Module 3A: Patient Intake and Vitals Flashcards
Vital Signs
Metrics (temperature, pulse, respiration, blood pressure) used to evaluate a patient’s overall health status.
- taken during each intake process and serve as key indicators of homeostasis
- alterations in values could indicate a precursor of illness or disease. Factors such as stress, food or liquid intake, medical conditions, age, and physical activity can affect vital signs.
Proper Patient Identification
2 methods of identification needed to validate that care and treatment are delivered to the correct patient.
- Full name
- DOB
(most common identifiers used when face-to-face and receiving care)
- Avoid saying the patient’s name and then asking them to confirm it. A patient could respond to the wrong name, especially in a time of crisis, stress, or illness.
When dealing with financial issues, such as billing, a common form of identification is to ask for the patient’s full name and verify the last four digits of their Social Security number.
Patient Identifiers
A patient’s medical record contains demographics that require verification at each visit. Demographic information includes name, address, telephone number, insurance information, and emergency contact.
Each established patient has a medical record. Some electronic medical record systems identify patients by an assigned medical record number, making each patient unique within the health care system.
Chief Complaint
(aka chief concern) is subjective information documented in the medical record in the patient’s own words of their primary reason for the office visit.
Subjective
Information gathered from what a patient described and experienced and it is not measurable.
Ex: The patient’s chief complaint of “My stomach hurts” would be subjective information. When recording a patient’s chief complaint, use quotation marks when indicating anything directly stated by the patient
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
Ex: A patient’s past medical history is objective information because it is documented and measured within their health record (Blood pressure 128/74 mm Hg, Weight 175 lb, hx of HTN)
Health Record Information Sections
The sections of the health record include the following:
- Administrative section
a. Patient information/demographics
b. Financial and insurance information
c. Correspondence - Clinical section
a. Past medical history/family history/social history/occupational employment
- Medical history: past illnesses, surgeries
- Family history: illnesses or diseases relevant to the immediate family
- Social history: diet, exercise, caffeine intake, smoking, use of alcohol or recreational drugs
- Occupational history: any occupational employment hazard or exposures
b. Orders/referrals
c. Clinical data
d. Progress notes
e. Diagnostic imagining information
f. Laboratory information
g. Medication list/allergies
Screenings and Wellness Assessments
Patients will be interviewed regarding their use of alcohol, tobacco, caffeine, recreational drugs or other chemical substances, and sexual practices. Also, question the patient about their occupational history to identify any hazards to which they may have been exposed during their employment, such as asbestos.
Ex: Tobacco Cessation, Alcohol Use, HIV Screening
*Be aware that the patient may not be comfortable answering these questions or even refuse to answer some of these questions. Attempt to ask the questions again or document “patient declined to answer” in the patient’s medical record.
Depression Screenings
Asks questions about the patient’s moods, thoughts, and feelings.
- The Patient Health Questionnaire-2 (PHQ-2) focuses on the patient’s frequency of depressed mood over two weeks.
- If the patient’s answers reflect a positive response to depression, the medical assistant can proceed to the Patient Health Questionnaire-9 (PHQ-9). This screening asks additional questions to assess if the patient meets the criteria for a depressive disorder diagnosis.
Mental Health Screenings
Assess the patient’s safety and mental status and screens for anxiety, depression, and degenerative disorders
Anxiety Screening
The GAD-7 questionnaire is for general anxiety and used to screen patients for anxiety.
Mini-Mental Examination
For older adults to evaluate for dementia or other degenerative disorders
Blood Pressure
Measures the force of the blood circulating through the arteries.
Sphygmomanometer
blood pressure cuff
Blood Pressure Measurement
Measured in millimeters of mercury (mm Hg), the systolic pressure is recorded when the first sharp tapping sound is heard, when the blood begins to surge into the artery that has been occluded by the inflation of the blood pressure cuff. The diastolic pressure is noted when the last sound disappears completely and the blood flows freely.
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.
Korotkoff Sounds
Distinct sounds that are heard throughout the cardiac cycle
Phase I: systolic pressure reading (the first sound heard)
Phase II: there is a swishing sound as more blood flows through the artery
Phase III: sharp tapping sounds are noted as more blood surges
Phase IV: the sound changes to a soft tapping sound, which begins to muffle
Phase V: diastolic pressure reading (the final sound heard)
Factors causing inaccurate BP readings
- Using the wrong cuff size can impact the systolic and diastolic pressure up to 6.9 mm Hg
- If a patient has their legs crossed while taking their blood pressure, the systolic blood pressure may be raised by 2 to 8 mm Hg
- The position of the arm can influence the blood pressure reading:
- If the arm is above the heart level, the reading is lowered.
- If the arm is lower than the right atrium (dangling at their side), the reading will be artificially elevated.
- If the patient holds their arm up, the muscular tension will raise the pressure.
Proper BP reading position
Patient in a sitting position, with uncrossed legs, and with the arm resting on the table or chair next to them at the same level as the heart.
The cuff should be placed one inch above the bend in the elbow, or antecubital space
Palpatory BP Method
*Only used in emergent situations when the blood pressure cannot be auscultated (heard)
- The systolic pressure may be checked by feeling (palpating) the radial pulse rather than hearing it (auscultating) with a stethoscope.
- The blood pressure cuff is placed in the usual position (one inch above the bend in the elbow, or antecubital space) and palpates the radial pulse, noting the rate and rhythm. Inflate the cuff until the pulse disappears, then add 30 mm Hg more inflation to get above the systolic pressure. Do not remove the fingers from the pulse or change the pressure of the fingers.
- Carefully watch the gauge while slowly releasing the pressure in the cuff and wait until the first pulse beat is felt.
- Note the reading on the gauge and document the first pulse felt as the systolic pressure.
Ex: if the MA first felt the pulse return at 104 mm Hg, the palpated blood pressure would be 104/P, with P indicating that the systolic reading was palpated.
Factors That Can Influence Blood Pressure and Cause Hypertension
- An increase in blood volume can increase a person’s blood pressure, while a decrease in blood volume can decrease a person’s blood pressure.
- Peripheral resistance can increase blood pressure. The lumen of the blood vessels becomes smaller, making it more difficult for blood to pump through the blood vessels, causing an increase in blood pressure.
- The overall condition of the heart muscle impacts blood pressure. When the heart muscle gets overworked and becomes weakened, it is unable to contract and provide the force it needs to pump the blood effectively, and the pressure in the vessels tends to increase to maintain an adequate level of circulating blood and oxygen to meet the supply and demand of nutrients the body needs.
Common Causes of Errors and Troubleshooting Blood Pressure Readings
- The limb used for measurement is positioned above the heart rather than at the heart level.
- The bladder in the cuff is not completely deflated before a reading is started or retaken.
- The pressure in the cuff is released too rapidly.
- The patient is nervous or anxious.
- The patient drank coffee or smoked a cigarette within 30 minutes of the blood pressure measurement.
- The cuff is applied improperly.
- The cuff is too large, too small, too loose, or too tight.
- The bladder is not centered over the artery, or the bladder bulges out from the cover.
- There was a failure to wait for 1 to 2 minutes between measurements.
- The instrument is defective. (Air leaks in the valve, Air leaks in the bladder, Aneroid needle not calibrated to zero)
Contraindications for limb selection for BP
- One-sided mastectomy: Use the arm on the side not impacted by the mastectomy.
- Bilateral mastectomy: Use leg.
- Lymphedema: Use leg.
- Dialysis fistula: Use arm that is not affected.
Expected BP for Ages: Older than 12 years
Systolic (mm Hg): 110 to 130
Diastolic (mm Hg): 65 to 80
Expected BP for Ages: 6 to 12 years
Systolic (mm Hg): 100 to 120
Diastolic (mm Hg): 60 to 75
Expected BP for Ages: 3 to 6 years
Systolic (mm Hg): 95 to 110
Diastolic (mm Hg): 60 to 75
Expected BP for Ages: 1 to 3 years
Systolic (mm Hg): 90 to 105
Diastolic (mm Hg): 55 to 70
Stages of Hypertension
Normal:
- Systolic (mm Hg): Less than 120 mm Hg
and
- Diastolic (mm Hg): Less than 80 mm Hg
Elevated:
- Systolic (mm Hg): 120 to 129 mm Hg
and
- Diastolic (mm Hg): Less than 80 mm Hg
Hypertension Stage 1:
- Systolic (mm Hg): 130 to 139 mm Hg
or
- Diastolic (mm Hg): 80 to 89 mm Hg
Hypertension Stage 2:
- Systolic (mm Hg): 140 mm Hg or higher
or
- Diastolic (mm Hg): 90 mm Hg or higher
Hypertension Crisis (Emergency care needed):
- Systolic (mm Hg): Higher than 180 mm Hg
and/or
- Diastolic (mm Hg): Higher than 120 mm Hg
Orthostatic Hypotension
(aka postural 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.
*In addition to a decrease in blood pressure, there is an increase in pulse rate.
Orthostatic Vitals
If the provider is concerned about orthostatic hypotension, they may ask the MA to measure orthostatic vital signs.
1. Have the patient lie down for 5 minutes and then measure blood pressure and pulse rate.
2. Next, have the patient stand and then repeat the blood pressure and pulse rate measurements after standing for 1 minute and after 3 minutes. (The practice’s protocol may also require measurements to be completed while the patient is in a sitting position.)
An increased pulse rate of at least 10 beats per minute (bpm) and a decreased blood pressure of at least 20 points between positions indicate orthostatic hypotension.
Orthostatic Vitals Troubleshooting
When checking orthostatic vital signs, keep the patient’s arm on a bed or table, as having the patient hang their arm down can lead to a false high blood pressure reading.
Heart Rate
(aka pulse rate) The number of times the heart beats per minute.
Pulse is evaluated on rate, rhythm or regularity, and volume or strength. A pulse can be described as 70/min (rate), regular (rhythm), and thready (strength). Thready reflects a pulse as difficult to detect or faint. Bounding describes a pulse as being very strong.
What is assessed when taking a pulse?
rate (BPM), rhythm or regularity, and volume or strength (strong, weak, thready).
How to Palpitate a Pulse
The second and third fingers of the dominant hand should be used to palpate the pulse.
The number of beats is counted for one full minute to obtain the patient’s pulse rate.
Pulse Points
There are nine various pulse points throughout the body
Most common:
- The radial pulse, located on the thumb side of the wrist, is the most common site for taking an adult pulse.
- The brachial pulse, inside the upper arm, is the most common for measuring pulse in children and using to measure blood pressure.
- The carotid, located in the neck just below the jawbone, is most common for use in emergency procedures.
Other:
- Temporal artery located on the side of the forehead
- Femoral artery located on the inner groin area
- Popliteal artery located behind the knee
- Posterior tibial artery located behind the ankle
- Dorsalis pedis artery located on top of the foot
Most common site for taking an adult pulse
radial pulse
Most common for measuring pulse in children
brachial pulse
Most common for use in emergency procedures.
carotid
How to Auscultate a Pulse
The apical pulse is measured by listening with a stethoscope to the heartbeat at the apex of the heart. The apical pulse is commonly measured in children, infants, and adults with irregular heartbeats. The apical pulse is measured for 1 full min.
Factors that influence HR
Pulse rates depend on the patient’s condition and age, time of day, activity level, and medications.
Average heart rates tend to slow with age.
Expected HR for Adolescent and Older
60 to 100 (beats/min)
Expected HR for School-Age Child (6 to 15 years)
75 to 118 (beats/min)
Expected HR for Preschooler (3 to 5 years)
80 to 120 (beats/min)
Expected HR for Toddler (1 to 2 years)
98 to 140 (beats/min)
Expected HR for Infant (1-12 months)
100 to 180 (beats/min)
Respiration
One complete inhalation and exhalation evaluated on rate, rhythm, and depth.
One respiration includes one complete inhalation and exhalation (indicated by the rise and fall of the chest with each breath).
Factors That Affect RR
Decreases with age and is affected by health conditions or environmental factors
Tachypnea
fast respiratory rate
Bradypnea
slow respiratory rate
Hyperventilation
Fast/Rapid breathing
Possible Causes:
- Intense pain
- Anxiety
- Panic attacks
Hyperpnea
Excessively deep breathing
Possible Causes:
- Extreme pain
- Anxiety
Dyspnea
Difficult or painful breathing
Possible Causes:
- Chronic obstructive pulmonary disease (COPD)
- Pneumonia
- Asthma
- High altitudes
- Physical exertion
Orthopnea
Difficulty breathing unless in the upright position
Possible Causes:
- Congestive heart failure
- COPD
Wheezing
Whistling sound on expiration as the body attempts to expel trapped air
Possible Causes:
- Asthma
Rales
Small clicking, bubbling, or rattling sounds
(can sound like moist or dry rhonchi heard on inspiration)
Possible Causes:
- Fluid in air sacs
- Pneumonia
Rhonchi
Large airway sounds
Possible Causes:
- COPD
- Chronic bronchitis
- Pneumonia
Respiratory Rhythm vs Depth
Respiratory rhythm is the breathing pattern, and depth describes how much air is inhaled.
Ex: a patient might have a rate of 28/min with an irregular rhythm and shallow depth. This would indicate some respiratory distress, as all three notations are abnormal.
Expected RR for Adolescent and older
12 to 20 (breaths/min)
Expected RR for School-age child (6 to 15 years)
18 to 25 (breaths/min)
Expected RR for Preschooler (3 to 5 years)
20 to 28 (breaths/min)
Expected RR for Toddler (1 to 2 years)
22 to 37 (breaths/min)
Expected RR for Infant (1 to 12 months)
30 to 53 (breaths/min)
How to measure RR
One respiration includes one complete inhalation and exhalation (indicated by the rise and fall of the chest with each breath).
- DO NOT announce that they are counting the patient’s respiration rate as the patient may alter their breathing pattern while being observed.
- It is common to count the respirations immediately following the measurement of the pulse rate.
- Without removing fingers from the pulse, shift eyes to the patient’s chest and count the respiratory rate with the rise and fall of the chest.
- The MA may watch the rise and fall of the shoulders or back to determine the respiratory rate.
- Count for 30 seconds and multiply the number by two, or count for 1 full minute.
Pulse Oximetry
Determines the percentage of oxygen saturation in the blood. (Not considered a vital sign)
Many oximeters also display the heart rate, which is why it is termed pulse oximetry.
Obtaining a pulse oximetry reading
- Attach a probe (PulseOx) to the patient, usually on a finger.
- This probe incorporates infrared light to obtain the measurement of oxygen saturation.
- An alternate site is an earlobe, which can be used if a finger is not an option. - Results are notated by using SpO2 and the percentage reading. For example, SpO2 equals 98%. Readings below 90% should be reported to the provider, and often, oxygen therapy for hypoxemia (decreased oxygen in the blood) may be ordered and initiated.
Factors that affect a pulse oximetry reading
- Nail polish and artificial nails block the infared light of the oximeter and interfere with the results. They should be removed prior to the test, or an alternate site should be used to obtain a reading.
- Darker skin may also be impacted when the oxygen level is low (less than 80%). In this case, a pulse oximeter reading of 95% or higher is considered a normal result.
Temperature
Determines the relationship between heat production and heat loss in the body.
Pyrexia
aka Fever greater than 100.4° F.
Most common cause of pyrexia
Infection
- Fever is the body’s natural defense to fight invasive organisms and is a normal reaction to illness.
Associated symptoms of fever
Patients who have a fever can present with chills, loss of appetite, malaise, thirst, and generalized aching.
Types of Temperature and Locations
- Oral temperature: mouth (via a digital thermometer, with a probe placed under the tongue on either side of the frenulum linguae)
- Axillary temperature: armpit
- Rectal temperature: rectum
- tympanic thermometer: ear
- Temporal artery scanner: forehead (moved across the forehead and behind the ear to produce a temperature reading)
Differences in temperature location readings
Axillary temperature (Ax) is approximately 1° F (0.6° C) lower than an oral reading because axillary readings are not taken in an enclosed body cavity, making them less accurate than the core body temperature.
Tympanic (T), rectal (R), and temporal artery (TA) temperatures are approximately 1° F (0.6° C) higher than oral readings
Factors that affect temperature
- Drinking hot or cold liquids, chewing gum, or smoking prior to taking an oral temperature can result in inaccurate results.
- Age: Infants’ and children’s body temperatures fluctuate in response to the external environment. Adults lose insulation and thermoregulatory control with age.
- External stressors: such as exercise and emotional stress can elevate the body temperature.
- Genders: Female patients have more hormonal secretion, especially during the menstrual cycle. This can cause fluctuation in the body temperature.
- Time of Day: lowest in the morning and highest in the late afternoon
Expected Temperature for Newborn (axillary)
98.2°F or 36.8°C
Expected Temperature for 1 year (tympanic)
99.7°F or 37.6°C
Expected Temperature for 6 years to adult (oral)
98.6°F or 37°C
Expected Temperature for Older adults over age 70 (oral)
96.8°F or 36°C
Temperature Conversion
To convert Fahrenheit to Celsius: ° C = (° F − 32) ÷ 1.8
To convert Celsius to Fahrenheit: ° F = (° C × 1.8) + 32
What temperature sites does not have to be indicated when documenting the reading in the patient’s health record?
Oral temperatures obtained do not have to indicate the site when documented. The site of the temperature only has to be documented if the medical assistant uses an alternative site other than oral.
Pain Scale
Pain is subjective and therefore difficult to interpret. Observe the patient to gather clues about pain level, such as facial grimacing or holding or clutching areas of pain on the body.
Ask the patient to rate pain on a scale of 1 to 10 (with 10 being the worst) to determine the pain level the patient is experiencing.
Pain Scale for Children
Children’s pain can be assessed using the Wong-Baker faces rating scale.
Ask additional questions to determine the location, onset, duration, and other characteristics of the pain to get a more precise clinical picture.
Menstruation
The body’s way to prepare for pregnancy or cleanse the uterine lining.
The hormonal changes of estrogen and progesterone stimulate a menstrual cycle. Each month (approximately every 28 days), the endometrium, which lines the uterus, is shed a lining via vaginal bleeding.
If the patient becomes pregnant, the endometrium will not shed, and they will miss a period.
Last Menstrual Period (LMP)
Considered the first day of the previous menstrual cycle
Anthropometric
Related to measurement and proportion of the body
Ex: height and weight
Obtaining Pediatric Height
If the child cannot stand erect, lay the child or infant flat on a paper-covered exam table to obtain a length measurement.
- Place a mark at the top of the head and the heel of the flexed foot.
- Measure the distance between the two lines and record this measurement in centimeters or inches, according to office protocol.
Obtaining Pediatric Weight
Infant scales are desirable when obtaining an infant’s weight.
- Weigh infants without clothing or a diaper and record the weight using both pounds and ounces.
- Always keep one hand hovering over the infant to ensure their safety on the scale. The medical assistat should never turn their back to an infant on a scale or leave them unattended.
Pediatric Measurements
Monitor growth
Height, weight, and head circumference are measured during a routine well-child visit during infancy and early toddler years.
Obtaining Pediatric Head Circumference
Using a tape measure, measure the head circumference at the widest area.
- Place the measuring tape directly above the eyebrows, around the side of the head, above the ears, and behind the back of the head at its widest point.
- The measurement is recorded in inches or centimeters, depending on office protocol.
Pediatric Growth Charts
Growth charts compare the child’s growth pattern with the national standard. The Centers for Disease Control and Prevention (CDC) developed growth charts that track growth continuously until age 20. These growth charts are sex-specific.
- Length, weight, and head circumference are tracked on growth charts from birth to 36 months.
- Head circumference is not recommended past 36 months (unless abnormal measurements are found)
- Stature and weight are tracked on specific charts from 2 to 20 years. These measurements are plotted on a growth chart to represent growth visually.
Growth Chart Percentiles
Ex: Weight
- below the 5th percentile= underweight
- between the 5th and 85th percentile= normal or healthy weight
- 85th to 95th percentile= overweight
- equal to or greater than the 95th percentile= obese
Weight Conversion Pounds and Kilograms
One kilogram equals 2.2 pounds (1 kg equals 2.2 lb).
- To convert pounds to kilograms, divide the weight in pounds by 2.2.
- To convert kilograms to pounds, multiply the weight in kilograms by 2.2.
Height Conversions Feet and Inches
- To convert height from inches to feet, divide the total number of inches by 12. The remainder is inches.
Example:
62 inches = 62 / 12 = 5 feet, 2 inches
Body Mass Index (BMI)
A patient’s BMI is a percentage used to represent body fat in relation to a person’s height and weight.
The weight status is determined by a person’s weight divided by the square of their height. This status can then correlate risk factors or predisposition for conditions such as heart disease or diabetes.
BMI= weight (kg)/height (m2)
or
BMI= weight (lbs)/height (in2) x 703
BMI Ranges
- less than 18.5%= underweight
- 18.5% to 24.9%= normal
- greater than 24.9%= overweight
- 30.0% and greater= obesity
Factors Affecting Vital Signs: Consuming a hot beverage
Increased oral temperature reading
Factors Affecting Vital Signs: Consuming a cold beverage
Decreased oral temperature reading
Factors Affecting Vital Signs: Anxiety
Increased blood pressure
Increased heart rate
Factors Affecting Vital Signs: Smoking
Increased blood pressure
Increased heart rate
Factors Affecting Vital Signs: Exertion (such as a long walk to the exam room)
Increased blood pressure
Increased heart rate
Lower oxygen levels
Factors Affecting Vital Signs: Age
Increased temperature fluctuation in young children (inability to regulate)
Decreased temperature in older adults (loss of insulation in the form of body fat)
Factors Affecting Vital Signs: Pain
Increased blood pressure
Increased heart rate
Factors Affecting Vital Signs: Illiness
Increased temperature
Factors Affecting Vital Signs: Beta-blocker medication
Decreased blood pressure
Decreased heart rate
