Domains of Healthcare

VI - I

Diagnostic Services - What’s happening, see health status

Therapeutic Services - Help change health status

Career Responsibilities

Plan patient care

  • Work within the scope of practice

  • Determine if a request is an app for a patient

  • Include the patient in care development

  • Develop a plan of care to meet needs

  • Assemble the needed and appropriate material

Implement patient care

  • Check position order

  • Verify patient ID

  • Evaluate if the patient can tolerate

  • Preppatient

  • Perfom ordelry, care produce

  • Follow direction

  • Use equipment rec by manufacturer

  • Maintain condition

  • Modify care as needed

Evaluate patient care

  • Responses or Lack of

  • Function of equipment

  • Personal performance

  • Analysis of the info gathered

  • Revise if unsuccessful or if the info gathered

Conducting a patient interview to collect Data

Collect Patient Data: Patient Interview - make sure everything is professional and done attentively.

  • Demographic: Defines the patient

  • Final info

  • Release of Info: Previous medical records to them, but follow HIPAA

SOAP

  • Subjective: What the patient tells you about thier care

  • Objective: The findings from physical examinations, laboratory tests, and imaging studies that you observe and document.

  • Assessment: Evaluation of the patient's condition based on subjective and objective findings, guiding the treatment plan.

  • Plan: Details the proposed treatment strategies, including medications, therapies, and follow-up appointments.

Vital signs

  • Provide info about body function

  • Incldes

- Temperature

- Pulse

- Respiration - Stethoscope (multi-use)

- BP - Sphygmomanometer

Changes may be the first sign of disease/illness

Accuracy is imperative!

Respiration

Process of taking in O2 and expelling CO2

  • 1 inspriton + 1 expiration = respiration

(When checking respirations, you should pretend that you are checking the patient's radial pulse to prevent them from changing thier breathing pattern

Normal Rate:

  • Adults - 12-20 breaths per minute

  • Children - 16-30 breaths per minute

Evaluate for rhythm and character

Rhythm - Regular or irregular

Character -depth, ease of breaths

Temperature

Measurement of the balance between heat lost and heat produced

Temp below 95F

Death can occur if below 93F

CYANOSIS - bluish discoloration of the skin

Normal ranges:

  • 97 - 100 F

  • 36.1 - 37.8 C

  • Afebrile - without fever; normal temperature

Heat lost through:

  • Persipration

  • Respiration

  • Excertion

Heat produced by:

  • Metabolism of food

  • Muscle and gland activity

Hypothermia - Temp below 95F

Death can occur if below 93F

CYANOSIS - bluish discoloration of the skin

Temperature decreases with:

  • enviorment

  • exposure to cold

  • inactivy

  • sleep

  • stravation

Sx - shivering, cold skin, confusion

Hyperthermia - Temp 100-104F, 104F + is life-threatening, Can cause brian injury if prolonged, FERBRILE = with fever, Pyrexia - another terminology for fever

Temp increases with:

  • Enviorment

  • Excerise

  • illness, infection, injury

Sx:

  • got, dry, red skin

  • nausea/vomiting

  • headace

  • low blood pressure

Where to take Temp?

  • Aural/Tympanic: auditory cancal = aural 98.6 (T) - Measures core body temp; however, if placed incorrectly in the ear or there is an infection or wax, it may be an incorrect temp.

  • Axillary/armpit = 97.6 (ax)

  • Oral/mouth = 98.6 (o) - If pts drank something hot or cold, wait 15 min for accurate temp

  • Rectal = 99.6 (R) - most accurate temp

How to take height + weight

The AMA recommends measuring height & weight to avoid serious health risks.

  • Height: Use a stadiometer; ensure the patient stands straight, looking forward with heels together and back against the wall.

  • Weight: Use a calibrated scale; have the patient remove heavy clothing and shoes for an accurate measurement.