General Patient Care

Joint Commission

a not-for-profit organization that evaluates and accredits different types of healthcare facilities

Joint commission stresses the need to use 2 methods of identifications is the first step for ensuring patient safety

two identifiers the most common method is to have pts state their full name and date of birth

Preparing exam rooms includes

at the end of the day cleaning, disinfecting and stocking of pt rooms. upon arriving to work the next day, recheck the rooms for cleanliness and adequacy of supplies

Review schedule to determine reason for visit

this ensures CCMA is familiar with pt. history. If pt is brought in due to a dx. such as Alzheimer's invite family to come back with pt.

Clean and disinfect the room In the beginning of the day and at the end of the day cleaning counters and exam tables with

sodium hypochlorite solution (which is 1:10 dilution of household bleach to water) or a commercial chemical surface disinfection.

Pull appropriate equipment and supplies for visit like

EKG for possible chest pain, but do not start test until Dr orders test. Pull P.P,E, gown, gloves, biohazard container etc.

RACE

rescue, alarm, contain, extinguish

PASS

Pull, Aim, Squeeze, Sweep

active listening

paying close attention to what someone is saying and communicating allowing receiver to fully understand the message being communicated

open-ended questions

questions that allow respondents to answer however they want v/s a yes or no response

Restatement

Expressing the same idea in different words to clarify and stress key points

Reflection

receiver focuses on the main idea of the message but incorporates feelings the sender might be exhibiting or possibly feeling

clarification

the act of making clear or understandable

nonverbal communication

communication using body movements, gestures, and facial expressions rather than speech

Safety Needs (Maslow's Hierarchy of Needs)

security, safety

Safety adjustments

children and older people and people with specific needs are prone to falls and injuries, They may need help walking or need help getting onto the table. Children need to be watched for putting things into electric sockets and choking hazards.DO NOT LEAVE PATIENTS WITH PSYCHIATRIC OR DISABILITIES ALONE

Rapport and empathy

Pt needs to be able to trust the CMA to communicate honestly

empathy

Identification with and understanding of another's situation, feelings, and motives

Intake process

also called "rooming pts" process of gathering initial information (every pt should have a chief complaint and medication review at each visit)

Chief Complaint (CC) subjective information

History of present illness

Review of symptom

Past, Family and or Social History

subjective information

Information from the patient's point of view. open-ended question(what brings you in today ?)

"I feel dizzy."

sympathy

feelings of pity and sorrow for someone else's misfortune

Medical Reconciliation

Formal process that compares patient's current medications to those of the medical record or medical orders; meant to identify and rectify discordances(pt should be asked to bring a list of current medications to Appt.)

allergy

abnormal hypersensitivity acquired by exposure to an antigen-antibody response

anaphylaxis (anaphylactic shock)

An extreme, life-threatening systemic allergic reaction that may include shock and respiratory failure.

Objective information includes:

Results from: physical exam, labs, radiology,

diagnosis, Treatment, progress notes,

information collected that is observed by someone other than the pt.

audiometry

the use of an audiometer to measure hearing acuity

visual acuity testing

Use of tools such as a Snellen chart to screen for visual impairments

anthropometric measurements

Measurements or estimates of physical aspects of the body such as height, weight, circumferences, and body composition.

Denver Developmental Screening Test

An instrument used to assess the development of children between birth and 6 years of age.

Scoliosis

abnormal lateral curvature of the spine(teenagers)

Mini-Mental State Examination (MMSE)

Brief 30-point questionnaire test that is used to screen for cognitive impairment; commonly used to screen for dementia.(older aged pts)

Personal/Family History

Declarant must be family member or close associate. Requires personal knowledge.

Homeostasis

process by which organisms maintain a relatively stable internal environment

Pyrexia/Febrile

elevated body temperature

Normal temperature range

normal oral, tympanic, and temporal tems are 98.6 F (37 C) Axillary temp will be 1 degree F cooler while rectal temp averages 1 degree F higher

malaise

a vague feeling of physical discomfort or uneasiness

Radial pulse site

Located at the wrist on the thumb side-(most common pulse used when taking an adult pulse)

brachial pulse site

inner aspect of forearm at the antecubital space (crease at elbow) (most common site in children)

carotid pulse site

at the neck just below the jaw bone on either side of the trachea(most commonly used during emergencies)

femoral pulse site

at the inner aspect of the upper thigh where the thigh joins with the trunk of the body

Pedal pulse site

top of foot

if pedal pulse is absent

circulation to the toes is affected (distal to pulse site )

palpation

an examination technique in which the examiner's hands are used to feel the texture, size, consistency, and location of certain body parts

Auscultation

Listening with a stethoscope to sounds within the body and can be used to take blood pressure

apical pulse site

chest. Over the apex of the heart. Point of maximum impulse, 4th-5th intercostal. we don't palpate, you auscultate.

pulse

evaluated on rate, rhythm or regularity and volume or strength varies with age (over 15 yr old to adult Normal pulse rate is 60-100)

A thready pulse is considered

a pulse that is difficult to detect or faint

Bounding pulse

A pulse with an increased volume that feels very strong and full

Popliteal

area behind the knee

newborn average heart rate (birth to 1 month old)

120-160/min

infant (1 to 12 months) pulse rate

80-140/min

toddler pulse rate(1 to 3 years)

80-130/min

preschool pulse rate(3 to 5 years old)

80-120 bpm

school age (6 to 15 years old)

70 to 100 bpm

adult (older than 15 years old)

60 to 100 bpm

Patient Identification

the first step in ensuring safety. Joint Commission stresses the need for two methods.(Have pt state full name and date of birth)

Ensure Pt and staff Safety in clinical setting by

planning for disasters and fires ahead to protect human life including policies and evacuation plans, and having emergency equipment easily available.

Medical Assistants should report

sidewalk crack, loose handrails, snow, or ice to their immediate supervisor.

Medical Assistants should avoid cluttered hallways and spills, items on the floor and avoiding loitering in the hallways due to

Safety concerns.

Pediatric and the elderly along with pts with disabilities should

have special attention and require special precautions in the waiting area and in the Pt. Room for fall prevention especially with children until they are returned to their guardians or parents

drug reconciliation

Formal Process of verifying with patients the medications they are currently taking at every office visit and reviewing the list with the Pts medical record

second and third fingers should be used when palpating

a pulse

Thready pulse

A pulse with a decreased volume that feels weak and thin

Pedal Pulse/Dorsalis Pedis Pulse

Pulse felt at top of bridge of either foot(if pedal pulse is absent circulation to the toes is affected

Respirations

The process of taking in oxygen (inspiration) and expelling carbon dioxide (expiration) by way of the lungs and air passages. Evaluated on rate, rhythm, and depth. normal rate for adult is 12-20/min

infant respiratory rate

30-50/min compared to the 12-20 in adults

Wheezing

The production of whistling sounds during expiration such as occurs in asthma and bronchiolitis.

rales (crackles)

crackling or bubbling lung noises heard on inspiration that indicate fluid in the alveoli or fibrosis

Rhonchi (sonorous wheeze)

loud, low, coarse sounds like a snore most often heard continuously during inspiration or expiration; coughing may clear sound (usually means mucus accumulation in trachea or large bronchi)

pulse oximetry

An assessment tool that measures oxygen saturation of hemoglobin in the capillary beds. A probe is applied to fingers that had nail polish removed or earlobe can be used. 95% or better is normal limits

pain scale

0-10 (10 being the worst pain)

Head Circumference Measurement

Measured on all infants and toddlers (3 years and younger)measure head circumference at the widest area, usually right across the eyebrows. in inches and cm. Repeat height and head circumference twice to confirm it.

The height measurement

Screening for Scoliosis & osteoporosis and BMI, Pt should stand erect and looking forward without shoes on. The leveling bar needs to sit squarely on the head, and the measurement might be in inches and converted to feet by dividing the inches by 12 (60/12 =5 foot)

BMI (body mass index)

Underweight - Less than 18.5

Normal - 18.5 - 24.9

Overweight - great than 24.9 - 29.9

Obese - 30 or greater

1 kg

= 2.2 lbs

figuring BMI

wt in pounds / height in inches squared *703=BMI

microcephaly

head growth that falls below the normal percentile of below 13.5 inches

macroencephaly

abnormally large head, Head circumference of 15.5 or above

systolic pressure

first sharp tapping sound heard which is when the blood begins to surge into the artery that has been occluded by the inflation of the blood pressure cuff.

diastolic pressure

last sound disappears completely and the blood flowing freely. The pressure in the arteries when the heart is at rest

Korotkoff phases(starts during systole ends at diastole)

Phase 1- A sharp thump

Phase 2- A blowing or whooshing sound

Phase 3- A crisp, intense tapping

Phase 4- A softer blowing sound that fades

Phase 5- Silence

Infant-child Height Measurement

If unable to stand erect have them lay supine on a paper-covered table. Place a mark at the top of the head and at the heel of the flexed foot. Record this measurement in cm's or inches.

Infant weight

Weigh infants without clothing or a diaper. Infants should double their wt in 6 months and triple it by 1 year old

Pts may need assistance in Height and Weight

CMA may have to assist pt with walking and standing on scale. Last resort the patient, family member or caretaker can give an estimated weight but document this in the medical record.

Orthopnea means

a breathing difficulty that is relieved by sitting upright

semi-fowlers position

Seated leaning against the back of a table that has been raised 45 degree angle. Pts with SOB, unable to lie supine for positions that should be done supine and exams of the chest

Fowler's position

a sitting position with the head elevated 90 degrees (sitting straight upright) Exams involving the eyes, ears, nose throat and chest.

Sims(lateral) position

laying on L. side with L.leg slightly flexed and the R.leg flexed at a 90% angle. Pillow can be placed between knees. Exams involving the rectum, enemas

knee-chest position

patient is lying Prone (face down) with the hips bent so that the knees and chest rest on the table and arms above head. Gyn or rectal exams or spinal adjustments

Jack-knife position

Lying over an exam table that is lifted in the middle. Rectal exams or flexible sigmoidoscopy

lithotomy position

lying flat on the table with buttocks at the end of the table and feet resting in stirrups. Exams female pelvic exams

dorsal recumbent position

patient is lying on the back, face up, with the knees bent. Exams-Catheterizations, genital exams of younger children, adolescents.

prone position

lying on abdomen, facing downward (head may be turned to one side) Exams-back of body and bottoms of feet.

supine position

lying flat on back, facing upward with arms down on side. Administration of CPR.

Trendelenburg position

The body is laid flat on the back (supine position) with the feet higher than the head by 15-30 degrees, Shock

otoscope

instrument used for visual examination of the ear

ophthalmoscope(s)/ophthalmoscopy

an instrument used to examine the interior of the eye/ visual examination of the fundus of the eye

Checking the Med Order

Check Medication 3 times before administering it helps prevent medication errors. 1st check is comparing the medication order to the medication. 2nd- check occurs after the medication is prepared for administration, 3rd check is completed immediately prior to administering the medication to the pt.

Alcohol swabs

are used to wipe off vials or wrap around the neck of an ampule, as well as skin preparation.