Patient Case Study 5000 words

Self assessment of the transcribed section.

 

When I entered the room I greeted the patient, used his name, introduced myself, explained my position as 3rd year medical student and we shook hands. I ensured that the gentleman was comfortable and that I was not disturbing him. I should have recorded this. However, when I commenced recording I started by thanking the patient for talking to me and asked if he was happy for me to record the interview. I went onto explain that if he wanted to stop at any point there would be no problem. In doing this I felt that I was respecting his wishes and empowering the patient.

 

I then moved on to an open ended question and asked “when did you come into hospital”? And “what was the reason”? I felt that this was the best way to begin as it gave the patient an open forum to speak and explain what had happened in his own words. I started early on in the interview to acknowledge the patient when he spoke but found that I kept saying “ok” after his responses. I could have responded to the patient in other ways to sound less repetitive but it did show that I was listening and acknowledging. In many cases the response of “ok” led onto another question and it was very useful in linking sentences.

 

I asked the patient when he last felt well. This allowed him to start at the beginning and give an account in chronological order. The patient did this and mentioned some symptoms that he had been experiencing. I allowed him to finish and then used another open question about his cough to direct the interview. I continued to listen attentively and acknowledged everything that the patient was saying by once again using “ok”. I perhaps could have used a pause instead of the word ok but I was reinforcing this with positive body language such as nodding my head. I felt for the benefit of the tape I had to say something after everything the patient said. This is not always necessary as I have realised.

 

I did experience areas of the interview where the patient did not understand my questions. For example I asked the gentleman how much blood he was coughing up. I used a comparison of a teaspoon. The patient did not understand this and it would have been better to say “was there much blood” or simply leave it at “how much blood was in the phlegm”?  I then clarified what I meant and used another comparison of a cup. The patient then pointed to a level on the cup besides his bed and this made it very clear for me how much blood he was coughing up.

 

There was a section of the interview concentrating on Mr ND’s chest pain. I obtained the information I required by asking directed questions but then encountered another area where the patient did not understand the question. Simply by changing my word from “short of breath: to “were you struggling to catch air” and then clarifying it by saying “you were puffy” the patient understood my question. I could have avoided the phrase short of breath because for many people it has a difficult meaning and it is used so freely in medicine without thinking, like so many other terms.

 

This situation arose again when we were talking about reliving factors. I asked if painkillers had helped, but as soon as I changed this to paracetamol or tablets it became clear to the patient. This is something that I will really learn from. You must use layman terms wherever possible as it will ease the conversation and prevent pauses and periods of misunderstanding which may impact negatively on the relationship and rapport with the patient.

 

Another area which I fell did not show enough empathy was when the patient was explaining about his chest pain, how it would wake him from his sleep and his struggling to catch air. On reflection I should have acknowledged this more for example “that must have been scary for you” and then paused rather than continue with my questioning.

 

There were areas were I felt confused, especially about the visits to the GP. So I asked for clarification, allowed the patient to summarise the events and continued to listen; I acknowledged this by saying “ok” or “right”. There was a point when the patient interrupted in order to correct me but I continued with my sentence. On reflection I should have paused to allow the patient to clarify the point.

 

To show that I had understood and now had a clear picture in my head about all the events I summarised what had occurred before we moved on in the interview. I paused at points during the summary, this gave the gentleman a chance to agree and correct me. I think this summary was a very important area of the interview as it helped to build greatly on my rapport with the patient as it showed that I was fully listening and understood what had occurred.

 

I then thanked the patient for making it clear to me a second time. The interview was then changing direction form the history of the presenting complaint to past medical history. I found the use of signposting made the change very easy and it also directed the patient and provided structure.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Discussion of the overall interview.

 

Recording of a patient clerking has raised many important points and analysing this has been a valuable learning process. In considering the patient response to the interview I feel that Mr ND reaction appeared positive. However, it could be said that I did not give him the opportunity to reflect on the interview process. In future I think could ask the patient how they found my style of questioning and if they think anything may be improved upon. It is important to do this as student and use the opportunities given to you.

 

On listening to the recording it was interesting to note how my impression of Mr ND’s emotions changed after the interview. During the interview I felt Mr ND was angry with the treatment and advice he had received from his general practitioner. However, on re listening Mr ND sounds withdrawn and perhaps anxious. There was evidence of intonation when asked if he was feeling better since receiving treatment in hospital and he sounded more positive in tone and outlook. I had not picked up on these points during the interview and this was a great benefit of recording and re-listening. The reason I missed this important area could have been due to me concentrating too much on gathering essential information of Mr ND’s presenting complaint. I have realised that it is crucial to not only take a history but communicate with patients on all levels and build a working relationship.

 

On reviewing the interview I felt that it flowed well with few pauses or difficult moments. This was helped by signposting and good preparation. The only areas of repetition arose when I was summarising or clarifying areas. I felt that this was essential to show the patient that I had been listening and to ensure that I understood events correctly.

 

The gathering of information was made easier by the use of open ended questions with some guided questions if the patient did not understand. I felt that this type of questioning allowed Mr ND to elaborate on events and paint a picture of his illness over the four week period. Mr ND responded well and understood when I rephrased sentences that I had use medical terms for example “shortness of breath” with lay terms.

 

On further review of the recording I realised that I had forgotten to ask Mr ND about his family history. Taking this history can be very important when trying to build up a picture of the patient. Their family history may point to illnesses which run in the family and you must be aware as the patient may be at increased risk, for example a family history of cancer.

 

 

 

 

On reflection if I could do the interview again I would explore the patient’s family history further and avoid medical terminology. I would have also included the areas of the introduction that I did not record at the star which I have discussed in my reflection of the transcription. Further to this I could have shown more empathy when Mr ND was discussing his chest pain. I will also remember in future that if a patient interrupts me to correct me on a point I will stop, acknowledge the patient and pause with my sentence. Other than this I regard the interview process as having been successful and take may positive points from this process. I gained nearly all the information I required and fulfilled the functions of the medical clerking. I successfully managed to build a rapport with the patient and this is evident when the patient is freely discussing his concerns over his treatment by his general practitioner.

 

 

Section 2:  The Medical History (see handwritten section).

 

Section 3a:  The Examination Findings (see handwritten section).

 

3b:  The Initial Assessment (see handwritten section).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 4: The Psychosocial Aspects.

 

There are some important psychosocial issues that must be considered in the case of Mr ND.

 

Mr ND had been made aware early on during his admission that there was a possibility that he may be suffering from pulmonary tuberculosis. As a result of this possible diagnosis and under the hospital infection control policy Mr ND had been moved to a side room and was being barrier nursed. The possible diagnosis of tuberculosis and being placed in an isolation room can have serious psychosocial implications. On reviewing the recorded interview I appreciated this more as Mr ND sounded quiet and withdrawn and this appeared to be in relation to his isolation, how long it would last and missing his family. Gammon (1999) suggests that isolation can be an extremely frightening and anxiety provoking experience. He also describes feelings of confinement, imprisonment, stigmatism, anger, depression, low self esteem and lack of control. These were feelings and that Mr ND was starting to experience and as stated this was reflected in the tone of his voice and body language.

 

When making the decision to move a patient into isolation the staff must involve the patient in this. It is vital that patients are involved in the planning and implementation of their care. The Department of Health’s (DoH 1998) publication “A first class service: Quality in the new NHS”outlines the importance of this involvement and interaction in the delivery of their care. When working in partnership with patients, healthcare staff must have an understanding on the importance of effective communication. Communication is a large part of a doctor’s role and should be a two-way process between him and the patient; it is an important factor in building a trusting, working relationship. The doctor must possess well developed communication skills in order to explain the treatment plan to the patient and address any issues the patient may raise.

 

It has been observed in practice that patients appear to be far less anxious when provided with adequate information; this allows them to be relaxed and more satisfied with the care they are receiving. A major challenge in today’s multicultural society associated with communication is language; the doctor should not presume that just because the patient lives in England that they can speak the language. It can be assumed that patients who do not speak English are less likely to receive adequate information; if they do not have the knowledge they are unable to make informed decisions. In such instances the doctor must ensure an interpreter is available at the earliest opportunity to provide an adequate explanation in the preferred dialect and gain informed consent.

 

 

 

 

The duration of isolation is also a factor that can be detrimental to a patient. Mr ND was unsure of how long his isolation would last. According to Rees (2000) it is very important to give a patient an estimated length of stay as a patient with a poor perception in isolation is more likely to be anxious or withdrawn. This withdrawn feeling applies to Mr ND and it is a very challenging area as positive test result for a diagnosis of pulmonary tuberculosis can take many weeks.

 

One method of trying to overcome these feelings related to isolation is to encourage visitors. Despite isolation visiting should be encouraged as it can satisfy an emotional and social need. Regular visitors can prevent boredom and loneliness. The regular visits of family members and close friends provide an important social context within which health is maintained and illness resolved (Bond and Bond 1994). It is crucial to inform visitors of the infection control measures and ensure compliance to minimise further transmission.

 

It was hard to determine how Mr ND was feeling about the possible diagnosis. On reflection and a further unrecorded discussion he was un-phased and more concerned with isolation and time away from work. This brings to the forum the psychosocial issues of work and illness. An illness which results in time off work can lead to loss of earnings, a feeling of low self esteem and inability to provide financially and emotionally for their family. These are all emotions and feelings that Mr ND appears to be experiencing from our interview.

 

Although there has not been a positive diagnosis of pulmonary tuberculosis consideration must be given to the treatment regime and its compliance. Adherence to treatment in the general sense depends on the patient’s understanding of the aims, benefits, possible side effects and importance of sticking to a set regime, and also their acceptance of their illness and the need to treat it. The main reasons that patients may not adhere to treatment are complex regimes that are hard to remember, no obvious benefits of treatment and the perceived consequences of the illness. The medication for tuberculosis is also likely to have side effects which can affect compliance.  It can be difficult for patients to perceive benefits when they have there are numerous side effects.

 

 

 

 

 

 

 

 

 

 

 

 

The main factors influencing adherence are illustrated in the following diagram (adapted from Ley 1997).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

It shows that adherence is most likely when patients understand the aims of their treatment and the benefits. Thus it will be very important to explain fully to Mr ND the above issues to ensure adherence to a possible treatment regime. This will ensure the best possible outcome for the patient.

 

It is recognised that psychosocial factors may contribute to the spread of pulmonary tuberculosis. Close contact with individuals who are affected with tuberculosis will increase your risk of infection. This most commonly occurs in over crowded housing conditions. However, the issues of overcrowding do not apply in Mr ND’s case. It was asked if he had travelled recently as this may have been a cause, but there was no recent travel. Therefore it was very difficult to relate psychosocial issues to an increase in Mr ND’s vulnerability to tuberculosis.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 5: Ethical Issues:

 

Before starting the recording of the interview it was necessary to consider the issue of consent. I explained to the patient exactly who I was, what the interview process involved and if he was happy for the interview to be recorded. This consent was not only required for the interview to be recorded but was essential if I was to examine the patient. Obtaining consent is a fundamental part of good medical practice and under pins the doctor patient relationship and fundamentally trust.

 

Informed consent is one of the key moral aspects surrounding a patient’s autonomy.  The patient must be competent to make their own decisions and they must have been provided with all available options and information of these options. The patient must have a reasonable understanding of the information and its consequences, and they shouldn’t be pressurised or coerced into a decision.  If a competent individual has not consented to a procedure or feels that they have been provided with insufficient information to allow an informed decision about treatment options, then a doctor can be accused of committing the crime of battery.  Further to this, the doctor will not have respected the patients’ autonomy, therefore breaching his second duty of care in medicine.

 

The information that should be included in informing the patient is as follows:

 

  • an explanation of what is wrong with the patient;
  • details of all the available treatment options, including the consequences of receiving no treatment;
  • reasons why some treatments may not be appropriate for the patient;
  • benefits and risks of treatment;
  • prognosis associated with each of the treatment options.

 

Therefore in gaining consent for the recording, history and examination I ensured that the patient was competent, not coerced and informed to a reasonable standard what will be involved in the history and examination process.

 

There were no issues in this case that made obtaining consent difficult and once verbal consent had been obtained Mr ND signed the attached consent form to state that he was happy for the recording.

 

Following gaining appropriate consent it is just as important to respect the confidentiality of the patient. General information regarding a patient’s health and care is confidential and is confined to those individuals involved in the patient’s treatment. Health care professionals are not permitted to divulge information regarding the patient without the consent of the person involved. If a patient’s case is discussed outside the team involved in their care, then the patient’s identity must not be disclosed.

Any personal information, unrelated to their health, told by a patient during an interview or in conversation must be kept confidential unless the patient gives permission for disclosure. However, there are occasions where these rules to not apply:

  • Patients have infectious diseases which must be notified, through informing the relevant local authority officer.
  • Police request information about patients who have been involved in a traffic accident.
  • Patients are suspected of engaging in terrorist activity in the United Kingdom.
  • Doctors are presented with a court order by a judge or asked to do so by a judge in judicial proceedings.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 6: Nursing and Paramedical Care

 

I spoke to two senior staff nurses involved in the care of Mr N D. They informed me that care for the patient is based on Roper et al’s (1983) nursing model which encompasses the 12 activities of daily living.  These include:

 

  1. Maintaining a safe environment. Mr ND is able to self care and maintains his own environment within the constraints of the hospital. It is the responsibility of the nursing staff to ensure a safe environment

 

  1. Communication. Mr ND’s communication may be affected by his shortness of breath. Staff need to be aware of this and provide aids if necessary to encourage good communication. For example the use of a pen and paper or allowing the patient sufficient time to speak and pause in shortness of breath.

 

  1. Breathing. Mr ND’s breathing is compromised. This requires close observation and treatment. It is necessary to make the medical team aware, ensure the provision of prescribed medications such as oxygen, optimal positioning for respiration, collection of any sputum and monitoring respiratory rate and oxygen saturation on a regular basis.

 

  1. Eating and drinking. The patient has a decreased appetite. This must be monitored by the nurses. This starts with recording Mr ND’s weight on admission and then close monitoring during his stay. It is essential to monitor his food intake using a chart. This can be completed in partnership with the patient and nursing staff. In Mr ND case this had occurred and he was referred to the dietician for nutritional support.

 

  1. Eliminating. Mr ND had no issues with passing urine or his bowel habit. However, due to his decreased food intake the nursing staff were aware of the increased risk of constipation.

 

  1. Personal cleansing and dressing. Mr ND is fully independent and able to maintain this despite the shortness of breath which may be limiting to his ability in performing personal hygiene activities.

 

  1. Controlling body temperature. Mr ND has a mild temperature and as requested the nursing team were carrying out regular observations and providing paracetamol as prescribed by the medical team. This increased temperature can also impact on Mr ND’s personal hygiene and ability to maintain it. The role of the nursing team further extended to providing a fan and sufficient quantities of water for Mr ND to ensure adequate hydration

 

  1. Mobilising. Mr ND is mobilising independently at present but the nursing team were aware that this could be compromised at any point by his shortness of breath and chest pain.

 

  1. Working and playing. Mr ND clearly stated to me and the nursing team that his illness had been hard for his wife. It left her having to work and support the household on her own. Mr ND was finding it difficult to cope with the position his illness had put his wife in. The nurses understood that this psychological aspect could affect Mr ND’s outcome.

 

  1. Expressing sexuality. Mr ND’s expression of his sexuality may have been affected for example he may believe he is the dominant figure in his household and his illness could have shifted this.

 

  1. Sleeping. The patient’s illness had resulted in a month long period of disturbed sleep. This was being addressed on the ward as Mr ND was in a side room which was quiet and also prescribed a sedative at night.

 

  1. Dying. As far as all of the team involved were aware Mr ND had no fears that his illness would lead to his death. But as the nurses clearly stated you never now how a case will turn out so you must unfortunately be aware of unexpected outcomes.

 

Encompassing the activities of daily living the nursing care of Mr ND on the ward was organised in the following way. The nursing team started their morning shift with handover, after which they make the patient’s beds and assist patient’s who require help with their hygiene needs. Breakfast is also served at this time and some patients also need assistance with eating theirs. During the morning the nursing staff attend doctors ward rounds, multi-disciplinary team meetings and feedback the outcomes of these meetings to the rest of the staff. Prior to lunch being served the drug round is carried out. At the same time as all of this is happening the nurses deal with any situations that may arise, for example, new admissions. After lunch there is a second handover to the late staff where any new developments are communicated. During the afternoon the nursing staff attend any remaining doctors rounds and perform outstanding tasks not achieved in the morning. Visiting hours are also during this time. The drug round precedes supper being served and a rest period follows. The night staff receive a handover, they carryout a drug round then settle the patients for sleep. During the night the nurse’s main tasks involved answering patient call bells, helping with hygiene and toilet needs, giving medications and welcoming new emergency admissions. Finally the night staff hand over to the day shift and the cycle begins again.

 

 

 

As mentioned the nursing handover occurs on 3 occasions between shifts and ensures that all relevant information about Mr ND would be passed on to the next nursing team. This included any changes in condition, relevant investigations carried out that day, results and the medical teams plan. An example of a nursing handover is:

 

“Side room number  … is Mr ND who’s 31 years old. He was admitted on the 17th May suffering with shortness of breath, chest pain and a productive cough. He is producing blood stained sputum and a sample has been sent to check for TB. Due to this he is being barrier nursed, he is aware of the possible diagnosis. He is self caring and independently mobile. He is on IVAB, regular oral analgesia and QDS observations.  He has been seen today by the doctors on the ward round, the plan is: await TB screen, continue IVAB, continue QDS observations and review by respiratory team. He has voiced no concerns and understands his treatment plan”.

 

Much emphasis has been placed on the role of the nursing team but there are many more individuals that are involved in Mr ND’s care. The team comprises:

 

  1. Cleaners: keeping the environment clean.
  2. Bed manager: providing an isolation room.
  3. Laboratory staff: processing investigations and making results available
  4. Porters: transferring the patient for investigations.
  5. Health care assistants: working closely with the nurses and involved directly in day to day care of patient.
  6. Catering staff: providing meals
  7. Dietician: addressing weight loss and ensuring good calorific intake
  8. Pharmacist: regularly checking drug chart to ensure it is correct.
  9. Infection control nurse: involved with barrier nursing.
  10. General Practitioner: especially involved in follow up.
  11. Physiotherapists.
  12. Phlebotomists.

 

Mr ND was not being considered for discharge at this point but there are a number of factors that need to be discussed prior to this. The most important being a positive diagnosis of TB. This would result in a strict regime of medication that would need to be taken for up to 6 months with regular out patient reviews. This regime of medication would have to be started whilst in hospital and continued at home. The patient will need to be discharged with an appropriate quantity to take home. It would be important to ensure that Mr ND understands the need and importance of the medication and when exactly to take it. Home situations also need to be considered fully, with particular emphasis on his ability to care for himself and is there adequate home support or does this support need to be provided. All of this information would then need to be transferred to Mr ND’s general practitioner for future reference and continuity of care.

Section 7: Critical Appraisal

 

Volmink, J. and Garner, P. (2006) Directly observed therapy for treating tuberculosis (Review) [online] The Cochrane Collaboration, Issue 2. John Wiley & Sons Ltd.

Available from: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003343/pdf_fs.html [Accessed 20/05/2007].

 

The aim of this review was to compare directly observed therapy (DOT) with self administration of therapy in people requiring treatment for clinically active tuberculosis or prevention of active disease. This involved 10 studies with 3985 participants. These 10 studies were further broken down into 7 in low or middle income countries and 3 in high income countries. These groups were randomised and quasi-randomised controlled trials, studied over a given period of time (longitudinal study).

 

The authors identified relevant studies through an extensive database search which included the Cochrane Central Register for Controlled Trials (CENTRAL), the Cochrane Infectious Diseases Group Specialised Register, MEDLINE, EMBASE, LILACS. Various organisations were contacted, for example The World health Organisation and The Centres for Disease Control and Prevention. Individual researchers working in the field of tuberculosis were approached as sources of information and the reference lists of the studies identified were also used.

 

The review included the appropriate type of studies by using ones which were longitudinally based, randomised and asking clearly focused questions. However, not all the studies were blind, which can create bias and not make the study flawless.

 

Many of the trials were conducted in countries where English may not have been spoken. It does not state whether the trials were conducted in English or in the native language and translated. However, it does indicate that all relevant trials were identified regardless of language or publication status. Therefore it is fair to say that the reviewers attempted to identify all relevant studies.

 

The reviewers assessed the quality of the studies to be included using an allocation sequence. This was supported by a minimum of 2 authors identifying suitable studies for inclusion. To be involved people must have been receiving treatment for active tuberculosis or prophylactic medication for the disease. However, a scoring system was not used.

 

The results of the studies have been combined in the body of the text and tables at the end of the article. There are some individual result tables and some comparative ones. This was reasonable due to the size of the review which, as mentioned, included ten studies with 3985 participants. The results have been discussed under four headings which enabled an easier interpretation of the results and comparison. Variation and bias in the results has been identified. It was suggested that in some studies treatment allocation concealment was not adequate due to the absence of blinding.

 

The results are expressed as random relative risk with confidence intervals. In one sentence these results can be summarised as:

 

Directly observing people administering their tuberculosis medication does not improve the cure rate when compared with patients self administering their drugs.

 

Having these results it now needs to be considered if they can be applied to the local population. The population samples included in the review come from many countries making coverage extremely diverse. This can be applied to the local population of East London which itself is ethnically broad. The results in our local community may differ as it may be considered easier to conduct a gold standard double blind randomised control trial in a local population.

 

The review considered a number of important outcomes such as:

 

  • Completion of course of treatment
  • Cure rate
  • Patients not followed up
  • % of medication taken on time
  • Missed doses of medication
  • Treatment failure
  • Death of patients

 

From the individuals point of view the best outcome would be completion of treatment and a cure. The results suggest that there were no more successful outcomes if the treatment was self administered or directly observed.

 

For professionals the outcomes may impact on clinical practice. DOT in low and middle income countries was not shown to improve cure or treatment completion in people with tuberculosis or those using it for prophylaxis. Clinicians working within these settings should be aware of these suggestions and avoid the use of expensive and time consuming treatments such as DOT in which patients much be regularly monitored for long periods of time.

 

Families and carers will be affected in a similar way to the individual. However, family and carers can play an important role in the motivation to adhere to and complete treatment. Failure to comply with treatment can then impact on the community as incidence of tuberculosis may rise.

 

 

 

Considering the points discussed should practice change as a result of this review? No. The review found that there were no more successful outcomes if the treatment for tuberculosis was self administered or supervised by DOT in low or middle income countries.  It suggested that directly supervised treatment was expensive and controversial with no sound evidence to continue routine use. However, it must be considered that some of the studies are flawed due to the omission of blinding. This may have led to bias making the study questionable. No recommendations for clinical practice were made for higher income countries. Therefore prior to changing practice in these communities more research is required.

 

 

Summary of key points:

 

This article is a review for two different types of treatment delivery for tuberculosis. Treatment for tuberculosis involves many months of medication and compliance with this treatment regime can vary greatly. It has been suggested that medication can be given to the patient to take supervised or unsupervised. This review attempts to compare the outcomes of these two methods for preventing tuberculosis or treatment of active tuberculosis.

 

The authors have used a wide range of sources to collect this data involving 3985 individuals in ten studies. They have assessed the data using statistical analysis to ascertain if there is a benefit to taking tuberculosis medication supervised or unsupervised.

 

The results showed that there is no statistical difference between supervised and unsupervised administration of medication in lower and middle income countries.

 

Thus directly observing patients taking medication does not improve the rate of cure compared with those patients self administering their medication without supervision. The provision of directly supervised therapy is expensive and the review shows that there is little valid research to support its use. The authors conclude that further research with tighter method guidelines to remove any bias in the results is required.

 

 

 

 

 

 

 

 

 

References:

 

Bond, J. and Bond, S. (1994) Sociology and health care: an introduction for nurses and health care professionals 2nd edition London, Churchill Livingstone.

 

Department of Health. (1998) A first class service: Quality in the new NHS [online] London, DoH. Availablefrom: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4006902  [Accessed 12/05/2007].

Gammon, J. (1999) The Psychological Consequences of Source isolation: a review of the literature Journal of clinical Nursing [online] 8(1): 13-21

Available from: http://www.biomed.niss.ac.uk/ovidweb [Accessed 12/05/2007]

 

Porter, M. Alder, B. Abraham, C. (2000) Psychology and Sociology Applied to Medicine. Edinburgh, Churchill Livingstone.

 

Rees J 2000 Psychological effects of Isolation Nursing (2): patient satisfaction      Nursing Standard [online] 14 (29): 32-6

Available from: http://www.biomed.niss.ac.uk/ovidweb [Accessed 12/05/2007]

 

Roper, N. Logan, W. and Tierney, A. (1983) Using a model for nursing Edinburgh, Churchill Livingstone.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Glossary:

 

PC      Presenting complaint

 

HPC   History of presenting complaint

 

PMH   Past medical history

 

DH     Drug history

 

SH      Social history

 

CVS   Cardiovascular system

 

RS      Respiratory system

 

GIT    Gastrointestinal system

 

GUS   Genitourinary system

 

JVP    Jugular venous pressure

 

PR      Per rectum

 

S        Subject

 

O        Objective

 

A        Assessment

 

P        Plan

 

I         Information for the patient