NHA CCMA: Patient Intake & Vitals

Apnea

periodic cessation of breathing

arteriosclerosis

thickening, decreased elasticity, and calcification of arterial walls

auscultated

Listened to with a stethoscope

bounding

Describes a pulse that feels full because of increased power of cardiac contractions or as a result of increased blood volume

bradycardia

a slow heartbeat

bradypnea

abnormally slow breathing

calibrated

determined by or checked against a standard

cerumen

a waxy secretion in the ear canal

cheyne-stokes respiration

deep, rapid breathing followed by a period of apnea

chronic obstructive pulmonary disease

progressive, irreversible lung condition that results in diminished lung capacity

diurnal variation

fluctuations that occur during each day

dyspnea

difficult or painful breathing

essential hypertension

elevated blood pressure of unknown cause that develops for no apparent reason

febrile

pertaining to an elevated body temperature

fluctuate

to shift back and forth

homeostasis

A steady state that is created by all the body systems working together to provide a consistent and unvarying internal environment

hyperpnea

excessively deep breathing

hyperventilation

abnormally increased breathing

hypotension

blood pressure that is below normal

idiopathic

of unknown cause

intermittent pulse

a pulse in which beats occasionally are skipped

lymphedema

a condition in which extra lymph fluid builds up in tissues and causes swelling

malaise

a condition of general bodily weakness or discomfort, often marking the onset of a disease

occlude

to close,shut,or stop

orthopnea

a condition of difficult breathing unless in an upright position

orthostatic hypotension

a temporary fall in blood pressure when a person rapidly changes from a recumbent position to a standing position

otisis externa

inflammation or infection of the external auditory canal; commonly called swimmers ear

peripheral

refers to an area outside of or away from an organ or structure

pulse deficit

a condition in which the radial pulse is less than the apical pulse; it may indicate a peripheral vascular abnormality

pulse pressure

the difference between the systolic and diastolic blood pressures

pyrexia

a febrile condition of fever

rales

an abnormal lung sound heard on auscultation, characterized by discontinuous bubbling noises

rhonchi

an abnormal rumbling sound heard on auscultation, caused by airways blocked by secretions or muscle contractions

sinus arrhythmia

an irregular heartbeat that originates in the sinoatrial node

syncope

fainting

tachycarida

a rapid but regular heart rate

tachypnea

rapid, shallow breathing

thready

pulse is so faint and weak that it is difficult to feel it long enough to count the rate

vertigo

dizziness, an abnormal sensation of movement when there is none

wheezing

whistling sound made during breathing

vital signs

metrics (temperature, pulse, respiration, blood pressure)used to evaluate a patient's overall health status

chief complaint

primary reason for the office visit

subjective

information gathered from what a patient communicates

medication reconciliation

Comparing the patient's list of medications to the medical record as a safety measure to reduce the risk of improperly prescribing an incorrect or contraindicated prescription, including medication interactions and adverse reactions.

objective

information that can be observed or measured

Auscultaion

listening with a stethoscope

systolic

measurement of force while the heart is contracting;top number on a blood pressure reading

diastolic

measurement of force while the heart is relaxing;bottom number on a blood pressure reading

orthostatic hypotension

a significant drop in blood pressure (20 mm Hg systolic or more or 10 mm Hg diastolic or more) after an upright posture is assumed

respiration

one complete inhalation and exhalation

pyrexia

fever greater than 100.4 degrees F

Anthropometric

Related to measurement and proportion of the body.

body mass index (BMI)

an individual's weight divided by the square of their height, used to determine weight status

TPR

temperature, pulse, respiration

BP

blood pressure

SpO2

saturation of peripheral oxygen

PAP

Papanicolaou test

When are vital signs taken?

during each intake process and serve as key indicators of homeostasis

What are 6 factors that can affect vital signs?

1.) stress

2.) food intake

3.) liquid intake

4.) medical conditions

5.) age

6.) physical activity

What serves as a key communication tool for healthcare professionals?

accurate documentation

What must you do until patients return with their parent or guardian?

maintain visual and physical contact

What 2 things must bathrooms be equipped with?

1.) handrails

2.) emergency alert buttons

What 5 things do demographic information include?

1.) name

2.) address

3.) telephone number

4.) insurance information

5.) emergency contact

What is the first step in ensuring safety?

Proper patient identification

What is the most common method for proper patient identification?

to have the patient state their full name and date of birth

What is the most common form of identification when dealing with financial issues?

ask for the patients full name and verify the last four digits of their social security number

What are the 2 most common patient identification face-to-face and receiving care?

1.) name

2.)birth date

What else can the patient screening process be referred to as?

rooming patients

What is a chief complaint?

it is referred to as chief concern, is subjective information documented in the medical record in the patient's own words.

What is another name for chief complaint?

chief concern

What must you use when recording a patient's complaint?

use quotations marks when indicating anything directly stated by the patient.

What must you routinely ask patient's to bring?

all medications or a current list of medications to the office for appointments

What is medication reconciliation?

is a formal process necessary at every office visit

Why is it safe to compare the patient's list of medications to the medical record?

it reduces the risk of improperly prescribing an incorrect or contraindicated prescription

When can patient's develop allergies?

any time

What must you do when a patient has allergies on a paper chart?

flag the patient's allergy i several areas, often noted in red ink or using red allergy stickers

When is a personal and family history completed?

before the first office visit

What is objective information?

is observed or can be measured

What is predispositions?

A liability or tendency to suffer from a particular condition, hold a particular attitude, or act in a particular way.

What do many clinics require patients to update?

their medical history forms annually

When doing screening and wellness on a patient patients will be interviewed regarding what 5 things?

1.) alcohol

2.) tobacco

3.) caffeine

4.) recreational drugs or other chemical substances

5.) sexual practices

Why must you ask questions patients about their occupational history?

to identify and hazards to which they may have been exposed during their employment

WHat do mental health screening asses?

the patients safety and mental status

What does depression screening do?

asks questions about the patients thoughts and feelings

What does the Patient Health Questionnaire-2 (PHQ-2) focus on?

the patients frequency of depressed mood over two weeks

What does the Patient Health Questionnaire-9 (PHQ-9) do?

This screening asks additional questions to assess if the patient meets the criteria for depressive disorder diagnosis

What is the GAD-7 questionnaire used for?

General anxiety and used to screen patients for anxiety

What are 4 common depression symptoms

1.) difficulty going to sleep, staying asleep, or getting up in the morning

2.) profound sadness and fatigue

3.) change in appetite

4.) loss of energy

What are the 7 common symptoms for anxiety?

1.) heightened ability to observe or make connections

2.)difficulty focusing on details

3.) a sense of panic

4.) irritabilty

5.) feeling cold, sweaty

6.) heart palpations

7.) shortness of breath

What does blood pressure do?

measures the blood circulating through the arteries

What are 2 devices used to determine blood pressure?

1.) sphygmomanometer ( a blood pressure cuff)

2.) stethoscope

When is the systolic sound heard?

first (Korotkoff sound 1)

When is the diastolic sound heard?

the final sound (Korotkoff V)

What are korotkoff sounds?

they are distinct sounds that are heard throughout the cardiac cycle

What is phase two in the korotkoff sounds?

there is a swishing sound as more blood flows through the artery

What is phase three in the korotkoff sound?

sharp tapping sounds are noted as more blood surges.

What is phase four in the korotkoff sound?

the sound changes to a soft tapping sound, which begin to muffle

How should the patient be when taking blood pressure?

in the sitting position

What are 5 different contributing factors that can potentially cause errors or influence blood pressure readings?

1.) using the wrong cuff size

2.) if a patient has their legs crossed while taking their blood pressure

3.) the position of the arm can influence the blood pressure reading

4.) if the arm is lower than the right atrium (dangling at their side)

5.) if the patient holds their arm up, the muscular tension will raise the pressure

What is the palpatory method?

it can be used in emergent situations when the blood pressure cannot be auscultated (heard)