providers gt Specialists include Medical Doctors Osteopaths pace special emphasis on skeletal amp muscular system similar to an MD Ophthalmologists or optometrists Eye Care Dentists Nurses Nurse practitioners NPs are nurses with advanced training Physician assistants PAs examine and diagnose patients offer treatment and write prescriptions under a physician39s supervision Bene ts of Modern Medicine gt gt gt gt Detectiontreatment of many diseases especiay infectious agents viruses and bacteria Vaccinations caused worldwide elimination of smallpox saving millions of lives Other killer diseases such as diphtheria typhus amp whooping cough now rare in modern countries Trauma treatment from accidents war injury etc second to none Importance of Discussing CAM with a Patient gt gt Use of CAM is prevalent so patients should routinely be asked about its use Health workers should be knowledgeable in CAM in order to be able to assist patients make informed decisions and choices about CAM Some CAM such as acupuncture have demonstrated bene cial effects such as pain control Some CAMs have adverse effects Adverse interactions can occur between conventional medicines and CAM Most CAM involve outof pocket expenditure because they are not covered by insurance oz Safety Issues gt gt gt gt gt gt Help patients choose safe and appropriate CAM approaches Give factual unbiased information for logical informed choices Direct harm from indiscriminate use of herbal medicines Variations in the same herb from different manufactures Duration for taking the herbs should be ascertained Discern scienti c data from other patients testimonies oz The Role of the Health Professional gt gt Be familiar with CAM especially those that are prevalent in certain geographical areas Regularly check with your patient about their use of CAM as patients use and interests in CAM may change over time Be honest with the patient when you lack knowledge of a particular CAM Be aware of the patient s unmet expectations for care which they may seek from CAM When you disagree about CAM provide sound rational evidence rather than fabricating or forcing the patient Meet with CAM practitioners to understand among others the philosophy training experience and cost of CAM Appreciate that CAM has become an exemplary framework for inter disciplinary and holistic health care CAM can be integrated into conventional care Chapter 12 Patient Education and Compliance Issues for Older Adults oz Patient Education Session for Older Adults gt gt Speci c factors associated with aging can in uence patient education process and its effectiveness Regardless of age group older people should be treated as individuals during patient education oz Demographic Change The number of older people 65 years and older living in the US has increased dramatically in the 20th century 4 of the population at the beginning of the century to 11 of the population by the end of the century Projection older people will be 17 of the population by 2020 Explanation for the trend aging population of baby boomers people living well into their 80 s and more reaching 100 years and beyond Implication Increased need for patient education both for patients and caregivers The need for overcoming challenges of effective patient education Addressing special needs of older adults in patient education Need for effective approaches to teaching older adults and their families De ning Age gt gt gt gt No uniform de nition of what constitutes aging exists Aging is a complex multidimensional process beginning at conception and changes throughout life Physical psychological social and economic factors determine aging Using a speci c cutoff age to de ne older people may result in stereotyping Older age can generally be de ned biologically based on the physical changes postural and gait changes facial features hair color body fat distribution stamina sleep patterns etc Other methods of de ning old age include legally legislatively psychologically and socially social roles social expectations for behavior Common terms used to de ne aging Elderly senior citizens individuals in their golden years may be offensive to some Older adults has more positive connotation and less offensive Speci c factors associated with aging can in uence patient education process Social psychological and physical domains of aging are more interdependent as aging progresses Rate of Aging gt gt gt All people don t age at the same rate Aging is not a disease but a cumulative process resulting from a sum of changes that occur gradually Many changes in the body are pathological conditions and not part of the normal aging process Health professionals should be able to distinguish pathological changes from normal aging changes Some changes associated with aging can be retarded although some cannot be reversed exercise can maintain exibility and stamina Good diet immunization Can diminish susceptibility to disease Use of hearing aids Maximizing vision and avoiding accidents Factors that in uence aging include Psychological and social stress Environmental factors ex exposure to extreme temperatures sun toxic substances Genetic factors ex susceptibility to certain diseases in uence on body functions etc Socioeconomic status 0 Access to healthcare level of stress Social expectations oz Attitude of Health Professionals gt gt gt Health professionals may have positive or negative attitudes about aging Attitudes consist of beliefs about or labels of people behaviors or circumstances that summarize expectations related to people or events Attitudes affect communication patterns and responses in interpersonal interactions Positive attitudes about older people facilitate effective patient education by enhancing teaching interaction and patient compliance Negative attitudes may be responsible for health professionals avoidance of patient education interaction with older patients completely and may decrease patient compliance with health advice Perception of older patients about the attitude of health professionals can promote their healthseeking behavior Myths amp Stereotypes gt gt gt Health professionals should avoid myths and stereotypes about aging Health professionals should avoid society s emphasis of youth vitality and productivity Myths may be perpetuated overtly or covertly through humor literature media and advertisements Stereotypes diminish the value of older adults Stereotyping results in compartmentalization of individuals rather than viewing them as individuals gt Patients may be in uenced by negative perceptions of others and this may affect their compliance General Differences gt gt gt Older adults of today are different from older adults of 50 years ago Their socia roles health heathcare and expectations for aging aso var Each individual has a unique life history a unique personality and a unique set of life circumstances The historical period in which people grew up impression of aging impression of health behavior may differ among a wide range of age groups Older people may view health professional s role as one of paternalism depending on their social expectations Cultural Differences gt gt VVV Important for all age groups and can impact patient education Cultural differences can affect patient s views of health and illness and may be more pronounced in older adults Older adults may cling to their cultural customs and beliefs despite immigration ex use of folk remedies for treating diseases Age roes differ from culture to culture The role of family in caring for older adults differ from culture to culture Some ethnic groups are more susceptible to development of certain diseases than others Cultural issues should be addressed directly and with respect Culture in uences the experience of aging the perspective on health and relationships Patient Education Needs of Older People gt gt gt VVV Age is not synonymous with disease However incidence of diseaseassociated disability increases with age Over 80 of all older people report one or more chronic conditions especiay hypertension or diabetes Higher levels of functional dependency due to many superimposed diseases One disease may mask the presentation of the other One disease may impair the symptoms of another Standard treatment may have to be altered because of coexisting conditions Conditions such as arthritis poor eye sight or memory loss may interfere with an older patient s ability to take medications Coexisting conditions frequently involves an increased use of medications Older adults will often believe themselves to be in good health despite simultaneous presence of chronic diseases Older patients may need to be taught about the normal aging process as opposed to treatable diseases 393 Barriers to Effective Patient Education with Older Adults gt gt gt gt gt gt Attitude of either the older patient or the health professional Social expectation about aging Expectation of health professionals to take a more paternalistic approach to healthcare Fear of offending the health people by asking questions Different perception of health and illness Auditory and visual impairment 393 Barriers to Patient Compliance in Older Adults gt VVVV Ability to implement recommendations eg physical tness dietary changes Ability to afford the recommendation eg diet Socials and economic needs of older patients Functional inability to implement a health recommendation Failure of the health professional to appreciate the older patient s limitations oz Special Teaching Needs of Older Patients gt gt gt gt Be aware of the differences in approaches to educating older adults and younger adults Employ a comprehensive individually tailored approach taking awareness of the whole person including the physical and psychological environment In case of functional dependency make alternative living arrangements Inform the older patient about available housing options 393 lnvolving a Third Party in Teaching Older Patients gt gt gt gt Health professional s primary obligation is to the patient Educating an older patient may require the involvement of a family member or caregiver Ensure patient autonomy is observed in the presence of a third party Be sensitive to caregiversfamily members but respect patient s rights 393 Maximizing Communication Effectiveness with Older Adults Provide information in a way the patient will understand Gather as much information about the patient as possible before starting an education session Assess the patient s alertness memory and cognitive ability Take care of visual and hearing impairment Convey respect for the patient Be exible in following the patient s train of thought and pace the patient education session accordingly VV VVVV Effective Patient Education with Older Adults gt Be geared to patient s speci c circumstances rather than chronologic age gt Perform an evaluation of the patient s educational potential gt Assess the patient s concept of aging gt Guide the patient s teaching by differentiating between acute and chronic symptoms gt Consider educating family members as well gt Structure the patient education to address the patient s problems Chapter 13 Patient Education and Endof Life Issues Routine Patient Teaching is About gt Focusing on helping patients to maintain or improve health by achieving longrange outcomes or lifestyle changes Provision of information about causes and treatments of health problems Counselling about risk factors for a disease Giving information about preventing a disease or its complications Why Teaching About EndofLife is Important gt Vital for assisting patients make informed choices even when death is imminent or distant gt Important for enhancing quality of life gt Advancement in technology and new treatment interventions can make patients with lifethreatening diseasesconditions live much longer than previously gt Growing awareness about compassionate and respectful care of individuals with terminal diseases gt There is a need to teach patients and families about endof life issues ex living wills gt Even terminally ill patients have preferences for different treatment oonns Information about endoflife issues can provide patients with a sense of preparedness and control Emphasis of endoflife education should still be about the needs of the patient and not that of the family For proactive planning basing on patients preferences and values lncrease a patient s state of wellbeing by providing complete and honest information to the patient How to Talk Endof Life Care With a Dying Patient gt gt gt gt Prognosis Fears about what is to come death Goals of what they want to do in the remaining days Tradeoffs how much suffering can they continue to sustain in the remaining days Reluctance to Talk About Endof Life gt Health professionals lack a basic understanding of pertinent principles and dynamics involved in death and dying especially patients beliefs and feelings Health professionals need to acknowledge their own beliefs and feelings about death and dying Health professionals may feel inadequately trained to communicate with patients about death and dying Health professionals feel they are trained about saving lives preventing or stabilizing conditions they feel dejected when they fail to do so Feeling a sense of helplessness That there is little left that they have to offer professionally The beliefs values and attitudes of the patient about death and dying may be different from that of the health professionals Discussing death and dying with the patient can be emotionally painful and distressing to the health professional Religion culture family attitude and past experience of a health professional can determine their reactions to death and dying of their patient Anxiety about the process of dying may render the health professional to feel inadequate Personal experience with the death of a loved one may result in projecting the feeling onto the patient Fear of the emotional ability to maintain emotional composure may make a health professional reluctant to talk about end of life 393 Cultural Variations in Death and Dying gt gt VVVV Culture is about shared belief system shared expectations shared behaviors and rituals Cultural beliefs rituals and attitudes impact upon concepts and reactions to death endoflife care and decisionmaking Health professionals need to inquire about concepts and practices about death and dying before initiating patient teaching about endof life Eastern cultures tend to accept death as part of the natural rhythm of life Western cultures look at death as something to be postponed for as long as possible Different religions have different perspectives to death and dying The role of the family in endoflife decisionmaking Patient autonomy vs the role of the family Language barrier and endoflife issues Cultural aspects of when to withhold care in endoflife situations Understanding Death and Dying in the Context of the Patient gt gt gt gt What is the health professional s feelings about death and dying What is the patient s feeling about death and dying Health professional should be mindful of the differences and give consideration to the patient s perspective Patient education in endoflife education should be presented in the patient s context Reactions to Bad News gt gt Most patients experience cognitive emotional behavioral and physical reactions to news of a terminal illness Bad news is contextual How news is interpreted may depend on the nature of the news and the meaning the individual attaches to the news Common Reactions to Bad News Include gt gt Fear of death and of the dying process Denial of implications of the diagnosis by either avoiding admitting anything is wrong or deny the terminal nature of the condition while admitting its seriousness Anxiety a universal reaction to threat Grief manifested as physical or psychological symptoms including depression Grief is a normal reaction to loss VVV Anger outbursts may be directed towards those closest to the patient or towards health professionals Retreat being by oneself Re ection reexamine goals and values Humor may be seen as inappropriate if the health professional takes it as denial but patients should be encouraged to continue using it Understanding Endof Life Issues in the Context of the Family gt gt gt Think of the family as a single entity with all members sharing the same views and values Approach all family members in the same way Consider individual differences to make family members appreciate each other s views and perspectives A terminal illness may disrupt family roles and others may have to take up additional roles leading to stress Family may react to a diagnosis of a terminal illness in many ways Health professional should identify with the family to help them accept and understand the situation Health professionals should be sensitive to family members needs Presence of a family member may not be the source of strength to the patient Communication Skills in Teaching About Endof Life Issues gt gt gt gt Good communication skills are important for forming an open and trusting relationship Be sensitive to the patient and family Use responses that show the health professional both hears and understands the patient Restate and re ect on the feelings the patient has expressed Teaching About Advance Directives gt gt Goal of advance directives is to ensure autonomy of the patient Advance directive a legal document in which a patient exert their right to accept or refuse medical care even if they should be incapacitated and unable to make their own decisions Living will the patient describes the type of health care they would or would not want to receive in certain situations Durable power of attorney for health care describes the living will as well as appoint a proxy to decide for them Breaking Bad News gt gt Bad news is subjective Bad news news that patient doesn t want to hear VVV How the patient reacts to the news is dependent on how it s delivered by the health professional Health professionals need to be sensitive to patient s perspectives and reactions before making assumptions about the impact Most patients want to be given more information about their conditions Providing patients with bad news may be delayed or passed from one health professional to another Causes unnecessary anxiety to the patient Have all the information you need at hand before giving bad news to the patient Start with a statement that gives the patient warning that bad news is coming Deliver bad news in a comfortable quiet place Give bad news directly to the patient Sit close to the patient Teaching Patients Living with LifeThreatening lllness gt gt gt gt gt gt Must be based on the patient s needs Patients and their family need honest and realistic information Determine patient s goals Direct the teaching to increasing patient s awareness Explore patient s underlying values Provide treatment information in small amounts as you explore patient s understanding Patient Education in Terminal Stages of Disease gt gt gt gt gt Based on appropriate assessment of the patient Assess the patient s family system Appropriate death dying in a way consistent with their concept of self maintaining values and ideals Spiritual component Help patient gain emotional comfort The Family Conference gt gt Basically when advance directive is not available Must entail complex dialogue as to continue treatment or not Impact of EndofLife Teaching gt gt Establishment of an emotional bond between the patient and their family Such a bond transcends mere information exchange gt Can result in an understanding of their values in crucial decision making for both the patient and the health professional
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