Interpersonal Relationships in the Clinical Setting

Interpersonal relationships are defined as interactions taking place between individuals and other individuals and groups. There are two types of interaction—actions and reactions or cause and effect. When these interactions unite individuals and groups into teams whose members mutually support one another to accomplish their goal, good interpersonal relationships are developed. Since the goal of health service is to restore a patient to physical and mental health, good interpersonal relationships among office personnel and between office personnel and patients are essential.

      TEAMWORK

It would be a mistake to think that good interpersonal relationships apply only in treatment units. Application must be throughout, including the reception area and the business desk. Through good interpersonal relationships, the patient receives the total physical and mental care that only team effort can provide. Authoritative studies have show that patients sense and react to the harmony or lack of harmony shown by members of a health-care team as they perform their duties. Personnel who work well with their group and others experience a feeling of harmony and job satisfaction that is communicated to patients. Because of this feeling, patient care improves. When a patient feels secure and accepted and has confidence in the team effort of personnel caring for him, he is motivated to help himself toward recovery. Thus, good interpersonal relationships help all areas concerned with patient care.

      PERSONAL GUIDELINES

Development of good interpersonal relationships is not always easy. They are easier to describe than to achieve, and there are few never-fail formulas that apply in all situations. Some guidance can be given, however, for developing good interpersonal relations:

1. Understanding Oneself.   The foundation for good relations with others is a state of good relations with oneself. Self-understanding and self-acceptance based on a realistic self-image and a genuine feeling of self-esteem justified by performance should not be confused with smugness, They are ingredients of an effective relationship with others. Just as each person is unique, each must accept the right of another person to differ within socially acceptable limits. Thus, in any instance in which relationships are less than the best, each person must first look within to see if a contribution has been made to the faulty relations.

2. Understanding the Line of Authority.   Each CA team should clearly understand her responsibilities and authority. She should observe the prescribed organizational relationships both in accomplishing one’s own assignment and in helping others. Each person functions effectively when working within the prescribed limitations. Every event must have goal lines and clearly defined boundaries.

3. Understanding the Need for Patient Orientation.   Since patients experience a distinct feeling of loss of control over what is happening to them during health care, all personnel having face-to-face contact with them should be considerate of the emotions involved. Patients need kindness, sympathy, and simple courtesy, as well as competent technical care cheerfully given. If patients know what to expect from health-service personnel and what the office expects of them, they will be less apt to become apprehensive, critical, or demanding. Orientation is essential for cooperation.

Legal Aspects of Clinical Health Care

The public has special trust and confidence in the healing professions and in the institutions and organizations that provide health care and treatment. Since laws are written primarily to safeguard the public welfare, those that apply to the provision of health services have special significance. The fact that incompetence in providing health services might result in the loss of health or even of life is recognized.

Any activity involving remedial treatment of a patient is a medical act, and many paraprofessional activities are conditioned or dependent on the order and direction of the doctor-employer. The practice of chiropractic is strictly controlled by licensing, but chiropractic practice acts may permit delegation of certain health-care activities if certain conditions are met. The legal right to perform acts defined as medical acts is conditioned on (1) training and skill, which give the ability to understand the cause and effect of the act performed; (2) the act being performed on the order of a doctor; and (3) the direction and supervision of the act remaining the responsibility of the physician. The paraprofessionals right to perform various duties is also conditioned by the order, direction, or supervision of a licensed physician. In general, diagnosing, prescribing, and treating are medical acts in the generic sense.

Functions and activities for which paraprofessionals will be responsible are even more difficult to summarize than professional functions. Examples of established functions that a nonprofessional performing a clinical function would be expected to do include:

1. Environmental and physical management of the patient, providing suitable surroundings and personal hygienic measures for safety and comfort.

2. Factual observation, reporting, and recording of overt clinical signs and symptoms.

3. Performance of selected clinical procedures, with an understanding of cause and effect, in support of the doctor’s orders.

4. Assistance in examinations, treatments, and diagnostic tests and procedures under the direction and supervision of the doctor.

A listing of typical duties of a chiropractic technical assistant is shown in Figure 13.1


These functions are performed under the supervision of a licensed practitioner, in conformity with state laws and regulations:

Diagnostic Assistance

Assists in the doctor's diagnostic procedures
Records the doctor's examination findings
Records general body measurements
Records height and weight data
Gathers vital signs, general vision data
Collects blood and urine samples
Conducts in-office laboratory tests
Prepares patient x-ray identification markers
Conducts assigned x-ray patient positioning and exposures
Conducts x-ray film processing

Therapeutic Assistance

Conducts certain physiotherapeutic applications
Conducts massage and muscle therapy
Explains and distributes diet and exercise regimens
Teaches routine home-therapy and rehabilitative procedures

Clinical Administrative Functions

Processes work and school leaves or absences
Processes narrative and medicolegal reports
Processes state health reports (ie, reportable diseases)
Processes external laboratory requests
Maintains laboratory data files
Checks outside laboratory invoices
Maintains roentgenography files
Checks clinical supply shipments
Maintains clinical supply inventory control
Sterilizes clinical instruments
Maintains cleanliness and sanitation of clinical areas and equipment

Patient Relations

Orients patients to pertinent equipment and procedures
Explains the necessity of patient cooperation for optimal recovery
Teaches good health habits and hygiene
Performs assigned counsel to patient's family when necessary

      CLINICAL NEGLIGENCE

There is no uniform code of health-care law, but there are laws that have special significance in care and treatment areas. A basic rule of law applying in the provision of health services is the rule of negligence, explained in the previous chapter. Every one, professional and nonprofessional, has an absolute duty to conduct himself and his property to avoid injury to the person or property of others.

Although the spirit of service to others is a key principle in the performance of health-care duties, there are responsibilities extending beyond being kind and thoughtful in the provision of services. When services are provided, there is an obligation to use due care to assure that the patient is not injured by negligence, which can be defined simply as failure to exercise due care in relation to a person to whom care is due. But law is not usually so simply defined. A more complicated legal definition of negligence is “the doing or failure to do the act, pursuant to a duty, that a reasonable person in the same or similar circumstances would or would not do and the acting or nonacting is the proximate cause of injury to another person or his property.” Law holds every individual responsible for his acts of negligence. Negligence is commonly held to be an unintentional injury, but once an act has been performed and injury results, the performance of the act and the consequence of the act are facts. Thus, negligence is one of the most common causes for lawsuits against health-care personnel. Examples of the effects of negligence include injuries caused by faulty equipment, burns from applications of heating devices, improper use of traction, therapy errors, falling, and careless handling of instruments.

The law of negligence applies in almost all medicolegal problems that arise when, in the course of treatment, something is done that interferes with the rights and privileges of a patient. Under our form of government, however, there is legal recognition of unforeseeable, unavoidable, or inevitable accidents. Responsible authority provides for investigation to establish the facts of an accident or incident, and the facts are usually obtained when five questions are asked: when, where, who, what, how? These questions are not asked to establish guilt or innocence but to establish the facts on which a legal decision can be made.

      Laws Governing Licensure

Professional practice acts are laws controlling the practice of legally recognized professions. The purpose of these acts is to protect the public from persons unqualified to practice. In general, professional practice acts:

(1)   define the chiropractic profession;
(2)   provide standards that control the preparation for practice;
(3)   provide for licensure; and
(4)   through licensure, define by law who shall be licensed to practice and under what terms.

Paraprofessional care is doing needful and helpful things for and with a sick or injured person to restore him to the best possible state of physical and mental health. These needful and helpful things include environmental, hygienic, therapeutic, and supportive measures to protect the patient against contracting any additional pathologic condition, physical or emotional. Body, mind, and spirit must all receive consideration.

Several different members of an office team may assist a patient, each of whom contributes something toward the patient’s welfare. Each member must understand and respect the role of others. Each must know where she fits in, what she is to do, to whom she is responsible, and how she is to do her part. Otherwise, proficient team function is impossible.

Basic Attributes

The technical assistant may perform any of a number of duties common to the provision of paraprofessional care for sick and injured individuals. To function effectively in this role, she must possess certain personal qualities. Many of these attributes are inherent (belonging to the nature of the individual), others must be cultivated and improved on, and all are interdependent. Basic traits of a reliable assistant include:

1. Aptitude.   This is potential capacity for learning and performing a duty. The ability to anticipate needs of patients, to make appropriate decisions, and to adapt to various working conditions; intelligence; and a fairly high degree of manual dexterity show an aptitude for paraprofessional duties.

2. Interest.   Interest in a duty assignment is a reflection of morale and leadership. It is a strong motivating force to perform satisfactorily. Interest leads one to improve on abilities and job-related knowledge. Experienced assistants should strive to stimulate and encourage less experienced individuals.

3. Attitude.   Attitude is a manner of acting, feeling, or thinking that shows the individual’s disposition or opinion. It is the action that speaks louder than words. A desirable attitude is one that leads to:
   (a) cooperation and understanding among people working together;
   (b) concern and consideration for the welfare of patients; and
   (c) a sense of satisfaction in knowing one’s job, with a resulting series of positive accomplishments. The gratitude of patients who have been helped to recovery is an extra but not minor dividend.

4. Personal Hygiene.   Personal hygiene is usually considered personal cleanliness. It is that, but it is also anything that promotes positive or total health, which includes mental hygiene.

5. Cleanliness.   Scrupulous body cleanliness and clean well-fitting uniforms, shoes, and underclothing are essential. Body odors are offensive, yet the offender may be unaware of her offense. Daily bathing, use of body deodorants, and good oral hygiene are assurance against such odors. It is also good practice to wear a freshly laundered uniform daily, especially in patient-care areas.

6. Mental Hygiene.   Mental hygiene is the practice of good habits of the mind. Good mental habits can be cultivated. These habits are as necessary to health as safe food and water are to body systems. A mentally healthy adult enjoys life, works well with others, and takes disappointments as a part of living. Tolerance and respecting the rights of others reflect good mental hygiene.

Classification of Procedures

1. Routine Procedures.   Procedures performed on a repetitive basis, requiring little or no modification to meet individual needs of a patient.

2. Basic Procedures.   Procedures developed to meet hygienic, comfort, and therapeutic needs of patients. Some of these procedures involve direct patient care such as positioning and measuring temperature, pulse, and respiration. Some involve indirect patient care such as assuring cleanliness, preparing supplies and equipment, and maintaining clinical records and reports.

3. Simple and Complex Procedures.   The term “simple” must be considered in relation to the total situation. Four factors decide a procedure’s simplicity or complexity. It is a simple procedure if:

   (a)   abilities required to perform the procedure are based on a limited knowledge of scientific facts,
   (b)   it can be performed by following a defined protocol step by step,
   (c)   it is performed for a patient whose clinical state is relatively stable, and
   (d) the instructional needs of the patient are minimal.

   A variation in any of these four factors contributes to the complexity of a procedure. For example, preparing a patient for therapy can be a routine, basic, simple procedure, or it can be an exceedingly complex procedure, depending on the condition of the patient. In a simple situation, the assistant would be assigned to carry out the procedure with minimal assistance and supervision. In a complex situation, the assistant would be assigned to help the doctor (or another assistant) with some phases of care and would carry out other phases with supervision and direction.

ACCIDENT PREVENTION IN THE OFFICE

Safety means freedom from danger or hazard. It is attained through accident prevention. This, in turn, calls for maintaining safeguards for patients, personnel, and visitors. The safety of the patient must always be considered when providing patient care. This involves ensuring a safe environment, practicing safe work methods, and using equipment properly. Accident prevention is a responsibility shared by all members of the health-care team.

The main causes of accidents are negligence by personnel, careless work habits, improper use of equipment, and use of faulty equipment. Most of these hazards can be avoided if all personnel observe safety rules, practice safety measures, and recognize and eliminate or report potential hazards.

      Promoting a Safe Environment

Following are ways to promote safety in the office environment:

1. Keep floors clean, dry, and free of objects that might cause a person to fall.

2. Keep corridors clear and well lighted.

3. Keep working areas well lighted and uncluttered.

4. Use care in handling sharp and pointed instruments and glassware.

5. Do not use chipped or cracked glassware.

6. Wrap glass connectors and glass tubing in a towel or protective gauze before twisting, pulling, or pushing them into rubber or plastic tubing. The glass connection and the tubing into which it is inserted should be of appropriate and matching diameters. Moisten (not by mouth) both insertion points for ease in assembling. Clean tap water is the common lubricant for unsterile equipment. A sterile solution is required for sterile assemblies.

7. Never pour any material from an unlabeled container, and never pour stock solutions or cleaning compound solutions in containers bearing labels of other substances. Keep poisons in locked cabinets and properly labeled.

8. Use proper body mechanics in moving and lifting objects. Report unsafe conditions to the doctor. Safety in handling patients and in carrying out treatments is imperative.

9. Monitor and give constant supervision to patients receiving treatment.

10. Know how to use and care for equipment properly. Read all directions in the operator’s manual accompanying the equipment.

11. Use precaution when using electrical equipment. Examine the cords and plugs of electrical appliances before using them. Arrange electrical cords so that there is no danger any one will trip over them. Keep electrical equipment dry. Do not use faulty equipment; tag it, and report (and document) that it needs repair.

12. Know and obey fire regulations. Practice fire prevention. Enforce smoking rules for patient and personnel. Never dim lights by covering them with a towel or paper product. Be careful when using flammable fluids such as ether or oxygen. Discard used oil or wax cleaning cloths in metal containers. Report gas odors immediately. Know the location and operation of fire extinguishers. Know how to report immediately the detection of any smoke or unusual fumes.

      MEASURING AND REPORTING CLINICAL DATA

The manner in which a patient is received in the examining or therapy area of the office is an important contributing factor to his attitude and therefore toward his recovery. A feeling of confidence must first be established. Entering an office sometimes stimulates a considerable amount of dread and apprehension in a patient. Admission procedures should be as brief and reassuring as possible. Personnel should show interest in the patient as an individual and make it apparent to him that his care is planned on a personal basis.

The patient’s clinical record is prepared and maintained according to office policy. A clinical record includes the forms on which are recorded the medical record of a patient during one current, continuous episode of a disease, injury, or other condition. The accumulation of forms is properly referred to as the patient’s clinical record file or chart. It serves as a basis for planning patient care, providing communication between physicians and members of other professional groups, and presenting documentary evidence of the course of illness and treatment.

Clinical records remain in the custody of their owner, the doctor, while the patient is under his care. They are always handled so that only authorized persons officially concerned will have access to them.

Assistants (either administrative or clinical) often enter information and assemble the forms in the prescribed order in the chart holder. They see that diagnostic and test reports are attached or inserted in the record file on receipt, after these reports have been seen by the doctor. Each form is placed in an approved sequence. As further laboratory reports, consultation reports, or other forms are completed, they are added to the record. Each form used must have complete and legible identifying data.

      Observation of Patients

Observation of a patient is taking notice of signs and symptoms that may suggest the patient’s physical or mental condition. Observation is essential at all times in a clinical setting, from the patient’s admission until his discharge. The doctor depends on technical personnel to observe and recognize, report and record the patient’s condition accurately during contact. Effective observation by assistants helps:

(1)   to enhance the doctor’s observation,
(2)   to aid the doctor in making a diagnosis and in prescribing treatment,
(3)   to decide the effects of a prescribed course of treatment, and
(4)   to modify care to fit the needs of a patient.

1. Signs and Symptoms.   Clinical signs and symptoms are evidence of a patient’s condition and any disability.
   
   Signs are objective evidences that can be detected by one of the senses (sight, hearing, touch, smell, or taste). They can be noticed by an observer as well as by the individual experiencing them. For example, a rash can be seen, a swollen area can be seen and felt, a snoring respiration can be heard, the odor of a patient’s body can be smelled.
   
   Symptoms are functional rather than structural evidence. They may be objective and therefore noticeable by an observer, as well as by the individual experiencing them—or they may be strictly subjective (the individual’s own sensations). Examples of subjective symptoms are pain, itching, nausea, vertigo, and ringing in the ears. Categories of functional and structural signs and symptoms are shown in Table 13.1

2. Causes of Symptoms and Signs.   There are two main groups of symptoms and signs to know to become efficient:

   (1) those caused by the disease or injury with which the patient suffers and
   (2) those relating to health care; ie, those caused by the therapy.

3. Training and Developing Power of Observation.   To increase skill in observing the patient’s condition, the technical assistant should (a) increase her background knowledge, (b) take an active interest in the patient, (c) develop a sympathetic understanding of the whole patient, and (d) strive to be a good listener, attentive and accurate. The assistant can increase her knowledge by conscientious and accurate use of all senses and by accumulating a fund of information from books and from the doctor concerning symptoms to expect in various patient conditions. She can give attentive interest when the patient states how he feels. She can also try to anticipate the patient’s emotional and physical needs and discomforts and do what can be done appropriately to relieve him. Lastly, she can be accurate and conscientious in the performance of procedures that uncover signs of illness such as noting pulse rate and rhythm, respiration rate and rhythm, and blood pressure levels.

4. Reporting and Recording Observations.   Detailed reporting should be done away from the patient and out of his sight and hearing if possible, in order to reduce patient anxiety or misunderstanding. Comments made in the patient’s presence should be appropriate to what the patient needs to know or hear about his condition. Plain, everyday, factual language is used in reporting and recording. The patient is always identified by name, and the time the observation was made is noted.

   • Any clinical measure provided should be reported, including a statement whether the measure seemed to help or not.

   • Complaints and signs of pain should be reported as precisely as possible. Such things as location, plus any statement from the patient that the pain is sharp, dull, aching, throbbing, constant, or knife-like, are important. If the patient is quoted, his exact words should be used. The patient should be asked how long he has had the pain. In observing him, particular note should be made of: (a) Position assumed to relieve the pain. Is he bent over, unwilling to take a deep breath or to straighten an arm or leg? (2) Measures previously used to relieve the pain. Did a specific therapy relieve him for a period? Did any change of position relieve him?

   • Observations to be made. It is important to note signs of health, indications of returning strength, and a feeling of well-being, as well as noting disabilities and signs of progressing distress.

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     Table 13.1. Functional and Structural Categories of Symptoms and Signs

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Symptoms resulting from physiologic changes:

• Altered function: eg, convulsions, tremors, arrhythmias, various visual disturbances, paresthesia, and aberrant articular movement
• Decreased function: eg, atrophy, flaccid paralysis, depression, bradycardia, constipation, numbness, dehydration, hypothermia, and articular fixation
• Increased function: eg, hypertrophy, spastic paralysis, anxiety, tachycardia, diarrhea, pain, edema, fever, and articular instability

Symptoms resulting from structural changes:

• Bone and joint infection with resultant soft-tissue reactions, subperiosteal calcification, decalcification, bone destruction, and infiltration processes
• Congenital anomalies
• Deformity --witnessed as abnormal changes in angulation, displacement, or loss of continuity
• Degenerative processes
• Endocrine and metabolic imbalances
• Malignant and benign tumors
• Trauma

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      Recording Initial Case History Data

In many offices, a clinical assistant is used to develop the patient’s initial case history. Her notations will later be embellished by the doctor.

The elements of a comprehensive patient history are often set up as follows:

A.   Presenting symptom

B.   Present illness

C.   Health history

D.   Accident history

E.   Family history

F.   Personal history (patient profile)

         Activities
         Diet and nutrition
         Education
         Hobbies and special interests
         Occupation and its environment
         Postural considerations
         Residences

G.   Systems Review

A typical medical history profile structure is described in greater detail in Table 13.2

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     Table 13.2. Medical History Profile Structure

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Presenting Symptom: The presenting symptom (chief complaint) consists of a brief statement, preferably in the patient’s own words, concerning his reason for seeing the doctor. It also portrays the patient’s sense of priorities about his problems. The presenting symptom is the major problem for which the patient is seeking help. It is the response to such questions as, “What seems to be the matter?” or “How can I help you?”

Present Illness: This is a detailed description of the patient’s current problems developed chronologically. After the presenting symptom has been discussed, the doctor should proceed to ask, “What else has been troubling you lately?” The interviewer’s goal is to encourage the patient to relate all his problems so he or she can arrive at a comprehensive description of the present illness. The quality of this judgment is determined to a great extent by how thoroughly the beginning and course of the problem is understood, where the problem is located and its radiation, the problem’s quantity and quality, what circumstances aggravate or aid the problem, and what manifestations are associated. Answers to these questions should be available for each complaint.

Accident History: Detail of where, when, and how each accident or severe strain occurred should be recorded. Ascertain the care administered, the scope and degree of trauma, the diagnostic tests taken and the care administered. In an automobile accident, for instance, it is important to know from which side the force came, the position of the patient at the time of impact and after. Was a seat belt or shoulder harness fastened? Did the patient’s head strike anything? Was there unconsciousness? What were the immediate symptoms? What were the later manifestations? These and similar questions must be deeply probed.

Family History: Genetic factors are sometimes involved in diabetes, renal disease, hypertension, mental illness, heart disease, cancer, and allergies. Inquiries should be directed toward the health status of grandparents, parents, and siblings. Ages and causes of death are important. Determine if one or more members of the family is experiencing or has experienced symptoms similar to those presented by the patient.

Health History: In this assessment, inquiries should be directed toward childhood diseases, major illnesses, hospitalizations, operations, pregnancies (deliveries and abortions), allergies (air-borne, contact, medications, food), drugs, immunizations and reactions to such.

Personal History: This is a brief narrative of the patient’s way of life:
(1) life history, including usual day’s activities,
(2) education,
(3) marital status,
(4) occupational mental and physical stress,
(5) personality and temperament,
(6) hobbies and special interests,
(7) habits,
(8) religion,
(9) diet, and
(10) unusual financial burdens. The purpose is to form a mental picture of the patient’s present life-style: home, work, and recreational activities to see if anything therein may be the cause of or contributing to the patient’s health status and to gain insight into the impact of the patient’s problems on his or her daily activities and vice versa.

Systems Review: The purpose of the systems review is
(1) to determine malfunction in areas not covered in the present illness; and
(2) serve as a check for a manifestation of the present illness that was previously overlooked or forgotten by either patient or doctor. What is pertinent depends on the patient’s chief complaint, present illness, uniqueness of the patient, and degree of suffering. Whenever symptoms suggest involvement of a particular system or organ, questions should be directed to determine if any other possible symptoms normally associated with such a dysfunction are or have been present.

Standard symptom descriptors for recording a patient’s presenting symptoms accurately are shown in Table 13.3

Characteristic            Examples                                       
Alleviating               Cold                     Lying
-exacerbating             Coughing                 Medication
factors                   Drinking                 Nothing
                          Eating                   Rest
                          Exercise                 Sitting
                          Heat                     Sleeping

Associated factors        Breathlessness           Loss of appetite
                          Bruising                 Nausea
                          Chills                   Pain
                          Dizziness                Palpitations
                          Emotional tension        Sleeplessness
                          Fever                    Sweating
                          Headache                 Swelling

Character                 Aching                   Lightning pains
                          Blocking                 Pressure-like
                          Burning                  Restriction
                          Coldness                 Sharp
                          Color (red, blue,        Shifting
                          green, yellow, etc)      Squeezing
                          Cramping                 Stabbing
                          Crushing                 Superficial
                          Deep                     Texture (soft, hard, thick,
                          Dull                     -watery, etc)
                          Expanding                Throbbing
                          Giving way               Tingling
                          Itching                  Twinges

Course                    Fluctuating              Relieved completely
                          Intermittent             Slow
                          Progressive              Stable
                          Rapid                    Subsiding
Duration
  Complaint duration      Recent (hours, days,     Long term (months, years,
                          weeks)                   since childhood)

  Episode duration        Seconds                  Days
                          Minutes                  Weeks
                          Hours                    Months

Location-radiation        From anterior chest to   From right upper quadrant
                          left arm                 to right scapula
                          From left flank to       From left shoulder to left
                          groin                    hand
                          From lower back to       From upper neck to eyes
                          left calf

Characteristic            Examples                                  
Number of episodes        Decreasing               Intermittent
                          Increasing               Occasional
                          Frequent                 Date of last episode

Occurrence                Morning                  During sleep
                          Afternoon                During exercise
                          Evening                  During meal time

Onset                     Abrupt                   Insidious
                          Gradual

Precipitating factors     Alcohol                  Position change
                          Environmental change     Resisted movements
                          Foods                    Weather change

Resulting life-style      Dependency               Recreation
changes                   Diet                     Sexual relations
                          Exercise                 Sleep
                          Hygienic habits          Social relationships
                          Personality              Work

Disease and Injury

Health is a state of physical and mental well being in which the body can function fully with comfort and the ability to renew and restore itself. On the other hand, disease is any departure from health; it is any disorder of a body system that interferes with the normal operation of a body process. For the purposes of this chapter, disease (or sickness) will be defined as any departure from health caused by pathogenic organisms or another factor not involving an external physical force; injury (wound) will be defined as any departure from health due to an external physical force or environmental condition.

Broadly speaking, the recognized causes of disease are pathogenic organisms, improper or insufficient nutrition, degeneration of tissues and organs, congenital anomalies, and neoplasms. Predisposing factors increasing the probability of an individual becoming ill are age, inadequate self-care, emotional factors, sensitivity reactions, and lowered resistance. Diseases can be classified by their cause, duration, or severity. For example:

1. Acute disease.   A disease characterized by a rapid onset and quick changes in its progress and symptoms. An acute disease is not necessarily a serious disease. The common cold, for example, is an acute disease that can be severe, moderate, or mild.

2. Chronic disease.   A continuous or recurrent persistence of a disease.

3. Primary disease.   A disease developing independently of any other disease.

4. Secondary disease.   A disease that develops because of a primary disease or an effect of an injury. In a secondary disease, the body may have much less capacity to deal effectively with annexed function impairment.

Classification of Injuries

Injuries and wounds can be classified by type, location, and cause. The extent of injury is described as severe, moderate, slight, superficial (involving surface tissue only), or deep (involving tissues below the subcutaneous layer). When there is no break in the continuity of the skin or mucous membrane, the injury is referred to as a “closed wound.” When skin or mucous membrane is cut or penetrated, the injury is called an “open wound.”

Injuries can be classed according to involved anatomical parts of the body as head wounds (subdivided into skull, face, and jaw wounds); chest wounds; abdominal wounds; wounds of the extremities (arms or legs); wounds of joints; and spinal or pelvic wounds. The part of the body most severely injured determines the primary classification of multiple wounds.

Classification by causes of injury or wound are abrasion, contusion, strain, sprain, dislocation, subluxation, fracture, incision, laceration, penetrating wound, perforating wound, puncture wound, and rupture.

Microorganisms

All things existing in nature are classified into three general groups animal, vegetable, and mineral. Animal and vegetable groups are living and therefore classed as organisms (any living thing). Plants and animals too small to be seen singly except with the aid of a microscope are called microorganisms. Varying in size, shape, and their effect on mankind, they become visible to the naked eye only when they form colonies or groups.

Microorganisms belonging to the animal kingdom are called protozoa; those belonging to the vegetable group are the bacteria, viruses, fungi (yeasts and molds), rickettsia, and spirochetes. Protozoa cause such diseases as malaria and amebic dysentery; spirochetes, syphilis. Most infectious diseases of man are caused by bacteria and viruses.

Microorganisms are found almost everywhere; in the air, on uniforms, on hands, on furniture, on feet, on flies and other insects, in bedding, and on the floor. They enter the body with every breath and every mouthful of food. Fortunately, many of these are nonpathogenic (unharmful) to man in small quantities. Furthermore, natural body defenses protect to a certain extent against the harmful types. As microorganisms are constantly present in our natural environment, complete absence of microorganisms on items commonly used is impossible. The goal is to have as few present as possible by using preventive measures against infection and disease.

There are many methods of destroying microorganisms, but some are more effective than others. Washing with soap and water or exposure to light, fresh air, heat, and chemicals are effective only with some microorganisms, not all. The only known methods assuring complete destruction of microorganisms are germicides, steam under pressure, burning, exposure to a gas such as ethylene oxide, and sometimes exposure to a bleach. Sometimes a substance will destroy a microorganism but not its toxin. Spores are extremely difficult to destroy.


Classification of Pathogenic Organisms

1. Bacteria.   Bacteria are minute, one-celled organisms that may occur alone or in large groups called colonies. Each bacterium is independent and may live and reproduce by itself. Since bacteria are in air, water, food; on man-made objects or normally clean skin; and in the mouth, throat, and intestines of healthy human beings, the possible sources of disease and wound infection are almost countless. Pathogenic organisms responsible for diseases other than wound infections are usually inhaled or swallowed. Most bacteria flourish in moist, slightly alkaline, surroundings at temperatures near that of the human body. Under less favorable conditions they may continue to exist, without multiplying, for a long time. Usually, all but the tough spore-forming bacteria are eventually destroyed by exposure to sunlight or by drying. Boils, wound infection, lobar pneumonia, and strep throat are common bacterial infections.

2. Viruses.   Viruses are protein bodies that are much smaller than bacteria. They multiply only in the presence of living cells. They cause measles, mumps, influenza, herpes, a form of hepatitis, and many other infectious ailments.

3. Rickettsia.   Rickettsia are organisms that are larger than viruses but smaller than bacteria. They are carried and spread chiefly by insects such as mites and ticks and cause diseases such as typhus and Rocky Mountain spotted fever.

4. Fungi.   Fungi (yeasts and molds) are simple plant organisms that are larger than bacteria. They most often attack the skin, including the hair and nails, causing such chronic infections as ringworm and athlete’s foot. Infections caused by fungi are called mycotic infections and can be serious when internal organs are invaded. Vaginal and rectal infections commonly have a yeast origin.

5. Worms.   A few types of worms can live in side the human body and cause disease. Hookworms and tapeworms are examples of common intestinal parasites. They are usually ingested in raw or undercooked meats or by placing contaminated fingers or utensils in the mouth.

6. Protozoa.   Protozoa are one-celled animals, a few of which cause illness in man. Common diseases caused by protozoa include systemic infections such as malaria and amebic dysentery and local infections such as trichomoniasis, which affects the external genitalia and distal urinary tract.

Body Defenses Against Pathogenic Organisms

The body has three lines of defense to combat invading organisms. In the healthy, these defenses show a remarkable ability to fight off invaders and to withstand their effects. However, such factors as impaired nerve function, malnutrition, injury, overexposure, fatigue, and chronic stress lower natural defense reserves.

1.   The first line of defense, the skin, protects the body’s surfaces. It acts like a wall to keep out most bacteria and other potential invaders. Bacteria entering the nose and mouth find another barrier, the mucous membrane coating the respiratory and digestive systems. Some cells of the membrane secrete mucus that entangles bacteria and molds, while others also have cilia that sweep the invaders out of the body.

2.   The second line of defense is systemic immunity. Previous encounters of the body with many types of bacteria, viruses, and allergens (eg, pollen) often produce a specific resistance (immunity) to those particular organisms. This acquired immunity is associated with the formation of antibodies by the body. Antibodies interfere with pathogenic invasion in several ways. They may neutralize toxins, kill the organism, make the organism more susceptible to attack by white blood cells, or cause the organism to clot into little clumps that the white cells of the blood can usually destroy. A healthy nervous system and good nutrition play an important role in maintaining the integrity of the immune system.

3.   The third line of defense is the lymphatic system. Lymph bathes, cleans, and lubricates tissues at the extracellular level, then flows through vessels into lymph nodes (rich in white cells) and the venous system. The nodes act as filters for the removal of invading organisms.

Body Reactions to Disease and Injury

      INFLAMMATION AND HEALING

Inflammation is the local reaction of the body to irritation or injury. It occurs in tissue that is injured but not destroyed. It is a defensive and protective effort by the body to isolate and eliminate the causative agent and to repair the injury. A certain degree of inflammation takes place following any type of injury (extrinsic or intrinsic).

Inflammation can be caused by physical, chemical, or thermal agents, or by invading organisms. The signs of inflammation are redness, heat, swelling, pain, and disturbance of function. These five cardinal signs are produced by reaction of blood vessels and tissue in the injured area. When injury occurs, the blood vessels dilate, thus increasing the supply of blood to the injured area. The blood is warm and red, producing the first two signs, redness and heat. As the blood vessels dilate, their walls leak and blood serum escapes into the tissues. This results in swelling. The swelling produces pressure or tension on nerve endings causing pain. Disturbance of function can result from the effects of impaired circulation by the swelling or the pain (eg, protective spasm).

While changes in blood vessels produce the cardinal symptoms of inflammation, the body reacts further to injury in another way. White cells and fibrinogen (a clot-forming substance) leave the dilated blood vessels and move through the tissue fluids to the site of injury. These cells make a wall around the area to seal off the injurious agent. Within this area, the white cells work as scavengers (phagocytes), ingesting small particles of foreign matter, dead tissue debris, or bacteria if present.

As the source of injury is overcome or expelled, tissues return to normal. White cells disperse, and blood vessels return to normal size. Fluid accumulations disperse through the lymphatics and veins. If tissue has been severely destroyed, it is replaced by scar tissue. Thus, the dilation of blood vessels and the mobilization of white cells against the injuring agent are the two basic reactions in the inflammatory process. Proper therapy enhances these processes and attempts to control them from overreaction.

Healing is a process related to inflammation, for both are started by tissue injury (overt stimulation). It would be ideal if the body could heal itself by replacing all damaged tissues with an exact counterpart; then, an eye would be replaced with a new eye and a tooth with a new tooth. But very few tissues are replaced in kind. Examples of tissues that may replace themselves are liver tissue, kidney tubules, and connective tissue. Bone, which is one type of connective tissue, may replace itself if broken; that is, the broken bone is repaired by the formation of new bone tissue.

Healing in most tissues is, however, a process of replacement: the destroyed tissue is replaced by scar tissue (a fibrous type of connective tissue). If brain cells are destroyed, they are replaced by connective tissue. If heart muscle is injured, the damaged fibers are replaced by connective tissue. When a tooth is pulled or an eye is lost, the sockets are filled with connective tissue. Hence, replacement by scar tissue is the usual order in healing. The healing process takes place in one of two ways—by primary union or granulation.

      INFECTIONS AND THERAPEUTIC MEASURES

Infection is the entry and development or multiplication of an infectious agent in the body. The agent can be any pathogenic organism. Factors contributing to the ability of the infectious agent to produce infectious disease include:

(1)   the number and kind of invading organisms,
(2)   the ability of the body to resist infection, and
(3)   the virulence of the infecting organisms. Virulence is the ability of pathogenic organisms to overcome, at least temporarily, the defensive reactions of the body (phagocytosis, antibodies, and lymphatic involvement) that are mobilized when infection occurs. Virulent organisms can multiply rapidly within body tissues and to form toxins (poisonous waste products).

Different pathogenic organisms produce dissimilar toxins. Some toxins destroy tissue cells, some dissolve blood cells (hemolysis), and some are absorbed rapidly into the blood to cause toxemia, a generalized systemic reaction to infection.

The general therapeutic measures used in treating acute inflammation and infection are based on the need to:

(1)   aid the body in mobilizing its natural internal defenses,
(2)   relieving pain,
(3)   promoting healing,
(4)   preventing complications, and
(5)   controlling the spread of infectious organisms if present. The typical measures used are rest, elevation of an involved extremity, use of cold or heat, professional therapy, promotion of elimination of waste products, and aseptic procedures to prevent and control the spread of infection.

1. Rest.   Rest allows all the body’s defensive effort to be directed toward healing and combating infection, rather than be veered by physical activity. This can hasten the defensive process of walling off an infected area, which will prevent the body from absorbing too much toxin. Rest conserves energy reserves and reduces movement of an inflamed and painful part.

2. Elevation.   Elevation of an inflamed extremity allows the force of gravity to help drain swollen tissue spaces and blood vessels. The degree of elevation needed to promote tissue drainage of an extremity is above heart level. To provide this degree of elevation for the arm, the hand and elbow must be higher than the shoulder; for the leg, the foot and knee must be higher than the hip.

3. Cold and Heat.   The effects of cold and heat are as follows:

   • Effect of cold.   Cold causes the blood vessels to constrict and tends to reduce edema. It reduces the pain of inflammation because it reduces the sensitivity of nerve endings in the skin. When applied immediately after an injury, it prevents or relieves swelling. The use of therapeutic cold is highly beneficial in the early stages of inflammation.

   • Effect of heat.   Heat applied to the body dilates capillaries and increases blood flow near the surface of the body (vice versa for deep tissues). The improved superficial blood supply increases the number of white cells in the area to combat pathogenic organisms and aid the formation and localization of pus. Due to increased circulatory flow, tissue nutrition and elimination of metabolic products are quickened.

4. Professional Therapy.   The type of therapy used in combating inflammation and infection is determined by the doctor when the infecting organism is identified. Cultures, smears, or the development of particular signs or symptoms help in this identification. Besides anti-infective or anti-inflammatory therapy, specific therapies to improve nerve function and nutrition, normalize circulation (arterial, venous, lymphatic), relieve pain, enhance elimination, and assure rest (eg, support) are often indicated.

5. Promotion of Elimination.   Toxic materials are eliminated largely by the kidneys. A daily urinary output of at least 1000 ml is necessary. An increased fluid intake (4000 ml or more) helps dilute toxins and protect the kidneys. Increased fluid intake also helps bowel elimination, inhibits dehydration, and serves as a medium for supplemental nutrients.

6. Aseptic Procedures.   Asepsis means freedom from disease-producing microorganisms.

Pediatrics is that area of interest in chiropractic that deals with:

(1)   the diseases of children and their treatment, and
(2)   the child’s development and care. It is important for anyone involved in health care to realize that a child is not a “little adult.”

An assistant should realize that illness has a distinct effect on the average child’s personality and behavior. The developing personality can be affected by illness; eg, “being different” because of illness can definitely change a child’s personality. The assistant can be of help once she understands the child’s feelings.

A child patient needs much closer observation than an adult patient. It is well that assistants learn to recognize the types of behavior that suggest specific conditions or problem areas. This recognition includes fear and withdrawal. The assistant should also realize that the quiet good child may be suffering the greatest trauma. Among the common causes of behavioral problems are:

(1)   The child’s response to examination and treatment as a threatening situation.
(2)   The belief that the illness is a punishment for previous “bad” behavior. The child may have been told that he will become sick if he does or does not do so and so.
(3)   Negative attitude of parents that affect the child and lead to tantrums, refusal to cooperate, and attempts to “run away.”
(4)   The belief that sickness is a punishment from a revengeful God for some “sin.” In such cases, you can expect different reactions on different days; sudden behavioral changes are common.

A proper psychologic approach is necessary to prevent as much trauma to the child as possible and to accomplish health-care objectives. Use as little force as possible and then only that which is absolutely necessary.

The following approaches are often helpful in dealing with children:

• Never lie to a child; never threaten a child. Tell the child that the treatment or procedure is given to make him well. Offer some explanation even if the child is crying. Remember that a child’s attention span is short, especially in the very young. Keep explanations brief and positive. Do not allow him to be in a position where he can say no.

• Do not tell a child of forthcoming treatments or other needs until immediately before they are performed, as the child will probably become anxious, but do inform him. Reward him for acceptable behavior by your approval. Do not talk down to a child, but be sure he understands you. Use the terms his family uses. Also, use his nickname, as he may not recognize his formal name.

• Attempt to keep him busy and distracted from unpleasant situations. Make games of procedures if possible. Consider each child an individual with rights of dignity and modesty, and respect these rights

If misbehavior occurs despite everything you can do, his misbehavior must be dealt with, but certain rules can be used for guidance. Keep discipline firm, just, and consistent. Deal with misbehavior as it happens. If you ignore the breaking of rules, you weaken discipline and confuse the child. However, do nothing when extremely angry. Explain the reason for rules. It will help the child (after 2-1/2 years) to understand that he is not just being pushed around— that each rule has a reason behind it. And be sure you have a good reason.

Keep your voice calm. It does no good to scream at a sick child (his illness is probably affecting his behavior) or to talk in a loud voice to a child who does not understand you. Avoid bribes; they let a child remain immature and be paid for it. Do not ridicule a child. Whenever possible, give the child a reason for changing undesirable behavior to good behavior. Make your suggestions positive rather than negative. Tell the child what to do, not what not to do.

When a child is being treated in the office, consider the feelings of the parents.
If they are worried and tense, the child will soon sense it.

Parents may be disturbed because of:

(1)   guilt feelings,
(2)   fear of the unknown,
(3)   fear of improper care for the child,
(4)   fear that the child will suffer, or
(5)   fear that the child may transfer his love to the people who now care for him during this time of need. These worries make parents often illogical, unreasonable, and demanding. Although this puts an extra load on both assistant and doctor, they must understand people and their problems and be empathetic with them.

Stages of a child’s growth and development are not marked with sharp lines. Mental development, for example, begins long before it is discernible. The degree of its progress is influenced by the child’s environment and his social development. No child will fit within any absolute pattern, but certain norms can be established. A child will change and develop continuously, but the growth can be uneven, with wide fluctuations within the normal. For example, most children will crawl before they walk, but they will not all crawl at the same age.

The inheritance of an individual can vary widely from that of his parents, since each parent cell supplies half of the 46 chromosomes that begin the new cell. Also, some characteristics are dominant and other are recessive. It is unlikely for a family of high intelligence to have a child with low intelligence or vice versa. A child is also likely to have personality traits similar to those of his parents.

Environment, too, is different and variable. An infant deprived of love and affection from birth will have a slower mental growth than one that is read to, loved, “mothered,” and kept comfortable. A child brought up in a family where a foreign language is spoken may seem stupid when he enters a school where English is spoken. Even the health of the mother before the child’s birth affects his development. There are also physical differences between the sexes and between people of various nationalities and races. Thus, many factors must be considered by personnel who furnish health care to children.

Here are some tips an assistant can teach parents to help their children: stress good posture habits, suggest regular exercise, and encourage a well-balanced diet and periodic health check-ups.

Geriatrics is that area of interest in chiropractic concerning the diseases of the elderly and their treatment. Chronological age does not make a person young or old. Some people are young in spirit at age 85; others are old at 25. However, the chronological age of 65 is arbitrarily considered the dividing point between the middle age and old age. This is the age when retirement from active employment generally takes place and when Old Age and Survivors Insurance (Social Security) benefits begin.

The Aging Process

The process of aging begins at birth and stops only with death. It is a very gradual process, yet changes occur in a fairly predictable pattern, with the rate of change varying from one individual to another. It is a period that is often marked by mental confusion and vagueness. An assistant must consider this confusion and help the patient as much as possible. She also must be aware that the old person’s body has undergone many other changes. The physiologic changes seen in the geriatric patient can be generally classified as loss of elasticity in tissues and a general slowing down of physiologic processes. Table 13.4 shows the typical consequences of old age.

Decreased Organic Function
  Skin                Decreased subcutaneous fat       Sweat gland atrophy
                      Increased  wrinkling

  Eyes                Decreased accommodation          Lens opacities
                      Decreased pupil size             Presbyopia
                      Lens discoloration

  Ears                Decreased perception of high     Intolerance to loud noises
                        frequencies

  Cardiovascular      Decreased cardiac output         Decreased heart rate
    system            Decreased elasticity of heart    adaptation to stress
                        and peripheral vessels

  Respiratory         Decreased ciliary activity,      Decreased cough reflex
    system              hyposensitivity                Decreased lung elasticity

  Gastrointestinal    Decreased calcium absorption     Decreased hydrochloric acid
    system            Decreased colon motility         Decreased salivation

  Genitourinary       Decreased renal circulation      Vaginal mucous membrane
    system            Decreased sexual response          drying and atrophy
                      Decreased urine osmolality     	
                      Prostate enlargement (with     	
                        outflow obstruction)

  Nervous system      Fewer hours of REM sleep         Slower righting reflexes
                      Slower psychomotor performance

  Musculoskeletal     Decreased bone mass              Decreased muscle tone (lack
    system            Decreased lean muscle mass         of conditioning)
                      Decreased ligament elasticity    Increased spondylosis

  Endocrine system    Decreased estrogen secretion     Increased ADH response
                      Glucose intolerance (decreased
                        peripheral utilization)

  Immune system       Absent thymic secretion          Decreased T cell function


Decreased Tolerance to Sress
  Mental/emotional    Decreased adaptability to        Decreased self-esteem
                        change                         Decreased vitality
                      Decreased recall of current      Increased tendency to
                        events                           depression

  Physical            Easy exhaustion                  Intolerance to temperature
                      Excessive reaction to trauma       extremes

Impaired Immunity
                      Increased susceptibility to      Increased susceptibility to
                        infection                        neoplasms

Miscellaneous
                      Increased atypical signs and     Increased susceptibility to
                        symptoms                         multiple diseases
                      Increased iatrogenic reactions 	
                        from drugs

Age may be a factor in musculoskeletal injuries. As a group, older persons are susceptible to fractures. Their vision and hearing may be impaired, increasing the possibilities of accidents. Atrophy of bone occurring as part of the aging process also may increase susceptibility to fracture. Besides, aged people may be poorly coordinated, have a decline in postural ability, and have difficulty walking. With age, one’s level of proficiency progressively deteriorates (but to a highly variable degree).

Aged persons may also have disorders predisposing them to musculoskeletal injuries, eg, “drop attacks,” cerebral ischemia osteoporosis, cancer of the bone, arthritis, “dizziness,” postural hypotension, muscular weakness, or neurologic disorders affecting locomotion. While disorders such as these predispose a person of any age to injury, the elderly person is particularly at risk because of other concomitant factors accompanying aging. Older women are especially prone to fractures. Men most commonly sustain fractures in their younger years, up to age 45. Musculoskeletal injuries range in severity from relatively minor soft tissue injuries to severe, crushing fractures.


The Assistant’s Approach

An assistant who helps with geriatric patients must be emotionally stable and even-tempered: a condition known as maturity. The aged may be talkative, secretive, hostile, rude, and childish, but the assistant must not take their remarks personally. She must try to understand their behavior and react in a nonjudgmental tradition.

The assistant must express sincere interest and affection for the geriatric patient. Old people recognize and detest insincerity. All office personnel should be kind, tolerant, and patient. These qualities come only when you have gained true respect for yourself; only self-respect can be given to others. One cannot pour from an empty container.

A capable assistant will also have empathy (a projection of one’s own personality into the problems and personality of another; a feeling with someone). If an assistant can imagine that she has lost her job, lost her friends, lost her sensory perceptions, lost her home, lost her ability to speak fluently, lost her health, and lost her self-esteem, then she can begin to understand the disagreeable stubborn outbursts of some elderly people. She must realize that hostility may be an expression of insecurity. She must also recognize the embarrassment that follows failure to do even a simple task by herself.

The admission of an aged person to a busy practice can be disruptive. Routines geared to the adult or younger patient will not meet the needs of the geriatric patient. Adapting routines and personnel habits is not without difficulty. but if the office is to fulfill its responsibility of providing health care to the elderly, it must be done. Older patients cannot and should not be rushed, particularly in the morning. An older patient will take almost twice the time as the younger patient. As an assistant, you must be aware of the time involved and plan accordingly.

Following are some helpful rules for caring for the aged:

  —   Do treat each as an individual.
  —   Do call by name such as Mr. Brown or Mrs. Green.
  —   Do be tolerant, patient, gentle, and kind.
  —   Do speak slowly and distinctly.
  —   Do help the patient to help himself.
  —   Do be extremely observant.
  —   Do be optimistic.
  —   Do not call old people “grandma” or “grandpa.”
  —   Do not stick to procedure just for authoritative reasons.
  —   Do not shout.
  —   Do not do “everything” for the patient.
  —   Do not ignore minor complaints.
  —   Do not try to change life-long habits or life-style.

It will often seem easier and quicker to do something for the elderly patient rather than let him do it for himself, because it takes him so long. However, oversolicitous care and too much waiting on a patient forces him into a dependent role—a role he does not want and one that is incompatible with a healthy outlook on life. Avoid the temptation to take over. The aim of proper assistance is to permit the patient to do as much for himself as he can, with only a minimum of assistance from personnel. His small accomplishments mean a lot to him. Grant him what independence and self-esteem is possible. It is an act of love for a fellow human being.