NHA CCMA Study Guide, Nha certification study guide for CCMA

Chief Complaint Definition

The reason why the patient came to see the physician.

Chief Complaint Abbreviation

CC

History of Present Illness Abbreviation

HPI

History of Present Illness Definition

This is an explanation of the CC to determine the onset of the illness; associated symptoms; what the patient has done to treat the condition, etc.

Past, Family and Social History Abbreviation

PFSH

Past Medical History Definition

Includes all health problems, major illnesses, surgeries the patient has had, current medications complete with reasons for taking them, and allergies.

Family History Definition

Summary of health problems of siblings, parents, and other blood relatives that could alert the physician to hereditary and/or familial disease.

Social History Definition

Includes marital status, occupation, educational attainment, hobbies, use of alcohol, tobacco, drugs, and lifestyles.

Review of Systems Abbreviation

ROS

Review of Systems Definition

This is an orderly and systematic check of each organ and system of the body by questions. Both positive and pertinent negative findings are documented.

3 Body Processes Necessary for life are:

Body Temperature, Respiration, Heart Function

4 Vital Signs of Body Function are:

Temperature, Pulse, Respiration, Blood Pressure

Define Body Temperature

Is a balance between heart production and heart loss in conjunction with each other, maintained and regulated by the hypothalamus.

Thermometers

Are used to measure temperature using the Fahrenheit and Centigrade or Celsius scale.

Temperature Sites

Mouth, Rectum, Ear (Tympanic Membrane), and the axilla (underarm).

Normal Temperature Range for Rectal

98.6F to 100.6F

37.0C to 38.1C

Normal Temperature Range for Oral

97.6F to 99.6F

36.5C to 37.5C

Normal Temperature Range for Axillary

96.6F to 98.6F

35.9C to 37.0C

Normal Temperature Range for Tympanic Membrane

98.6 F

37 C

Define Febrile

Presence of Fever

Define Afebrile

Absence of Fever

Define Fever

Elevated body temperature beyond normal range.

Intermittent Fever

Fluctuating fever that returns to or below baseline then rises again.

Remittent Fever

Fluctuating fever that remains elevated; it does not return to baseline temperature.

Continuous Fever

A fever that remains constant above the baseline; it does not fluctuate.

Oral Temperature

Is the most common method of measurement.

Oral Temperature is not taken from what patients:

-infants and children less than six years old

-patients who has had surgery or facial, neck, nose, or mouth injury

-those receiving oxygen

-those with nasogastric tubes

-patients with convulsive seizure

-hemiplegic patients

-patients with altered mental status

How long after a patient eats, smokes or drinks do you wait to take an oral temperature?

30 minutes

When taking an oral temperature how long do you leave the thermometer in the patient's mouth?

3-5 minutes

Rectal Temperature

Is taken when oral temperature is not feasible.

Rectal Temperature is not taken from what patients:

-patient's with heart disease

-patients with rectal disease or disorder or has had rectal surgery

-patients with diarrhea

Axillary Temperature

Is the least accurate and is taken only when no other temperature site can be used.

When taking an axillary temperature how long should the thermometer be held in place?

5-10 minutes

Tympanic Temperature

Is useful for children and confused patients because of the speed of operation.

Tympanic Temperature is not taken from what patients:

-patients with an ear disorder or ear drainage

When taking a Tympanic Temperature:

A covered probe is gently inserted into the ear canal and temperature is measured with seconds (1-3 seconds).

What is the normal range for an adult pulse:

60 to 100 beats per minute

The site most commonly used for taking a pulse is:

The radial artery (found in the wrist on the same side as the thumb).

When taking a pulse at the radial artery it is felt with the:

First two or three fingers (never with the thumb) and usually taken for 30 seconds multiplied by two to get the rate per minute.

(Taking a pulse at the radial artery) If the rate is unusually fast or slow then:

Count it for 60 seconds

The _____ _____ is a more accurate measurement of the heart rate and it is taken over the apex of the heart by auscultation using the stethoscope.

Apical Pulse

Taking an apical pulse is used for patients with:

Irregular heart rate and for infants and small children.

Respiratory Characteristics

Rate, Rhythm, and Depth

Respiratory Rate

Is the number of respirations per minute.

Normal Adult Range of Respiratory Rate

12 to 20 per minute

What counts as one respirations:

One inspiration (inhale) and One Expiration (exhale).

How is a Respiratory Rate calculated:

Count respirations for 30 seconds then multiplied by two or count for a full minute.

Define Apnea

This is a temporary complete absence of breathing which may by result of a reduction in the stimuli to the respiratory centers of the brain.

Define Tachypnea

This is a respiration rate of greater than 40/min. It is transient in the newborn and maybe caused by the hysteria in the adult.

Define Bradypnea

Decrease in numbers of respirations. This occurs during sleep. It may also be due to certain diseases.

Define Respiratory Rhythm

Refers to the pattern of breathing. It can vary with age: infants have an irregular rhythm while adults have regular.

Define Cheyne-Stokes

This is a regular pattern of irregular breathing rate.

Define Orthopnea

This is difficulty or inability to breath unless in an upright position.

Define Respiratory Depth

Refers to the amount of air that is inspired and expired during each respiration.

Define Hypoventilation

State in which reduced amount of air enters the lungs resulting in decreased oxygen level and increased carbon dioxide level in blood. It can be due to breathing that is too shallow, or too slow, or to diminished lung function.

Define Hyperpnea

Abnormal increase in the depth and rate of breathing.

Define Hyperventilation

State in which there is an increased amount of air entering the lungs.

Define Blood Pressure

This is the measurement of the amount of force exerted by the blood on the peripheral arterial walls and is expressed in millimeters (mm) of mercury (Hg).

Blood Pressure Abbreviation

BP

BP consist of two components:

The Highest (systole) and lowest (diastole) amount of pressure exerted during the cardiac cycle.

Common errors in blood pressure measurements:

-Improper Cuff Size

-The arm is not at heart level

-Cuff is not completely deflated before use

-Deflation of the cuff is faster than 2-3mmHG per second

-The cuff is re-inflated during the procedure without allowing the arm to rest for 1-2 minutes between reading

-Improper cuff placement

-Defective Equipment

Define Anthropometric Measurements

Refers to comparative measurements of the body.

What age groups use Length, Height, Weight, Weight-for-Length, and Head Circumference - Anthropometric Measurements:

Are used to assess growth and development in infants, children, and adolescents.

What age groups use Height, Weight, Body Mass Index (BMI), waist-to-hip ratio, and % of body fat - Anthropometric Measurements:

Are the measurements used for adults.

The 4 principles of a physical examinations:

Inspection, Palpation, Percussion, Auscultation

Define Inspection

Which provided an enormous amount of information. The observer uses observation to detect significant physical features or objective data.

Inspection focuses on certain aspects of the patient:

General Appearance, State of Nutrition, Body Habitus, Symmetry, Posture and Gait

Define Palpation

The examiner uses the sense of touch to determine the characteristics of an organ system.

Define Percussion

This involves tapping or striking the body, usually with the fingers or a small hammer to determine the position, size and density of the underlying organ or tissue.

Define Auscultation

This involves listening to sounds produced by internal organs. It is usually done to evaluated the heart, lungs, and the abdomen.

The Medical Assistant's Role In the Physical Examination:

-Room Preparation

-Patient Preparation

-Assisting the Physician

Horizontal Recumbent Position

Is used for most physical examinations. The patient lies on his/her back with legs extended. Arms may be above the head, alongside the body or folded on the chest.

Dorsal Recumbent Position

Is when the patient is on his/her back with knees flexed and soles of feet flat on the bed. The MA will need to fold a sheet once across the chest and fold a second sheet crosswise over the thighs and legs so that genital area is easily exposed.

Fowler's Position

Is used to promote drainage or to ease breathing. A sitting or semi-sitting position where the back of the examination table is elevated to either 45 degrees (45 degrees (Semi-Fowler's) or 90 degrees (High-Fowler's).

Dorsal Lithotomy Position

Is used for examination of pelvic organs. This position is similar to the dorsal recumbent position, except that the patient's legs are well separated and thighs are acutely flexed. The feet are usually placed in stirrups and a folded sheet or bath blanket is places crosswise over thighs and legs so that genital area is easily exposed.

The Pone Position

Is used to examine the back. The patient lies on his/her abdomen with head turned to one side for comfort, the arms may be above head or alongside the body.

The Sim's Position

Is used for rectal examination. The patient is on his/her left side with the right knee flexed against the abdomen and the left knee slightly flexed. The left arm is behind the body; the right arm is placed comfortable.

The Knee-Chest Position

Is used for rectal or vaginal examinations and as treatment to bring uterus into a normal position. The patient is on his/her knees with his/her chest resting on the bed and elbows resting on the bed or arms above head. The head is turned to one side.

Trendelenburg Position

The patient is placed flat on the back, face up, the knees flexed and legs hanging off the end of the table, with the legs and feet supported by footboard. The table is positioned with the head 45 degrees lower than the body. This position is used primarily for surgical procedures of pelvis and abdomen.

OSHA stands for

Occupational Safety and Health Adminstration

OSHA is

Responsible for the identification of the various hazards present in the work place and for the creation of rules and regulations to minimize exposure to such hazards.

Physical Hazards - Electrical Safety Regulations:

-Use only ground plugs that have been approved by Underwriters' Laboratory (UL)

-Never use extension cords

-Avoid electrical circuit overloading

-Inspect all cords and plugs periodically for damage

-Use a surge protector on all sensitive electronic devices

-Before servicing, UNPLUG the device from the electrical outlet

-Use signs and/or labels to indicate high voltage or electrical hazard

Chemical Hazards - Chemical Safety Regulations

-If skin or eyes come in contact with any chemicals, immediately wash the area with water for at least 5 minutes

-Store flammable or volatile chemicals in a well-ventilated area

-After use, immediately recap all bottles containing toxic substances

-Label all chemicals with the required Material Safety Data Sheet (MDSD)

Material Safety Data Sheet Abbreviation

MDSD

Patient's have the Right to:

-Information about pain and pain relied

-A caring staff who believes in your reports of pain

-A care staff with concern about your pain

-A quick response when you report your pain

Patient's have the responsibility to:

-Ask for pain relief when you pain first starts

-Help those caring for you to asses you pain

-Tell those caring for you if your pain is not relieved

-Tell those caring for you about any worries that you have about taking pain medications

-Decide if you want your family and/or significant others to aid in your relief of pain

Patient Representative

Primary assignment is to assist you in exercising your rights as a patient.

Good Samaritan Law

This law deals with the rendering of first aid by health care professionals at the scene of an accident or sudden injury.

Needle Stick Prevention Act

OSHA has put into force the Occupational Exposure to Bloodborne Pathogen (BBP) Standard when it was concluded that healthcare employees face a serious health risk as a results of occupational exposure to blood and other boy fluids and tissues..

Bloodborne Pathogen Abbreviation

BBP

Bloodborne Pathogen Standard

-Revision and updating of the exposure control plan

-Solicitation of employee input in selecting engineering and work practice controls

-Modification of definitions relating to engineering controls

-New record keeping requirements

Sharps Injury Log must contain, at the minimum:

-The type and brand of device involved in the incident

-The department or work area where the exposure incident occurred

-An explanation of how the incident occured

Define Tort

Is a wrongful act that results in injury to one person by another.

Define Battery

The basis of tort in this case is the unprivileged touching of one person by another. When a procedure is to be performed on a patient, the patient must give consent in full knowledge of the procedure and the risk it entails (informed consent).

Define Invasion of Privacy

This is the release of medical records without the patient's knowledge and permission.

Define Defamation of Character

This consists of injury to another person's reputation, name, or character through spoken (slander) or written (libel) words.

Define Negligence

This is the failure to exercise the standard of care that a reasonable person would give under similar circumstances and someone suffers injury because of another's failure to live up to a required duty of care.

The 4 Elements of Negligence:

-Duty: duty of care

-Derelict: breach of duty of care

-Direct cause: legally recognizable injury occurs as a result of the breach of duty of care

-Damage: wrongful activity must have caused the injury or harm that occurred

Define Patient Confidentiality

This is the key concept of HIPAA. All patients have a right to privacy and all information should remain privileged.

Define Informed Consent

This is consent given by the patient who is made aware of any procedure to be performed, its risks, expected outcomes, and alternative.