Operational Medicine 2001
United States Naval Hospital Corpsman 3 & 2 Training Manual
NAVEDTRA 10669-C June 1989

Hospital Corpsman 3 & 2: June 1989

Chapter 5: Patient Care

Naval Education and Training Command

Introduction

Twentieth century advances in the medical and technological sciences have made a significant impact on the methods of marketing health care services. The numbers and kinds of health care providers have expanded greatly. The consumers have become more informed regarding both their health care needs and expectations. Additionally, the consumers has become more vocal, seeking answers for both the whats and whys of the entire spectrum of health care services.

The goal of this chapter is to provide the hospital corpsman with a limited amount of theory concerning the multidisciplinary aspects of patient care. It is an introduction to some of the more critical basic concepts applicable to providing care to individuals whose physical or psychological needs have motivated them to seek some kind of health care service.

Personnel seeking information concerning the how and what to do regarding a specific procedure will find step-by-step instructions in the Nursing Procedures Manual, NAVMED P-5066-A, January 1985 edition. Use of both the Nursing Procedures Manual and the Hospital Corpsman 3 & 2 Rate Training Manual will not only assist the hospital corpsman in advancing in rate but more importantly will prepare him or her to provide safe and effective health care services. An additional and very important reference is the Navy Customer Service Manual, NAVEDTRA 10119-B. It presents the importance of proper attitude and its effect on everyday performances and stresses the need for developing positive attitudes in interpersonal relationships. The concepts in the Navy Customer Service Manual integrate closely with the patient contact point program.

Health and Illness

To intelligently and skillfully discharge your duties as a member of the Navy Medical Department health care team, it is critical that you first understand the concepts of health and illness.

The concept of health includes the physical, mental, and emotional condition of a human being that provides for the normal and proper performance of one's vital functions. Not only is health the absence of disease or disability, but health is also a state of soundness of the body, mind, and spirit.

On the other hand, the concept of illness includes those conditions often accompanied by pain or discomfort that inhibit a human being's ability to physically, mentally, or emotionally perform in a normal and proper manner.

In most cultures when people need assistance in maintaining their health, dealing with illness, or coping with problems related to health and illness, they seek assistance from personnel specialized in the fields of health care.

In chapter 1, the concepts of the health care team were briefly introduced. Although physicians, nurses, and hospital corpsmen are frequently referred to as the core team, all health and allied health personnel comprise the total health care team. Obviously, each member of the team uses his or her skills differently, depending upon their personal, professional, and technical preparation and experience. Nevertheless, despite the differences in clinical expertise, they all share one common objective; that is, to respond to the consumer's health needs. The overall goal of this response is to assist the consumer to maintain, sustain, restore, or rehabilitate a physical or psychological function.

 The Patient

No discussion about health care or the health care team would be complete without including the patient, often referred to as the consumer. A patient may be defined as a human being under the care of one or more of the health care providers. The patient may or may not be hospitalized. However, regardless of their health care needs or environmental disposition, they are the most important part of the health care team. Without the patient, the health care team has little, if any, reason for existence.

As a hospital corpsman, you are tasked to provide every patient committed to your charge with the best care possible. This care must reflect your belief in the value and dignity of every person as an individual human being. Additionally, you must be knowledgeable about both the patient's rights and responsibilities as they apply to the providing and receiving of health care services.

The Joint Commission on Accreditation of Hospitals (JCAH) has developed standards that address both the rights and responsibilities of patients. Because the goal of JCAH is the continual promotion of excellence in providing health care services, these goals are compatible with those of the Navy Medical Department. The following breakout is a brief summary of some of the major rights and responsibilities of patients when they enter into a relationship with a health care service facility. Students seeking additional information are referred to the Accreditation Manual for Hospitals that is published by the JCAH.

• Patient's Rights

• Access to care

• Respect and dignity

• Privacy and confidentiality

• Personal safety

• Consent

• Hospital (facility) rules and regulations

• Patient's Responsibilities

• Provision of information

• Compliance with instructions

• Hospital (facility) rules and regulations

• Respect and consideration

The above listing is in no way intended to be all inclusive. It is, however, an introduction that emphasizes the need for the observance of rights and responsibilities of patients when they are engaged in a provider-consumer relationship.

The above listing is in no way intended to be all inclusive. It is, however, an introduction that emphasizes the need for the observance of rights and responsibilities of patients when they are engaged in a provider-consumer relationship.

Professions Ethics

The word ethics is derived from the Greek "ethos" that means custom or practice, a characteristic manner of acting, or a more or less constant style of behavior in the deliberate actions of people. When we speak of ethics, we refer to a set of rules or a body of principles. Each social, religious, and professional group has a body of principles or standards of conduct that provide ethical guidance to its members.

During your indoctrination into the military, you were introduced to the Code of the U.S. Fighting Forces. This code of conduct is an ethical guide that charges you with certain high standards of general behavior as a member of the Armed Forces.

All professional interactions must be directly related to certain codes of behavior that support the universal principles of justice, equality of human beings as persons, and respect for the dignity of human beings. In chapter 1 of this manual, professional ethics in relation to your responsibilities as a hospital corpsman was briefly discussed. Upon completion of basic Hospital Corps School, you took the following pledge.

"I solemnly pledge myself before God and these witnesses to practice faithfully all of my duties as a member of the Hospital Corps. I hold the care of the sick and injured to be a privilege and a sacred trust and will assist the Medical Officer with loyalty and honesty. I will not knowingly permit harm to come to any patient. I will not partake nor administer any unauthorized medication. I will hold all personal matters pertaining to the private lives of patients in strict confidence. I dedicate my heart, mind, and strength to the work before me. I shall do all within my power to show in myself an example of all that is honorable and good throughout my naval career."

The Hospital Corpsman Pledge morally binds you to certain responsibilities and rules that are included in the science of health care ethics. Health care ethics is not unique in the development of methods, assumptions, and principles. Ethics, whether they be classified general or special (e.g., legal or medical), teach us how to judge accurately the moral rightness or wrongness of our actions. The one element that makes health care ethics different from general ethics is the inclusion of the moral rule "Do your duty." This is a moral rule because it involves expectations (e.g., confidentiality). It involves what others have every reason to believe will be forthcoming. To fail in fulfilling these expectations of others is to harm them. Through the Hospital Corpsman Pledge, you committed yourself to fulfilling certain duties, not only to those entrusted to your care but also to all members of the health care team. It is this commitment to service and to human beings that has traditionally distinguished the United States Navy Hospital Corps wherever its members have served. 

Interpersonal Relations

As a health care provider, you must be able to identify, understand, master, and use various kinds of information and scientific skills. In addition to information data and scientific skills, it is also very important that you develop a special kind of skill called interpersonal relations. In providing total patient care, it is important that you see the individual not only as a biological being but as a thinking, feeling person. Your commitment to this concept is the key to the development of good interpersonal relationships.

Simply stated, your interpersonal relationships are the result of how you regard and respond to people. Many elements influence the development of that regard and those responses. In the following discussion, some of these elements will be discussed as they apply to your involvement in the military service and your relationships with other health care providers and the consumer.

Culture

Because of the cross-cultural nature and military mission of the Navy Medical Department, you will frequently encounter members of various cultures. Culture may be defined as a group of socially learned, shared standards (norms) and behavior patterns. Things such as perceptions, values, beliefs, and goals are examples of shared norms; whereas health practices, eating habits, and personal hygiene reflect common behavior patterns of specific groups of people. An understanding of common norms and behavior patters enhances the quality and often quantity of service a provider is able to make available. An individual's cultural background has an effect on every area of health care services, ranging from a simple technical procedure to the content and effectiveness of health education activities. Becoming familiar with the beliefs and practices of different cultural and subcultural groups (the military community for example) is not only enriching to the health care provider but promotes an understanding and acceptance of the various peoples in the world community.

Race

The term race is a classification assigned to a group of people who share inherited physical characteristics. This term becomes a socially significant reality since people tend to attach great importance to assuming or designating a racial identity. Information identifying racial affiliation can be an asset to the health care provider in assessing the patient's needs, carrying out direct care activities, and planning and implementing patient education programs. Racial identification has the potential to create a negative environment in the health care setting when factors such as skin color differences motivate prejudicial and segregational behaviors. When this is permitted to occur, an environment that feeds a multitude of social illnesses and destructive behaviors develops. In the Navy Medical Department, no expressions or actions based on prejudicial attitudes will be tolerated.

It is both a moral and legal responsibility of the health care provider to render services with respect for the life and human dignity of the individual without regard to race, creed, sex, political views, or social status.

Religion

A large majority of people have some form of belief system that guides many of their life decisions and to which they turn to in times of distress. A person's religious beliefs frequently help give meaning to suffering and illness; they also may be helpful in the acceptance of future incapacities or death.

Close contact with illness and death can increase our awareness of our own mortality and that of our patients. For some there will be heightened religious involvement and for others a sense of frustration or loneliness. It is important for health care personnel to be aware of this to meet the needs of patients, co-workers, and even ourselves. We must accept in a nonjudgmental way the religious or nonreligious beliefs of others as valid for them, even if we personally disagree with such beliefs. Although we may offer religious support when asked and should always provide chaplain referrals when requested or indicated, it is not ethical for us to abuse our patients by forcing our beliefs (or nonbeliefs) upon them. We must respect their freedom of choice, offering our support for whatever their needs or desires may be.

Sex

An individual is born either male or female and learns roles and responses associated with their gender through parental models, family relationships, and his or her specific society. As one enters into the world of providing health care services, it is necessary to learn and adopt new roles and responses regarding gender identification. As the number of females entering the military service increases, health care providers are increasingly being challenged to expand their functions in relation to caring for patients of the opposite sex. The health care provider who has developed sound moral principles and consciously strives to provide a service based on a firm ethical foundation has little to fear when providing care for an individual of either sex. However, the development of such a foundation requires diligent study, a commitment to growth, and an availability of professionally guided experiences. Throughout your career as a member of the Hospital Corps, you will be given opportunities and guidance to achieve a sound ethical background. Your only responsibility toward this growth is a desire and commitment to make yourself available and respond as a real professional.

Because of the increasing frequency with which hospital corpsmen are required to attend to persons of either sex, the following guidelines are presented to assist you in developing some decision-making judgments.

To ensure the protection of health care personnel from unjustified accusations, a witness should be present when a member of the opposite sex is being examined or treated. Whether this witness is a member of the same sex as the patient may be dictated by the availability of personnel. When you are caring for a patient, sensitivity to both verbal and nonverbal communication is paramount. A grin, a frown, or an expression of surprise may all be misinterpreted by the patient. Explanations and reassurances will go far in preventing misunderstandings of actions or intentions. Knowledge, empathy, and mature judgment should guide the care provided to any patient; this is especially crucial when the care involves touching. As a member of the health care team, you are responsible for providing complete, quality care to all who need and seek your service. This care must be provided in a manner compatible with your individual legal and technical limitations.

Communication Skills

Communication is a highly complicated interpersonal process of people relating to each other through conversation, writing, gestures, appearance, behavior, and at times, even silence. Such interpersonal relating not only occurs among health care providers and patients but also between health care providers and support personnel. Some of these support personnel include housekeeping, maintenance, security, supply, and food service staff. Another critical communication interaction occurs among health care providers and visitors. Because of the critical nature of communication in health care delivery, it is important that the hospital corpsman understand the communication process and the techniques used to promote open, honest, and effective interactions. It is only through effective communication that the health care provider is able to identify the goals of the individual and the Navy health care system.

The human communication process consists of four basic parts: the sender of the message, the message, the receiver of the message, and the feedback. The sender of the message starts the process.

The receiver is that individual intended to receive the message. The message is that body of information the sender wishes to transmit to the receiver. Feedback is the response given by the receiver to the message. It can be a way of validating that effective communication has taken place.

There are two basic modes of communication; verbal and nonverbal. Verbal communication is that which is spoken or written. A characteristic that distinguishes the verbal from the nonverbal is that verbal communication involves the use of words. Nonverbal communication, on the other hand, does not involve the use of words. Dress, gestures, touching, body language, face and eye behavior, and even silence are forms of nonverbal communication. It should be remembered that even though there are two forms of communication, both the verbal and nonverbal are inseparable in the total communication process. Conscious awareness of this aspect is extremely important for the health care provider whose professional effectiveness is highly dependent upon successful communication.

Ineffective communication occurs when obstacles or barriers are present. These barriers can be classified as physiological, physical, or psychosocial. Physiological barriers are those that result from some kind of sensory dysfunction on the part of either the sender or the receiver. Such things as hearing impairments, speech defects, and even vision problems influence the effectiveness of communication. Physical barriers consist of elements in the environment (such as noise) that frequently contribute to the development of physiological barriers (such as inability to hear). The final kind of obstacle, called psychosocial barriers, are usually the result of one's inaccurate perception of self or others, the presence of some defense mechanism an individual employs to cope with some form of threatening anxiety, or factors such as age, education, culture, language, nationality, and a multitude of other socioeconomic factors. This last category of barriers is the most difficult to identify and the most common cause of communication failure or breakdown.

Listening is a critical element of the communication process and becomes a primary activity for the health care provider who must use communication as a tool for collecting or giving information. When one is engaged in listening, it is important to direct attention to both the verbal and nonverbal cues provided by the other person. Like many other skills necessary for providing a health care service, the skill of listening requires conscious effort and constant practice. Listening skill can be improved and enhanced by developing the following attitudes and skills:

• Want to listen.

• Develop your interests and knowledge.

• Look at the content of the message.

• Hear the speaker out.

• Focus on ideas.

• Remove or adjust distractions.

• Maintain objectivity.

• Concentrate on the immediate interaction.

As a health care provider, you will be using the communication process to service a consumer's needs. Briefly, these needs can be classified as either short-term or long-term. To simplify this discussion, short-term needs of communication will be discussed under the heading of "contact point. " Long-term needs will be discussed under the heading of "therapeutic communications."

Contact Point

To provide you with a frame of reference for the following discussion, the following definitions will clarify and standardize some critical terms:

• Initial contact point-a physical location where the consumer experiences his or her first communication encounter with a person representing, in some role, the health care facility.

• Contact point-the place or event where the contact point person and the consumer meet. The contact point meeting can occur anywhere in a facility and also includes telephone events.

• Contact point person-the health care provider in any health care experience who is tasked by role and responsibility to provide a service to the consumer.

The contact point person has certain criteria to meet in establishing a good relationship with the patient. Helping the patient through trying experiences is partially the responsibility of all contact point personnel. Such health care providers must not only have skills related to their professional assignment, but they must also have the ability to interact in a positive, meaningful way to communicate concern and the desire to provide a service.

Consumers of health care services expect to be treated promptly, courteously, and correctly. They expect their care to be personalized and communicated to them in terms they understand. The Navy health care system is a service system, and it is the responsibility of every health care provider to improve the professional nature of the system.

The significance of the contact point and the responsibility of the personnel staffing these areas are important to emphasize. The following message from a former Surgeon General of the Navy reflects the philosophy of the Navy Medical Department regarding contact point interactions.

"Some of the most frequent complaints received by the Bureau of Medicine and Surgery [now known as Commander, Naval Education and Training Command] are those pertaining to the lack of courtesy, tact, and sympathetic regard for patients and their families exhibited by Medical Department personnel at initial points of contact within Navy Medical facilities. These points of initial patient contact, which include central appointment desks, telephones, patient affairs offices, emergency rooms, pharmacies, laboratories, records offices, information desks, walk-in and specialty clinics, and gate guards, are critical in conveying to the entering patient the sense that Navy Medicine is there to help them. The personnel, both military and civilian, who man these critical areas are responsible for ensuring that the assistance that they provide is truly reflective of the spirit of "caring" for which the Navy Medical Department must stand.

No matter how excellent and expert the care in the facility may be, an early impression of nonchalance, disregard, rudeness, or neglect of the needs of patients reflects poorly on its efforts and achievements. Our personnel must be constantly on their guard to refrain from off-hand remarks or jokes in the presence of patients or their families. We must insist that our personnel in all patient areas are professional in their attitudes. What may be commonplace to us may be to a patient frightening or subject to misinterpretation.

By example and precept, we must insist that, in dealing with our beneficiaries, no complaint is ever too trivial not to deserve the best response of which we are capable. . . . "

Therapeutic Communications

As mentioned earlier in this chapter, a distinguishing aspect of therapeutic communication is its application to long-term communication interactions. Therapeutic communication may be defined as the face-to-face process of interacting that focuses on advancing the physical and emotional well-being of a patient. This kind of communication has three general purposes: collecting information to determine illness, assessing and modifying behavior, and providing health education. In the process of using therapeutic communication, we attempt to learn as much as we can about the patient in relation to the illness. To accomplish this, both the sender and the receiver must be consciously aware of the confidentiality of the information disclosed and received during this process. The health care provider must always have a therapeutic reason for invading the patient's privacy.

When used to collect information, therapeutic communication requires a great deal of sensitivity and expertise in using interviewing skills. To ensure the identification and clarification of thoughts and feelings, the interview must include observing behavior, listening, giving and receiving verbal and nonverbal responses, and interpreting and recording data.

Observation of behavior is simply the recognition of any sign the body makes when responding to a need. The quivering, excited tone of voice you hear when a mother rushes into the emergency room after her child has swallowed bleach is communicating fear and anxiety.

Listening is probably one of the most difficult skills to master. It requires the health care provider to maintain an open mind, eliminate both internal and external noise and distractions, and channel attention to all verbal and nonverbal messages. Listening involves the ability to recognize pitch and tone of voice, evaluate vocabulary and choice of words, and recognize hesitancy or intensity of speech as part of the total communication attempt. The patient crying aloud for help after a fall is communicating a need for assistance, which is different from the way you might sound in communicating a need for assistance in requesting help to transcribe a physician's order.

The ability to recognize and interpret nonverbal responses depends upon consistent development of observation skills. As you continue to mature in your role and responsibilities as a member of the health care team, both your clinical knowledge and understanding of human behavior will also grow. Your growth in both knowledge and understanding will contribute to your ability to recognize and interpret many kinds of nonverbal communication. Your sensitivity in listening with your eyes will become as refined as, if not better than, listening with your ears.

The effectiveness of an interview is influenced by both the amount of information and degree of motivation possessed by the consumer (interviewee). Factors that enhance the quality of an interview consist of the participant's knowledge of the subject under consideration, their patience, temperament, listening skills, and attention to both verbal and nonverbal cues. Courtesy, understanding, and nonjudgmental attitudes must be mutual goals of both the interviewee and the interviewer. Finally, the health care provider must be an informed and skilled practitioner to function effectively in the therapeutic communication process. This kind of provider development requires an individual's commitment to consistently seek out and participate in a variety of continuing education learning experiences related to the entire spectrum of health care services.

Assessing and Reporting

Although the physician determines the overall medical management of the person requiring health care services, he or she depends upon the assistance of other members of the health care team in implementing and evaluating the patient's ongoing treatment. Nurses and hospital corpsmen spend more time with the hospitalized patient than all other providers. This places them in a key position as data collecting and reporting resource persons.

The systematic gathering of information is called data collection and is an essential aspect in assessing an individual's health status, identifying existing problems, and developing a combined plan of action to assist the patient in his or her health needs. The initial assessment is usually accomplished by establishing a health history. Included in this history are elements such as previous and current health problems; patterns of daily living activities, medication, and dietary requirements; and other relevant occupational, social, and psychological data. Additionally, both subjective and objective observations are included in both the initial assessment gathering interview and throughout the course of hospitalization.

Subjective observations, which include symptoms, consist of the verbal information given to the provider by the patient or a significant other person. These include such things as a description of pain or discomfort, the presence of nausea or dizziness, and a multitude of other descriptions of dysfunction, discomfort,' or illness.

Objective observations, which may also include symptoms, are those that can be actually seen, heard, touched, felt, or smelled by the health care, provider. Included in objective observations are measurements such as temperature, pulse, respiration, skin color, swelling, and even the results of tests.

Intelligent assessments are the result of accurate observations that require a combination of theoretical insight and perfected skills, both of which require a constant effort towards professional development in the provider. Accurate and intelligent assessments are the basis of good patient care and are essential elements for providing a total health care service. As such, hospital corpsmen must know what to watch for and what to expect. It is important to be able to recognize even the slightest change in a patient's condition, since this may indicate a definite improvement or deterioration. Health care providers must be able to recognize the desired effects of medications and treatments, as well as undesirable reactions to them. Both of these factors may influence the physician's decision to continue, modify, or discontinue parts or all of the treatment plan.

Equally as important as assessments is the reporting of these data to appropriate team members. Reporting consists of both vocal and written communications and to be effective must be done accurately, completely, and in a timely manner. Written reporting, commonly called recording, is documented in the patient's record. Maintaining an accurate, descriptive clinical record serves a dual purpose. It provides a written report of the information gathered about the patient and serves as a means of communication to all those involved in the patient's care. The record also serves as a valuable source of information for the development of a variety of care-planning activities. Additionally, the clinical record is a legal document and is admissible as evidence in a court of law in claims of negligence and malpractice. Finally, these record serve as an important source of material that can be used for educating and training health care personnel and for compiling research and statistical data.

It is imperative that the health care provider follows some basic guidelines when making written entries in the record. All entries must be recorded accurately and truthfully. The omission of an entry is as inaccurate as an incorrect recording. Each entry should be concise and brief; therefore, extra words and vague notations are to be avoided. Recordings must be legible; if an error is made, it must be deleted following the standard Navy policy for correcting erroneous written notations. Lastly, all health care providers making entries in the clinical record must indicate the time and date and sign their name and rate or rank.

The following self-questioning technique is a good guide to assist you in developing proficiency in assessing and reporting patient conditions.

• General appearance:

  • Is the patient

    • of average build, short, tall, thin, or obese?

    • well-groomed?

    • apparently in pain?

    • walking with a limp, wearing a cast, walking on crutches, or wearing a prosthetic extremity?

   

• Behavior:

  • Does the patient

    • appear worried, nervous, excited, depressed, angry, oriented, confused, or unconscious?

    • refuse to talk?

    • connect thoughts appropriately?

    • lisp, stutter, or have slurred speech?

    • appear sullen, bored, aggressive, friendly, or cooperative?

    • sleep well or arouse early?

    • sleep poorly, moan, talk, or cry out when sleeping?

    • join in ward activities?

    • react well toward other patients, staff, and visitors?

   

• Position:

  • Does the patient

    • remain in one position in bed?

    • have difficulty breathing while in any position?

    • use just one pillow or require more to sleep well?

    • move about in bed without difficulty?

   

• Skin:

  • Is the patient's skin

    • flushed, pale, cyanotic, hot, moist, clammy, cool, or dry?

    • bruised, scarred, lacerated, scratched, or showing a rash, lumps, or ulcerations?

    • showing signs of pressure, redness, mottling, edema, or pitting edema?

    • appearing shiny or stretched?

    • perspiring profusely?

    • infested with lice?

   

• Eyes:

  • Are the eyelids swollen, bruised, discolored, or drooping?

  • Is the sclera clear, dull, yellow, or bloodshot?

  • Are the pupils constricted or dilated; are they equal in size; do they react equally to light?

  • Does the patient complain about pain; burning; itching; sensitivity to light; or blurred, double, or lack of vision?

  • Are the eyes tearing or showing signs of inflammation or discharge?

   

• Ears:

  • Does the patient

    • hear well bilaterally?

    • hold or pull on his or her ears?

    • complain of a buzzing or ringing sound?

    • have a discharge or wax accumulation?

    • complain of pain?

• Nose:

  • Is the nose bruised, bleeding, or difficult to breathe through?

  • Is it excessively dry or dripping?

  • Are both nares equal in size?

  • Does the patient sniff excessively?

• Mouth:

  • Is the mouth excessively dry?

  • Does the breath smell sweet, sour, or alcoholic?

  • Does the tongue appear dry, moist, clean, coated, cracked, red, or swollen?

  • Are the gums inflamed, ulcerated, swollen, or discolored?

  • Are the teeth white, discolored, broken, or absent?

  • Does the patient:

    • wear dentures, braces, or partial plates?

    • complain of mouth pain or ulcerations?

    • complain of an unpleasant taste?

   

• Chest:

  • Does the patient have shortness of breath, wheezing, gasping, or noisy respirations?

  • Does he or she cough?

  • If coughing, is it dry, moist, hacking, productive, deep, or persistent?

  • Is the sputum white, yellow, rusty, or bloody?

    • Is it thin and watery or thick and purulent?

    • How much is produced?

    • Does it have an odor?

  • Does the patient complain of chest pain?

    • Where is the pain?

    • Is the pain a dull ache, sharp, crushing, or radiating?

    • Is the pain relieved by resting?

    • Is the patient using medication to control the pain (i.e., nitroglycerin)?

   

• Abdomen:

  • Does the abdomen look or feel distended, boardlike, or soft?

  • If distended, is the distention above or below the umbilicus or over the entire abdomen?

  • Does the patient belch excessively?

  • Is the patient nauseated or vomiting?

    • If so, how often and when?

    • What is the volume, consistency, and odor of the vomitus?

    • Is it coffee ground, bilious, or bloody in appearance?

    • Is it projectile?

   

• Bladder and Bowel:

  • Is the patient incontinent of urine or stool?

  • What is the volume and frequency of urination?

    • Does the urine have an odor?

    • Is it dark amber or bloody?

    • Is it cloudy; does it have sediment in it?

    • Is there pain, burning, or difficulty when voiding?

  • Does the patient have diarrhea, soft stools, or constipation?

    • What is the color of the stool?

    • Does it contain blood, pus, fat, or worms?

    • Does the patient have hemorrhoids, fistulas, or rectal pain?

   

• Vagina or Penis:

  • Are there ulcerations or irritation?

  • Is there a discharge or foul odor?

    • If there is a discharge present, is it bloody, purulent, mucoid, or watery? What is the amount?

    • Is there associated pain?

    • If pain is present, where is it located?

    • Is it constant or intermittent?

    • Is it tingling, dull, aching, burning, gnawing, cramping, or crushing?

   

• Food and Fluid Intake:

  • Is the patient's appetite good, fair, or poor?

  • Does the patient get thirsty often?

  • Does the patient have any kind of food intolerance?

   

• Medications:

  • Is the patient presently taking any medications?

    • If so, what, why, and when last taken?

    • Does patient have medications with him/her?

    • Does patient have any history of medication reactions or allergies?

Health Education

As mentioned earlier in this chapter, patient education (health education) is an essential part of the health care delivery system. In the Navy Medical Department, patient education is defined as "the process that informs, motivates, and helps people to adapt and maintain healthful practices and life styles." Specifically, the goals of this process are:

• To assist individuals to acquire knowledge and skills that will promote their ability to care for themselves more adequately

• To influence individual attitudinal changes from a disease to a health orientation

• To support behavioral changes to the extent that individuals are willing and able to maintain their health

All health care providers, whether they recognize it or not, are teaching almost constantly. Teaching is a unique skill that is developed through the application of principles of learning. Patient teaching begins with an assessment of the patient's knowledge. Through this assessment, learning needs are identified. For example, a diabetic patient may have a need to learn how to self-administer an injection. After the learner's needs have been established, goals and objectives are developed. Objectives inform the learner of what kind of (learned) behavior is expected. Objectives also assist the health care provider in determining how effective the teaching has been. These basic principles of teaching/learning are applicable to all patient-education activities, from the simple procedure of teaching a patient how to measure and record his or her fluid intake/output to the more complex programs of behavior modification in situations of substance abuse (i.e., drug or alcohol) or weight control.

As a member of the health care team, you share a responsibility with all other members of the team to be alert to patient education needs, to undertake patient teaching within the limitation of your own knowledge and skills, and to communicate to other team members the need for patient education in areas you are not personally qualified to undertake.

Professional Practice

Each member of the health care team has certain responsibilities and limitations that define their area of practice. To fulfill your role as a member of the Hospital Corps within the context of the total mission of the Navy Medical Department, it is imperative that your practice be based on a sound body of knowledge and the development of well-defined technical skills. The rate training manuals are one mechanism that contribute to the development of your body of knowledge. The occupational standards define minimal technical skills required of hospital corpsmen at various levels in their career. Other members of the health care team through the mechanism of on-the-job training, inservice classes, and continuing education programs con- tribute significantly to your continued growth in both health care knowledge and skills.

In conjunction with their professional responsibilities, all health care providers must realize that they are subject to certain limitations in providing health care services. These limitations are based on amount and kind of education, training, experience, and local regulations and guidelines. It is the mature, responsible individual who recognizes, accepts, and demands that these limitations be respected. In clinical settings, hospital corpsmen are tasked with administering medication, performing treatments, and providing individual patient care in compliance with a physician's orders. In the hospital and some clinical environments, a Nurse Corps officer divides and delegates portions of the patient's care to other members of the team based on the skills and experience of each. In situations where a Nurse Corps officer is not a member of the team, such delegation of duties will generally be made by a senior and experienced petty officer of the Hospital Corps.

Regardless of rank, rate, or corps membership, all members of the health care team are held accountable for their performance. Accountable means to be held answerable. As a health care provider, you must continue to acquire new knowledge and skills and strive for professional proficiency. Equally important is your ability to apply new knowledge and acquired skills as a helping professional in providing total health care.

Accountability becomes a critical issue when determining incidents of malpractice. Malpractice occurs when an individual delivers improper care due to negligence or practicing outside of his or her area of expertise. Because the areas of expertise and responsibility in medicine are frequently overlapping, legal limits of practice are defined by each state. The assignments and responsibilities of hospital corpsmen frequently include areas of practice usually provided by physicians and nurses in the civilian sector. These responsibilities are only legal when hospital corpsmen are performing such duties while under the authority of the United States Government. Because of this, it is vital that you thoroughly understand your legal rights and limitations when providing patient care services both in government and civilian sectors.

Another area that has potential medicolegal implications regarding your role as health care provider consists of giving advice or opinions. As a result of your frequent and close contact with patients, you will often be asked your opinion of the care or the proposed care a patient is undergoing. For the most part, these questions are extremely difficult to respond to, regardless of who the health care provider is. No one is ever totally prepared or has so much wisdom that they can respond spontaneously in such situation. In such cases, it is best to refer the question to the nurse or physician responsible for the patient's care.

You must always be conscious that you are seen as a representative of Navy medicine by the recipients of your care. As such, you will be accorded the respect that goes with having a specialized body of knowledge and an inventory of unique skills. A caduceus on the sleeve of the hospital corpsman marks that person as a member of a prestigious corps worthy of respect. How one responds to this respect will quickly determine whether the individual will continue to earn it.

Remember, you have been charged to provide care to a total, feeling, human person. The person seeking health care service has the same needs for security, safety, love, respect, and self-fulfillment as everyone else. When something threatens the soundness of the body, mind, or spirit, an individual frequently behaves inappropriately. Occasionally there are temper outbursts, episodes of pouting, sarcastic remarks, unreasonable demands, or other inappropriate responses, often to the point of disruptive behavior. The health care provider is challenged to look beyond the behavior being displayed to identify the underlying stress and to attempt to relieve the immediate and obvious source of anxiety. This is as simple as communicating, through your care and understanding of the patient as an individual, that Navy medicine is pleased to provide a caring service.

 Safety Aspects

In the introductory section of this chapter, we established the primary goal of the health care provider as maintaining, sustaining, restoring, and rehabilitating a physical or psychological function of the consumer. To achieve this goal, health care facilities and providers are charged with developing policies and implementing mechanisms that ensure safe, efficient, and therapeutically effective care. The theme of this discussion is safety and will address the major aspects of both environmental and personal safety.

Environmental Safety

For purposes of this discussion, the environment is defined as the physical surroundings of the patient and includes such things as lighting, equipment, supplies, chemicals, architectural structure, and the ever present accident potential activities of both patient and staff personnel. Maintaining safety becomes even more difficult when working with people who are ill or anxious and cannot exercise their usual control over the environment. Loss of strength, decreased sensory input, and disability often accompany illness. Because of this, the health care provider must be constantly alert and responsive to maintaining a safe environment.

Both JCAH and the National Safety Council of the American Hospital Association (AHA) have identified four major types of accidents that continually occur to patients. These hazards consist of falls, electrical shocks, physical and chemical burns, fires, and explosions. The most basic of hospital equipment, the patient's bed, is a common cause of falls. Falls occur among oriented patients getting in and out of bed at night in situations where there is inadequate lighting. Falls occur among disoriented or confused bed patients when bedrails are not used or used improperly. Slippery or cluttered floors contribute to patient, staff, and even visitor falls. Patients with physical limitations or those being treated with sensory altering medications fall when attempting to ambulate without proper assistance. Falls result from running in passageways, carelessness when going around blind corners, and personnel and equipment collisions. Unattended and improperly secured patients fall from gurneys and wheelchairs.

Health care personnel can do much to prevent the incident of falls by following some simple procedures, such as properly using side rails on beds, gurneys, and cribs; and locking the wheels of gurneys and wheelchairs when transferring a patient or leaving one unattended. Safety straps must also be used to secure patients on gurneys as well as those in wheelchairs. Maintaining dry and uncluttered floors markedly reduces the number of accidental falls. Patients with physical or sensory deficiencies should always be assisted during ambulation. Those using crutches, canes, or walkers must receive adequate instructions in ambulating with the aids before being permitted to ambulate independently. The total care environment must be equipped with adequate night lights to assist orientation and to prevent falls resulting from an inability to see potential hazards.

The expanded variety, quantity, and complexity of electrical and electronic equipment used for diagnostic and therapeutic care has markedly increased the hazards of burns, shock, explosions, and fire. It is imperative that health care providers at all levels be alert to such hazards and exert a continued effort to maintain an electrically safe environment. Knowledge and adherence to the following guidelines will contribute markedly to providing an electrically safe environment for all personnel whether they be patients, staff, or visitors.

• Do not use electrical equipment with damaged plugs or cords.

• Do not attempt to repair defective equipment.

• Do not use electrical equipment unless it is properly grounded with a three-wire cord and three-prong plug.

• Do not use extension cords or plug adapters unless approved by medical repair or the safety officer.

• Do not create a trip hazard by passing electrical cords across doorways or walkways.

• Do not remove a plug from the receptacle by gripping the cord.

• Do not allow the use of personal electrical appliances without approval of the safety officer.

• Do not put water on an electrical fire.

• Do not work with electrical equipment with wet hands or feet.

• Have newly purchased electronic medical equipment tested for electrical safety by medical repair before putting it into service.

• Operate all electrical and electronic equipment according to manufacturer's instructions.

• Remove from service electrical equipment that sparks, smokes, or give a slight shock. Tag defective equipment and expedite repair.

• Be aware that patients with intravenous therapy and electronic monitoring equipment are at high risk from minor electrical shocks.

• Call medical repair when equipment is not functioning properly or public works if there is difficulty with the power distribution system.

Since accidents resulting in physical and chemical burns have initiated numerous consumer claims of health care provider and facility malpractice, all health care personnel must be thoroughly indoctrinated in the proper use of potential hazardous equipment, supplies, and chemicals.

The following discussion will address common causes and precautions to be taken to eliminate the occurrence of injurious burns. Additional information regarding the equipment and specific procedure for its use will be found in the Nursing Procedures Manual.

• Hot water bottles-a common cause of burns particularly in the elderly, diabetics, and patients with circulatory impairments. When you are filling the bottle, the water temperature must never exceed 125 degrees F (51 degrees C). Test the bottle for leaks and cover it so that there is a protective layer of cloth between the patient and the bottle itself.

• Heating pads-these appliances create a dual hazard of potential burns and electrical shock. The precautions taken when using heating pads are the same ones used for hot water bottles in relation to the kind of patient, temperature control, and protective cloth padding. Precautions to avoid shock consist of proper maintenance of the equipment, preuse inspections and testing of the equipment for wiring and plug defects, and periodic safety inspections that are conducted by medical repair personnel.

• Ice bags-like hot water bottles, ice bags can cause skin contact burns. This kind of burn is commonly referred to as local frostbite. The precautions taken for applying ice bags are the same as those for hot water bottles in regard to attention to elderly, diabetic, and circulatory-impaired patients.

• Hypothermia blankets-like ice bags, this mode of therapy can also cause areas of contact burns. When using hypothermia blankets, check the patient's skin frequently for signs of marked discoloration, indicating indirect localized tissue damage. Ensure that the bare blanket does not come in direct contact with the patient's unprotected skin. This is easily accomplished by using sheets or cotton blankets between the patient and the hypothermia blanket itself. When using this form of therapy, follow both the physician's orders and the manufacturer's instructions in managing the temperature control of the equipment.

• Heat cradles-when using this equipment, protect the patient from burns resulting from overexposure or placement of the equipment too close to the area of the patient being treated. As with heating pads, heat cradles create a dual hazard such as potential burns and electrical shock. Another hazard to keep in mind is that of fire. Ensure that the bedding and the heat source do not come in direct contact and cause the bedding to ignite. Occasionally heat lamps will be used to accomplish the same results as a heat cradle. Do not use towels, pillow cases, or linen of any kind to drape over heat lamps. In fact, no lamps of any kind should be draped with any kind of material, regardless of what purpose the draping is intended to accomplish.

• Steam vaporizers, hot foods, and liquids-these are common causes of patient burns. When using steam vaporizers, ensure that the vapor of steam does not flow directly on the patient as a result of the initial positioning of the equipment or by accidental movement or bumping. Patients may be more sensitive to hot foods and liquids and more likely burned. Also, due to lack of coordination, weakness, or medication, patients may be less able to handle hot foods and liquids safely without spilling.

In the direct patient care units as well as in diagnostic and treatment areas, there are unlimited potentials for inflicting burns on patients. When modern electrical and electronic equipment and potent chemicals used for diagnosis and treatment are used properly they contribute to the patient's recovery and rehabilitation. When these are used carelessly or improperly, these same sources only cause the patient additional pain and discomfort, serious illness, and, in some cases, even death.

Often when we speak of safety measures, one of our first thoughts is of a fire or an explosion involving the loss of life or injury to a number of people. Good housekeeping, maintenance, and discipline help to prevent such mishaps. Remember that buildings that are constructed of fire-resistant materials are not fireproof, and certainly not explosion proof. Good maintenance includes checking, reporting, and ensuring correct repair of electrical equipment, and routine checking of fire fighting equipment by qualified personnel. The education and training of personnel are the most effective means of preventing fires. Used in the context of fire safety measures, good discipline means having a plan to use as outlined in a Fire Bill, having periodic fire drills, and enforcing no-smoking regulations.

Staff members should be familiar with the fire regulations at their duty station and know what to do in case of fire. This includes how to report a fire, use a fire extinguisher, and evacuate patients. When a fire occurs, there are certain basic rules to follow: someone must take charge, remain calm, and notify the fire department and the officer of the day, giving the exact location of the fire. All oxygen equipment and electrical appliances must be turned off unless necessary to sustain life. All windows and doors should be closed and all possible exits clear. All patients must be removed in a calm and orderly fashion, and mustered.

Careless handling of cigarettes is one of the most frequent causes of serious and often fatal accidents. Cigarettes and matches must be removed from the bedside or placed out of reach of the incompetent or irrational patient. Regulations should specify areas and times when smoking is permitted. Patients, visitors, and staff must be informed of the facility's smoking regulations. To be an effective safety measure, these regulations must be enforced by all staff personnel. Smoking stands and ashtrays should be provided only in areas where smoking is permitted. Metal wastebaskets must be used throughout the hospital. They should NEVER be placed under the bed or used for cigarette disposal. "NO SMOKING" signs should be visibly displayed in rooms and areas where oxygen and flammable agents are used or stored. In addition to posting NO SMOKING signs, ALL staff must impress upon the patient and visitors the life-threatening dangers of disobeying or ignoring smoking regulations.

 General Safety Guidelines

In addition to the specifics already presented above, there are some basic principles that are relevant to patient safety. The following concepts should direct the actions of the provider in any health care service environment.

• Familiarity with the environment makes it less hazardous to the individual.

• An individual's body senses inform him or her about the nature of the environment.

• Age and illness affect an individual's ability to perceive and interpret sensory stimuli from the environment.

• All diagnostic and therapeutic measures have the potential to cause a patient harm.

• Documenting and analyzing all accidents and incidents are necessary to identify and correct high-risk safety hazards.

Environmental Hygiene

Today's public is very much aware of the environment and its effect on the health and comfort of human beings. The health care setting is a unique environment and has a distinct character of its own. The health care provider must be aware of that character and ensure that the environment is one that will support the optimum in health maintenance, care, and rehabilitation.

In the context of the environment, hygiene may best be described as those practices that are conducive to providing a healthy environment. Basically, this includes the following three areas of concern: safety (which has already been addressed), environmental comfort and stimuli, and finally infection control (which will be discussed under "Pathogenic Organism Control"). The health care provider has certain responsibilities to control the facility's general environment as well as the patient's immediate surroundings.

Maintaining cleanliness not only provides for patient comfort and a positive stimulus, it also impacts on infection control. Cleanliness is a major responsibility of all members of the health care team, regardless of their position on the team. As a provider, the hospital corpsman, who has the most direct and frequent contact with the patient, becomes very familiar with concurrent and terminal cleaning. Concurrent cleaning ensures that the patient's individual unit is kept neat and clean during hospitalization. Terminal cleaning is performed when the patient is discharged from the unit or hospital. Both concurrent and terminal cleaning are extremely important procedures that not only aid the patient's comfort and psychological outlook but also contribute to both efficient physical care and control of the complications of illness and injury.

Aesthetically, an uncluttered look is far more appealing to the eye than an untidy one. Other environmental factors such as color and noise can also enhance or hinder the progress of a person's physical condition. At one time almost all health care facilities used white as a basic color for walls and even bedside equipment. Research has shown that the use of color is quieting and restful to the patient, and rest is a very important healing agent in any kind of illness. Noise control is another environmental aspect that requires the health care provider's constant attention. The usual number of people and equipment traffic in a facility creates a high noise level and must be monitored. Add to that the noise of multiple radios and televisions, and it is understandable why noise control is necessary if a healing environment is to be created and maintained.

Another important aspect of environmental hygiene is climate control. Many facilities use air-conditioning or similar control systems to maintain proper ventilation, humidity, and temperature control. In facilities without airconditioning, open windows from the top and bottom to provide for cross ventilation. Ensure that the patient is not located in a draft area. Windowsill deflectors or patient screens are often used to redirect drafty airflows. Maintain facility temperatures at recommended energy conservation levels that are also acceptable as health promoting temperatures. In addition to maintaining a healthy climate, good ventilation is necessary in controlling and eliminating disagreeable odors. In cases where airflow does not control odors, room fresheners should be discretely used. Offensive odor-producing articles such as soiled dressings, used bedpans, and urinals should be removed to appropriate disposal and disinfecting areas as rapidly as possible. Objectionable odors such as bad breath or perspiration are best controlled by proper personal hygiene and clean clothing.

Natural light is important in the care of the sick. Sunlight usually brightens the area and helps to improve the mental well-being of the patient. However, light can be a source of irritation if it shines directly in the patient's eyes or produces a glare from the furniture, linen, or walls. Adjust shades or blinds for the patient's comfort. Artificial light should be strong enough to prevent eyestrain and diffuse enough to prevent glare. Whenever possible, provide a bedlamp for the patient. As discussed under "Safety Aspects," a dim light is valuable as a comfort and safety measure at night. It should be situated so it will not shine in the patient's eyes and yet provide sufficient light along the floor so that all obstructions can be seen. A night light may help orient elderly patients if they are confused as to their surroundings upon awakening.

In conclusion, it is important that the health care provider understand the effects of the environment on the patient. Most persons are more sensitive to excessive stimuli in the environment when they are ill and often become irritable and unable to cooperate in their care because of these excesses. This is because their body is already under stress due to their illness and does not have the energy to cope with added stimuli. This is particularly apparent in critical care areas (e.g., in CCUs and ICUs) and isolation, terminal, and geriatric units. It is important that all health care providers realize and respond to the vital importance of the environment in the total medical management plan of each patient.

Pathogenic Organism Control

All health care, regardless of who provides it or where it is provided, must be directed towards maintaining, promoting, and restoring health. Because of this, all persons seeking assistance in a health care facility must be protected from additional injury, disease, or infection. Adherence to the principles and practices of safety aspects protects a patient from personal injury. Additionally, attention to personal and environmental hygiene not only protects against further injury but also constitutes the first step in controlling the presence, growth, and spread of pathogenic organisms. Some of the basic concepts of personal hygiene and communicable disease control are addressed in the "Preventive Medicine" chapter of this manual. Additional information concerning patient-related personal hygiene will be found integrated throughout various sections of this chapter. The discussion that follows addresses infection control particularly in the context of medical and surgical aseptic practices.

Medical Asepsis

Medical asepsis is the term used to describe those practices used to prevent the transfer of pathogenic organisms from person to person, place to place, or person to place. Medical aseptic practices are routinely used in direct patient care areas as well as in other service areas in the health care environment to interrupt a chain of events necessary for the continuation of an infectious process. The components of this chain of events consists of the following:

Infectious Agent - An organism capable of producing an infection or infectious disease.

Reservoir of Infectious Agents - A carrier on which an infectious agent depends primarily for survival. The agent lives, multiplies, and reproduces so that it can be transferred to a susceptible host. Reservoirs of infectious agents are man, animal, plants, soil, or organic matter. Man himself is the most frequent reservoir of infectious agents pathogenic to man.

Portal of Exit - The avenue by which the infectious agent leaves its reservoir. These avenues include various body systems, such as respiratory, intestinal, and genitourinary tract, and open lesions when the reservoir is a human.

Mode of Transmission - The mechanism by which the infectious agent is transmitted from its reservoir to a susceptible being (host). Air, water, food, dust, dirt, insects, inanimate objects, and other persons are examples of modes of transmission.

Portal of Entry - The avenue by which the infectious agent enters the susceptible host. In the human being, these correspond to the exit route avenues, including the respiratory and gastrointestinal tracts, and through a break in the skin or direct infection of the mucous membrane.

Susceptible Host - A human being or other living organism which affords an infectious agent nourishment or protection to survive and multiply.

Removal or control of any one component in the above chain of events will control the infectious process.

Two basic medical asepsis practices are handwashing and linen handling procedures. Frequent handwashing and proper linen handling are absolutely essential practices for preventing and controlling the spread of infection and transmittable diseases. The following are some common instances when provider handwashing is necessary: