Module 3A: Patient Intake and Vitals Flashcards
(105 cards)
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)
