NHA CCMA - Vital Signs

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

auscultation

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 during positional changes, particularly when the patient is moving from lying down to sitting or from sitting to standing; also known as postural hypotension

respiration

one complete inhalation and exhalation

pyrexia

fever greater than 100.4 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

apnea

abnormal, 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; a pulse below 60 beats per minute

bradypnea

abnormally slow breathing

calibrated

determined by or checked against a standard

cerumen

a waxy secretion in the ear canal; commonly called ear wax

Cheyne-Stokes respiration

deep, rapid breathing followed by a period of apnea

chronic obstructive pulmonary disease (COPD)

a progressive, irreversible lung condition that results in diminished lung capacity

diurnal variation

fluctuations that occur during each day

essential hypertension

elevated blood pressure of unknown cause that develops for no apparent reason; sometimes called primary hypertension

febrile

pertaining to an elevated body tempature

fluctuate

to shift back and forth

homeostasis

the internal environment of the body that is compatible with life. A steady state that is created by all the body systems working together to provide a consistent and unvarying internal enviornment

hyperpnea

excessively deep breathing

hyperventilation

abnormally increased breathing

hypotension

Blood pressure that is below normal (systolic pressure below 90 mm Hg and diastolic pressure below 50 mm Hg).

idiopathic

of unknown cause

intermittent pulse

a pulse in which beats occasionally are skipped

larynx

the voice box

lymphedema

a condition in which extra lymph fluid builds up in tissues and causes swelling. It may occur in an arm or leg if lymph vessels are blocked, damaged, or removed by surgery

malaise

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

myocardium

the middle layer, and thickest layer, of the heart; composed of cardiac muscle

occlude

to close, shut, or stop up

orthopnea

a condition of difficult breathing unless in an upright position

orthostatic (postural) hypotension

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

otitis externa

inflammation or infection of the external auditory canal (swimmer's ear)

peripheral

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

pulse deficit

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

pulse pressure

the difference between the systolic and diastolic blood pressures (30 to 50 mm Hg is considered normal).

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 (pacemaker).

stertorous

heavy, as related to snoring

syncope

fainting; a brief lapse in consciousness

tachycardia

a rapid but regular heart rate; one that exceeds 100 beats per minute

tachypnea

rapid, shallow breathing

thready

Describes a pulse that is thin and feeble

vertigo

dizziness; an abnormal sensation of movement when there is none

wheezing

whistling sound made during breathing

What are vital signs a key indicator of?

1. homeostasis

What are the 5 factors that can affect vital signs?

1. stress

2. food or liquid intake

3. medical conditions

4. age

5. physical activity

What is a key communication tool among health care professionals?

1. accurate documentation

With what 3 things are children prone to falls and injuries?

1. Sharp objects

2. Choking on small items

3. Touching electrical outlets

What do you maintain with patients until they return to their parent or guardian?

1. Visual and physical contact

What 2 things should restrooms be equipped with?

1. Handrails

2. emergency alert buttons

What 5 things does demographic information include?

1. Name

2. Address

3. Telephone number

4. Insurance information

5. Emergency contact

What is the most common method for patient identification? (2)

1. full name

2. date of birth.

When dealing with financial issues, such as billing , what is the common form of identification? (2)

1. full name

2. last four digits of their social security number

What is also referred to as rooming patients?

1. The patient's screening process

What is the patients screening process?

1. Gathering information from the patient

When does the screening process vary?

1. Depending on the type of visit and amount of information collected during the process.

All patients should have a minimum of what? Including what two things?

1. Screening (chief of complaint) (medication review)

A chief complaint is also referred to as what?

1. Chief concern

What is a chief concern?

1. A subjective information documented in the medical record in the patients own words

What are two examples where the medical assistant states that identifies the reason for the visit?

1. "Please tell me why you are coming in today?"

2. "What brings you to the office today?"

What do you use when recording a patients chief of complaint?

1. Quotation marks when indicating anything directly stated by the patient

What should you routinely ask patients to bring in?

1. All medications or a current list of medications to the office for appointments.

What is reconciliation?

1. Reviewing or checking

Medication reconciliation is a safety measure that reduces what?

1. The risk of improperly prescribing an incorrect or contraindicated prescription.

What is subjective information?

1. Usually described and experienced by the patient and is not measurable

What are 2 sections included in the health record information?

1. Administrative

2. clinical

What are 3 things included in the administrative section?

1. Patient information/ demographics

2. Financial and insurance information

3. Correspondence

What are the 11 things included in the clinical information?

1. Past medical history/ family/ social/ occupational employment

2. Medical history: past illnesses, surgeries

3. Family history: illnesses or disease relevant to the immediate family.

4. Social history: diet, exercise, caffeine intake, smoking, use of alcohol or recreational drugs.

5. Occupational history: ay occupational employment hazard or exposures.

6. Orders/ referrals

7. Clinical data

8. Progress notes

9. Diagnostic imaging information

10. Laboratory information

11. Medication list/ allergies

When can patients develop an allergy?

1. at any time

If a patient has allergies, what do you ask?

1. What allergies and what type of reaction occurred

What do most electronic formats offer?

1. Safety measures of alerting the provider

In a paper chart, what should you flag?

1. The patient's allergy in several areas

The patients allergies are often noted in what?

1. Red ink or using red allergy stickers

What is objective information?

1. Observed or can be measured

What is predispositions?

1. Being susceptible

Clinics request patients to update their medical history forms when?

1. annually

The patients responses can trigger what?

1. The need for a wellness screening or assessment

Question the patient about their occupational history to identify what?

1. Any hazards to which they may have been exposed during their employment

Patients are interviewed regarding their use of what 5 things?

1. Alcohol

2. Tobacco

3. Caffeine

4. Recreational drugs or other chemical substances.

5. Sexual practices

Ask the patient about diet and exercise to provide what?

1. Greater detail regarding their health status

What do you do if a patient refuses to answer any questions?

1. Attempt to ask the question again or document "patient declined to answer" in the patients medical record

What do mental health screenings assess?

1. The patients safety and mental status

For depression screenings, what 3 things do you ask patients?

1. mood

2. thoughts

3. feelings

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

1. The patients frequency of depressed mood over two weeks

What does the medical assistant proceed to if the patient's response is positive to depression?

1. Patient Health Questionnaire-9 (PHQ-9)

What is the PHQ-9?

1. Additional questions to assess if the patient meets the criteria for a depressive disorder diagnosis

Older adult patients could require what and to evaluate what?

1. A mini-mental examination to evaluate for dementia or other degenerative disorders

What is the most common emotional response for many people?

1. Anxiety

Anxiety can be a response to what?

1. Fear or an unfamiliar situation

What is the GAD-7 questionnaire?

1. For general anxiety and used to screen patients for anxiety