Patient Interviewing and Assessment

Kimberly A. Trotter

LEARNING OBJECTIVES

On completion of this chapter, the reader should be able to:

1. Review patient chart documentation including physician order, history, and physical examination.
2. Explain the principles of interviewing and observing the patient to assess special physical, cognitive, or emotional needs.
3. Orient the patient to the facility utilizing appropriate technologist-patient interaction.
4. Recognize patients with special needs (mental age, physical, or emotional discomfort) and assess patients’ readiness to learn and their ability to cooperate.
5. Determine the need for any special precautions or special testing considerations (prosthetic devices, electromechanical devices, etc.).
6. Review protocols; analyze and respond to unclear, inappropriate, or contradictory orders.
7. Identify the patient’s current sleep schedule, recent caffeine or alcohol intake, and current medications.
8. Orient the patient to the facility and testing procedure.
9. Interview the patient during the setup to clarify any gaps in history or symptoms identified during chart review.
10. Document any special needs identified or pertinent clinical information in the patient’s chart.
11. Discuss positive airway pressure and other therapeutic modalities with the patient.
12. Assist with pre- and postprocedure questionnaires and follow-up processes.

It is a new encounter every night when the sleep technologist comes to perform a polysomnography (PSG) and reviews a patient’s chart for the first time. The technologist may not know anything about the patient he or she is about to see. Perhaps a sleep consultation was performed before the PSG; however, the needs of the patient have to be evaluated during the initial meeting in the sleep center by the technologist. Sometimes clinical notes are not as exact as we would like them to be. If the sleep consultation was completed by the referring physician, it may be vague and general. This is why patient interviewing and assessment is so important in making the most of the sleep study and, most importantly, making sure that the patient’s accommodations are met.

CHART REVIEW

It is important for the daytime sleep technologists or chief technologist to review all charts before the night shift, because there may be special testing or equipment that needs to be set up before the night shift arrives. Once the nighttime sleep technologist arrives, he or she should thoroughly review the chart.

The chart should contain a recent history and physical (H&P). This is a report of the patient’s general health status, regular medications, past surgeries, and family history. The H&P can come from the primary care physician or referring physician. Reviewing this information is helpful to understand the patient’s general status. If the patient is a “direct referral,” meaning he or she bypasses a sleep consultation and workup with the sleep specialist and is referred directly for a sleep study, then a comprehensive H&P, with sleep specific information, is very important and is required by the American Academy of Sleep Medicine standards of accreditation.

The sleep consultation is an integral part of the chart, and because it is sleep specific, it should be reviewed by the sleep technologist. Information such as sleep medications, sleep schedule, chief complaint, and family sleep history should all be addressed in the sleep consultation. During the consultation, a sleep questionnaire, sleepiness scale, and a sleep diary that usually consists of 2 weeks of data are usually obtained.

If the patient was referred directly to the sleep disorders center by the referring physician, the sleep questionnaire may be administered to the patient upon his or her arrival at the sleep center. The technologist will need to assess whether the patient is able to read, understand, and answer the questions. The technologist may need to assist the patient by asking the questions. Once the sleep questionnaire is filled out, then the technologist will have information he or she can use for determining what degree of special or accommodating treatment the patient may need. The technologist must make sure that the patient is able to fill out the pre- and postquestionnaires, as well, and assist if necessary.

The physician order form must be included in each PSG patient chart. It must be signed and must give clear instructions regarding what type of procedures are to be performed. It must also be clear if the patient has any special needs or considerations for his or her care. This documentation is very important to the technologist and, consequently, to the patient.

MEETING AND ASSESSING THE PATIENT

As mentioned, the sleep technologist is at a disadvantage before he or she first meets the patient, unless the former has prior information that he or she can review. Meeting and assessing the patient may be the only information he or she gets as far as special needs or considerations are concerned.

Visual Assessment

Visual assessment occurs when the sleep technologist first meets the patient. How is he or she dressed? Is the patient alert or sleeping in the chair? Does the patient seem nervous or relaxed? Are there any visible challenges?

Readiness to Learn

Once the formal introductions are made, and you escort the patient to the sleep room, it is time to check his or her readiness to learn. Readiness to learn is a phrase used to determine by casual interview of the patient if he or she is ready to learn. Obstacles to readiness to learn include feeling nervous, being too sleepy to listen and participate in a conversation or presentation, not understanding the language, or not paying attention. Other reasons include diminished intellect and hearing loss.

Mental Age

Mental age is defined as the age level the patient functions at mentally or intellectually. Does he or she seem to understand simple words and phrases? Does the patient act like he or she is 13 years old, when he or she is really 35? This is important information, so the sleep technologist can simplify his or her presentation to the patient if necessary, assuring the patient will be able to understand the process and cooperate better.

Physical Limitations

Many times, physical limitations will be obvious when you first greet the patient. This valuable information may also be found in the patient’s chart, the physician order form, sleep questionnaire, or consultation notes. If the patient was referred directly to the sleep center and the referring physician conducted the sleep consultation, this information may not be available because the referring physician is familiar with the patient and may not consider it an issue for the sleep technologist. This can result in a challenge for the technologist.

Emotional Needs

Emotional needs may be the most difficult to determine. If the patient seems withdrawn or distant, it will be a difficult night for both the sleep technologist and the patient, unless the technologist is able to break through and reach the patient, making him or her feel more comfortable and assured. Sometimes emotional needs are related to mental age; the patient may be immature and may need a lot of reassuring and attention. It is important to note that sometimes patients will act out in order to receive this added attention. In cases like this, the sleep technologist needs to set boundaries with the amount of attention and service he or she can give the patient. This is important when the sleep technologist is monitoring two patients because if he or she is overly busy with one patient, then the other patient suffers.

PATIENT ORIENTATION PROCESSES

Facility Orientation

When the patient arrives, escort him or her to the bedroom and show other pertinent areas of the facility that he or she may want to use, such as the bathroom, showers, and areas to store food. Show the patient how to
operate the TV and fans. Allow them the opportunity to ask questions.

Patient Confidentiality and Patient Rights

The Health Insurance Portability and Accountability Act of 1996 regulations require each patient to sign an acknowledgment of receipt of patient confidentiality regulations. If this is the patient’s first visit to the center and he or she has not previously signed this form, this must be collected by the technologist. Many facilities, particularly hospitals, also make a copy of information pertaining to patient rights and responsibilities available to the patient.

Procedure Consent

In many sleep centers, the technologist may have the patient review and sign a consent form, which describes the procedure. If the patient is to be videotaped, the technologist may obtain consent for this as well.

Recognizing and Accommodating Patients with Special Emotional Needs

Once the sleep technologist has had time to assess the patient’s emotional needs, it is time to work with the patient to obtain the best PSG.

What Are Special Emotional Needs?

Special emotional needs are related to patients with disorders that include posttraumatic stress disorder (PTSD), depression, panic attacks, claustrophobia, and more serious mental illnesses. As stated previously, mental age can play a part in relation to special emotional needs.

The sleep technologist must develop strategies for dealing with these types of patients. For patients with PTSD, it is important to find out the best way to communicate with them during the night, and more importantly, the best way to wake them up should the technologist need to adjust sensors or apply positive airway pressure (PAP). Waking a patient with PTSD the wrong way can result in injury to the technologist! Ask the patient before lights out how he or she should be awakened. Some patients may prefer being awakened using the intercom, and others may need the light on and to be called from the doorway. A night light may also be appropriate.

PAP titration for these patients, as well as patients with claustrophobia, can be tricky, and these patients should be treated with caution and great care. Always allow the patient to be in control of the mask on the face. If the patient starts feeling panicky (a common symptom of PTSD), then he or she can take the mask off the face and try again later. Always remind the patient to breathe slowly, focusing on breathing out. A full-face mask, which equalizes the positive pressure delivered between the nose and the mouth allowing the patient to breathe with the mouth open, may be helpful. Sometimes a nasal mask or nasal pillows can make the patient feel less claustrophobic. Nasal pillows or other types of small masks that do not touch the patient’s face can be less restrictive and more comfortable. The technologist’s impressions should always be documented in the patient’s chart.

Depression is not evident in all patients, but in patients who seem down or disengaged, it is important to identify possible depression. It is important to note that the technologist is not licensed to diagnose the patient, but to merely document his or her impressions. Dealing with depressed patients is not easy, and the technologist should try to be sensitive to the patient’s needs. Spending extra time with the depressed patient is important, especially if he or she seems withdrawn about the procedure.

Some patients may tell the technologist that they have panic attacks at night. These panic attacks may be related to obstructive sleep apnea (OSA) or PTSD. Assure such patients that you are nearby should they feel anxious.

The best way to handle the patient with a mental disorder is to be calm and not argumentative. Being argumentative with such patients can challenge their reality and can provoke them. Ideally, the medical director or sleep physician would have screened out unstable patients and you will not see them in the sleep center until they are stable. If the technologist feels threatened in any way, he or she should immediately leave the room and contact security if available, contact the medical director, or call 9-1-1. A technologist should never allow a patient to stand between him or her and the exit of the room. A sleep center policy for these types of situations should be available.

Recognizing and Accommodating Patients with Special Physical Needs

Patients who come to the sleep center with physical disabilities can be a challenge for the technologist. The referring physician should mention these disabilities in the H&P or consultation notes. If the patient is severely disabled, then it is important that a caregiver be present for the entire sleep study to assist with lifting and other personal needs.

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