Client Intake Form (cont. Client Intake Form. Interview. Interview. Interview (cont. (cont d.)

Transcription

1 Mosby s PATHOLOGY for Massage Therapists Chapter 2 Treatment Planning Lesson 2.1 Objectives Discuss the importance of a treatment plan. Compare and contrast subjective versus objective data. Design a client intake form. Discuss important elements of a client interview. 2 Lesson 2.1 Objectives (cont'd.) Introduction Identify assessment domains of the method. Discuss several ways to assess client pain. Contrast and compare acute pain with chronic pain. Treatment Plan Actions to resolve health issues identified during client assessment Assessment Process of appraising a client s condition Based on subjective reporting and objective findings 3 4 Assessment Assessment Purpose of assessment: Appraise client s s heath Identify conditions requiring precautions or treatment modifications Aspects of assessment: Client intake form Physical assessments Subjective data information learned from the client Objective data information that is measurable and quantitative Palpation touching with purpose and intent 5 6

2 7 Client Intake Form Client Intake Form (cont Personal and contact information Health and medical information Emergency contact person Regular physician or health care provider Date the information is recorded 7 8 Client Intake Form (cont Presenting the intake form: Greet client Escort client to a quiet area with adequate lighting Present form, clipboard, and writing pen Obtain important forms (prescriptions, referrals, clearance) Obtain client signature Purpose of interview: Helps the therapist screen for contraindications or realize the need for adaptive measures Gives the therapist a chance to gather details needed to provide better service, such as Primary purpose for session Client s s personal preferences 9 10 (cont process: Greet client by name Introduce yourself Review information on intake form Be sure form is complete, dated, and signed Organize interview; highlight health and individual issues (e.g. method) Conclude interview Sit facing the client at eye level Begin with a brief orientation Use open- and closed-ended ended questions Open-ended ended questions offer little restriction when answering Close-ended ended questions require a yes or no response From Salvo S: Massage therapy: principles and practice, ed. 2, Philadelphia, 2003, Saunders

3 13 Listen carefully and use reflective questions Take notes sparingly Use silence This gives client time to talk, giving therapist greater understanding of client Signal your interest stands for the first letter of five assessment domains From Salvo S: Massage therapy: principles and practice, ed. 3, St. Louis, 2007, Saunders Five steps of treatment planning: Ask client questions using the format Collect data Appraise and synthesize data; integrate data with one s s own clinical expertise Discuss plan with client Implement plan Purpose of session Identify client s s reason for session Discuss client s s past experience with massage therapy If client is a minor, obtain permission from: Child s s parent or Child s s legal guardian Pain Ask about pain Is it related to injury or illness? How is it being treated? Pain can be acute (began abruptly) or chronic (developed slowly) Assess pain using OPPQRST and pain scales Fig from Salvo SG: Massage therapy: principles and practice, ed 3, 2007, St. Louis, Saunders; Fig from Hockenberry MJ: Wong s s nursing care of infants and children, ed 8, 2007, St. Louis, Mosby

4 19 Allergies and skin conditions Inquire about allergies to ingredients in massage lubricants Use hypoallergenic products when needed Ask client about skin conditions Lifestyle and vocation Factors include occupation, leisure or sports activities, physical exercise, stress level, and nutrition Medical history Inquire about the client s s heath status If a disease is present, ask how long the client has had the condition, how it is managed, current symptoms, and any activity limitations If a client s s symptoms are unstable, obtain medical clearance before massage Ask about medication use and their purpose Lesson 2.2 Objectives Screening Clients for Contraindications Describe the importance of screening clients for contraindications. List items included in a treatment plan. Discuss postmassage communication. Design treatment plans for subsequent sessions. Ruling out contraindications is our duty and obligation Most conditions require only slight adjustments Elevating the upper body or avoiding an area Reducing pressure or session time Sometimes, massage is postponed Contraindications (cont Contraindication Presence of disease or condition so a particular client cannot be treated in the usual manner Absolute Massage is inappropriate, not advised, and may be harmful Local Massage can be administered while avoiding infected/inflamed area or area in question Based on: Client health intake form Other assessments, such as soft tissue palpation Take into account a client s s financial and time restraints 23 24

5 25 Includes: Techniques and areas to include or avoid Recommendations for self-care Duration, frequency, and length of treatments Reassessment Referrals Includes : Whether client needs assistance Use of special support or bolstering devices Use of adjunctive therapies Suggested reading material Communication After Treatment Subsequent Sessions Client evaluation of massage Ask client to evaluate massage Modify plan for future sessions if needed Discuss client education and homework assignments Review notes Update plan based on progress toward client s goals In general, the initial treatment period consists of frequent sessions, tapering off as symptoms subside Ask about symptoms and tailor treatment based on client symptoms that day 27 28