Module 9: General Patient Care Flashcards
1
Q
the first step in ensuring patient safety
A
patient identification
2
Q
patient identification methods
A
- Joint Commission stresses using two pt identifiers
- state name and date of birth
- never state to pt and get them to confirm
3
Q
what should you do at the end of each day
A
- disinfect the work area
- stock exam rooms
4
Q
what should you do at the beginning of each day
A
- check rooms for cleanliness and adequate supplies
5
Q
what does the daily schedule identify
A
- patient name
- reason for visit
6
Q
how often should surfaces like counters and exam tables be cleaned
A
- beginning and end of each day
- between pts
7
Q
2 common solutions used to disinfect surfaces
A
- sodium hypochlorite solution (1:10 bleach to water)
- commercial chemical surface disinfectant
8
Q
things to keep stocked in an exam room
A
- personal protective equipment (PPE)
- sharps and biohazard waste containers
- exam gowns
- table paper
- anything specific needed or a particular visit
9
Q
what injuries are children prone to in a medical setting
A
- fall on sharp objects
- choking on small items
- touching electrical sockets
10
Q
precautions when assisting older patients or patients with disabilities
A
- assist with walking to room or getting on table
- emergency alert buttons in bathrooms
11
Q
active listening
A
techniques to fully understand what is being communicated
12
Q
open-ended questions
A
elicit a more detailed response without leading pt toward intended response
13
Q
restatement
A
repeating or paraphrasing info relayed by pt to confirm accuracy
14
Q
reflection
A
focusing on the main idea of the message and incorporating feelings the pt may be feeling
15
Q
clarification
A
summarizing info relayed by pt to clear up confusion
16
Q
nonverbal communication
A
gestures or actions that leave interpretation up to receiver
17
Q
empathy
A
- displaying an understanding of what pt might be experiencing by imagining the experience is happening personally
- effective in establishing rapport
18
Q
sympathy
A
- feeling pity for hardships of pt
- poor communication and burn-out
19
Q
what is part of patient intake at every visit
A
- chief complaint
- medication review
20
Q
chief complaint
A
- subjective
- best documented in pts own words
- identities reason for visit
21
Q
drug reconciliation
A
- comparing meds a pt is taking with what it says they are taking in medical record
- necessary at every office visit
22
Q
documenting allergy status
A
- ask pt about allergies and what reactions they had
- document in the medical record
23
Q
personal and family history
A
- completed prior to first office visit
- starting point for objective information
- identifies predispositions to diseases
- overall picture of pt health based on past events
- always ask if anything has changed
24
Q
audiometry
A
test determining level of hearing
25
visual acuity testing
use of tools such as Snellen chart to screen for visual impairments
26
urinalysis
evaluates urine for the presence of dissolved substances
27
anthropometric measurements
height and weight; head circumference in infants
28
vital signs
- aka cardinal signs
- temp, heart rate, respirations, blood pressure
- evaluate homeostasis
29
denver developmental screening test
series of activities used to determine developmental stage of children
30
who has scoliosis screenings
teenagers
31
mini-mental state examinations
- determines level of awareness of current events and recall of past events
- screens for dementia
- done on older adults
32
most common cause of pyrexia
- infection
33
pyrexia
- fever
- natural defense to fight invasive organisms
34
symptoms of fever
- chills
- anorexia
- malaise
- thirst
- generalized aching
35
what is used to measure oral temp
digital thermometer
36
what is used to measure aural/tympanic temp
tympanic thermometer
37
what is used to measure temporal temp
temporal artery scanner
38
what temperatures do axillary and rectal measurements determine
- axillary: skin
- rectal: core
39
what can result in inaccurate temperature results
- oral temp: ingesting hot or cold liquids
- aural/tympanic temp: cerumen (ear wax)
40
how is heart rate best palpated
- when artery can be pushed against a bone
- with second and third fingers
41
radial pulse
- thumb side of wrist
- most common for taking adult pulse
42
brachial pulse
- inside upper arm
- most common for children
43
carotid pulse
- in neck below jaw bone
- most common for emergency procedures
44
two ways to determine pulse
- palpation: touching
- auscultation: listening, usually with a stethoscope
45
apical pulse
listening to heart beat at apex of the heart
46
how is pulse evaluated
- rate: 70/min
- rhythm: regular
- strength: thready
47
thready
pulse difficult to detect or faint
48
bounding
very strong pulse
49
how are respirations evaluated
- rate
- rhythm: breathing pattern
- depth: how much air is inhaled
50
what counts as one respiration
inhale and exhale
51
wheezing
- whistling sounds on expiration
- body's attempt to expel trapped air
52
rales
- clicking or crackling sounds on inspiration
- can sound moist or dry
53
rhonchi
- rattling snoring sounds
- associated with chronic lung diseases
54
blood pressure
- force of blood circulating through arteries
55
sphygmomanometer
- instrument used to measure blood pressure
56
units of blood pressure
millimeters of mercury (mmHg)
57
systolic pressure
- first sharp tapping sound heard
- blood begins to surge into artery
- Korotkoff phase 1
58
diastolic pressure
- last sound disappears
- blood flows freely
- Korotkoff stage 5
59
Korotkoff stage 2
- swishing sound as more blood flows
60
Korotkoff stage 3
- sharp tapping sounds as blood continues surging
61
Korotkoff stage 4
- sound changes to soft tapping
- begins to muffle
62
what happens to blood pressure as you age
tends to rise
63
blood pressure 140/90 mmHg or higher
hypertension
64
blood pressure 120-139/80-89 mmHg
prehypertension
65
pulse oximetry
- the percentage of oxygen saturation in the blood
- infrared light obtains a reading
66
where can a pulse oximetry probe be attached
- finger
- earlobe if necessary
67
what interferes with a pulse oximetry reading
- nail polish
- blocks infrared light
68
pain scale
- subjective
- rating pain from 1 to 10
69
from who and when should you gather a chief complaint and history
- all pts
- every visit
70
from who and when should you measure height
- all pts
- complete physical exam, scoliosis exam, if growth concerns are present
71
from who and when should you measure weight
- all pts
- every visit
72
from who and when should you measure head circumference
- children 3 y/o and younger
- complete physical exam, if growth concerns are present
73
from who and when should you measure temperature
- all pts
- every visit
74
from who and when should you measure heart rate
- all pts
- every visit
75
from who and when should you measure a respirations
- all pts
- every visit
76
from who and when should you measure blood pressure
- adults (children and infants vary)
- every visit
77
from who and when should you measure pulse oximetry
- pts with chronic lung disease or respiratory symptoms
- as needed based on symptoms and condition
78
from who and when should you measure visual acuity (Snellen chart)
- children (adults vary)
- complete physical exam, adult exams for work hiring
79
from who and when should you perform an EKG
- adults (uncommon for children in ambulatory care)
- complete physical exam in middle-aged adults, if experiencing chest pain
80
from who and when should you perform a urinalysis
- all pts
- maternity visit, complete physical exam, when urinary symptoms are present
81
what is one reason it is important to get a pts weight at every visit
medications are often determined based on weight
82
should BMI be used as an indicator of health or means to deliver diagnosis
no
83
how to measure infant height
- lay them on paper-covered table
- place mark at the top of their head and at the heel of the flexed foot
- record measurements from table paper
84
where should you measure head circumference on an infant
- widest area
- usually right across the eyebrows
85
can measurements as reported by a pt be recorded
- yes, as a last resort
- make note in chart to explain how measurement was obtained
86
fowler's
- sitting at 90-degree angle
- exams of eyes, ears, nose, throat, chest
87
semi-fowler's
- sitting at a 45-degree angle
- chest exam, supine exams is pt can't lat flat, pt has SOB
88
sims'
- laying on left side with right leg flexed
- exams of rectum, enema
89
knee-chest
- prone, bent at waist, resting on knees
- gynecological or rectal exam, Tx of spinal adjustments
90
jack-knife
- lying over exam table
- rectal exam, sigmoidoscopy
91
lithotomy
- lying flat with feet in stirrups
- female pelvic exams
92
dorsal recumbent
- laying flat with knees bent
- catheterization, genital exam of younger children
93
prone
- laying flat on abdomen
- exams of the back, bottoms of feet
94
supine
- lying flat on back
- front of body exams, CPR
95
trandelenubrg
- legs above head
- shock
96
reflex hammer examines which body part
knees
97
tuning fork examines which body part
head
98
temporal thermometer examines which body part
forehead
99
otoscope examines which body part
ears
100
stethoscope examines which body parts
heart, lungs, abdomen
101
sphygmomanometer examines which body part
arm
102
ophthalmoscope examines which body part
eyes
103
speculum examines which body part
nose
104
what should be obtained from the pt prior to administering medication
consent
105
how many times should you check a medication
- 3
- compare med to order
- after med is prepared
- right after administering
106
supplies for injection
- correct syringe and needle
- medication
- alcohol swabs
- gauze pad
- bandage
- sharps/biohazard container
- gloves
107
what is the needle safety act
OSHA needlestick safety act
108
how to maintain sterility with injections
- needle/medication packaging
- expiration date of solutions
-alcohol swabs on vial stopper
- do not place exposed needle on countertop
109
can you introduce a needle into a vial more than once
no, dulls needle and causes contamination
110
only way to ever recap a needle
- one-handed scoop method
- only if absolutely necessary
- only on clean needles
111
what does needle gauge describe
- diameter of the lumen of the needle
- lower gauge = wider lumen
- range from 14 to 31
112
what does needle length describe
- distance from hilt to point of needle
- range from 3/8 to 4 in
113
gauge and length for intradermal administration
- gauge: 27 to 28
- length: 3/8 in
114
gauge and length for subcutaneous administration
- gauge: 25 to 26
- length: 1/2 to 5/8 in
115
gauge and length for intramuscular administration
- gauge: 20 to 23
- length: 1 to 3 in
116
how long should a pt wait after getting medication
10 to 15 mins to observe any adverse reactions
117
why is the dorsogluteal site no longer recommended
potential complications that can occur if the sciatic nerve is damaged
118
location and angle of deltoid muscle administration site
- 1 to 2 in below acromion
- 90-degrees
119
who cannot receive an injection in the deltoid muscle
infants or children under 3 y/o
120
max amount of medicine that can be administered in deltoid
- 1 mL
- some protocols say 2 to 3 mL
121
is the deltoid massaged after medication administration
yes
122
location and angle of ventrogluteal muscle administration site
- placing heel of hand on greater trochanter, injection given where v is made between index and middle finger
- 90-degrees
123
when would you use the ventrogluteal site
- deep IM injections
- larger quantities needed
- viscous medications
124
location and angle of vastus lateralis muscle administration site
- mid to upper outer thigh
- 90-degrees
125
when is the vastus lateralis muscle site used
- infants and children under 3 y/o
126
location and angle for subcutaneous administration
- multiple sites should be rotated: upper outer arm, abdomen, thigh
- 45-degrees
127
should you massage the site after administering heparin or insulin
no
128
location and angle for intradermal administration
- anterior forearm with one hand width from wrist and elbow, upper back
- 10 to 15 degrees
129
what should you expect to see after intradermal medication administration
wheal
130
should you massage an intradermal injection site
no
131
what is the most common site for TB testing
- mid forearm
- intradermal
132
what is the most common site for allergy testing
- back
- intradermal
133
oral medication route
- in the mouth
- read liquids at lowest point of meniscus
134
buccal medication route
- between cheek and gums
- fast absorption
- do not chew or swallow
135
sublingual medication route
- under tongue
- nitroglycerin tablets and spray
136
inhalation medication route
- bronchial passages
- can be delivered via nebulizer
- pt must hold medication in lungs for as long as possible
- pt can become shaky and dizzy
137
topical medication route
- reacts locally
- typically oil or water-based
138
mucosal medication route
- absorb through mucous membranes
- nose, vagina, rectum, eye, ear
- can cause mucosal irritation
139
transdermal medication route
- continuous slow absorption
- nicotine patches, pain meds, hormones delivery
140
what should you do prior to administering medications to the ears or eyes or topical medications
- ensure medication is at room temperature
- pt properly positioned
- gloves are worn
141
how should you administer topical medications
with an applicator
142
why would the eye be irrigated
remove foreign body or toxic substance
143
why would the ear be irrigated
remove foreign body or wax
144
how should eye irrigations be conducted
so solutions don't flow down tear duct
145
contraindication of ear irrigation
- ruptured tympanic membrane
- pt has tubes in the ears
146
how often should you review emergency evacuation and response plans
annually
147
triage
- deliver immediate care to pt with life-threatening condition
- ranking most critical to least critical
148
what is the medical assistant responsible for in an emergency situation
making sure all equipment and supplies are ready
149
what is imperative to wear when administering first aid
personal protective equipment
150
what must be obtained for any open wound injury
tetanus immunization status
151
abrasion
- scrape or rub, superficial
- apply pressure if bleeding, clean or flush to remove debris, apply bandage
152
incision
- sharp object causing straight cut, can be profuse bleeding
- apply pressure to control bleeding, clean gently, apply bandage
153
laceration
- jagged, sharp object, profuse bleeding
- apply pressure, clean gently, apply bandage
154
puncture
- stab, small, limited bleeding
- pressure if bleeding, clean or flush to remove debris, apply bandage
155
contusion
- bruise, blunt-force trauma
- apply ice, elevate, observe for complications (signs of intracranial pressure)
156
concussion
- brain shaken
- measure vitals, observation, possible CT scan
157
strain
- stretching or tearing of muscle or tendon
- RICE
158
sprain
- stretching or tearing of ligament
- RICE
159
fracture
- bone break
- control bleeding, immobilize, ice, check for pulse below fracture site, treat for shock
160
anaphylaxis
- severe allergic reaction, circulatory shutdown and respiratory distress
- basic life support, oxygen, epinephrine, 911
161
acute abdominal pain
- general symptom, could be life-threatening
- get detailed complaint, pt NPO, keep pt warm but don't apply direct heat
162
bleeding emergencies
- internal or external
- pressure, elevate, ice, monitor vitals, observe for shock
163
degrees of burns
- 1st degree: first layer, sunburn
- 2nd degree: subcutaneous layer, blister
- 3rd degree: muscle, dry and charred
- electrical, chemical, thermal
164
treatment of burns
- remove pt from source
- flush with cool water
- do not remove clothing (unless chemical burn)
- monitor vitals
- observe for shock
165
choking
- obstruction of airway
- ask pt if choking, Heimlich maneuver, perform CPR if unconscious
166
diabetic coma
- hyperglycemia
- malaise, dry mouth, polydipsia, polyuria, nausea, vomiting, dyspnea
- life-threatening if untreated
- administer insulin, call 911
167
insulin shock
- hypoglycemia
- sweating, anxiety, irritability, tachycardia, headache, hunger
- life-threatening if untreated
- administer glucose, call 911
168
what should you administer when in doubt about the type of diabetic emergency
glucose
169
seizures
- can result from trauma, fever, disorders, or unknown causes
- help pt lay down, tilt head to prevent aspiration, time seizure, 911
170
generalized seizure
grand mal
171
short staring episode seizure
petit mal
172
term for when seizure continues
status epilepticus
173
stroke
- hypoxia in brain due to blood clot or vessel rupture
- weakness or paralysis on one side of the body, difficulty speaking, drooping mouth
- pt NPO, monitor vitals, get medical history, oxygen, 911
174
signs of infection
- redness or swelling at or around site
- feeling hot to touch
- drainage (other than clear)
- foul odor from site
- fever
- malaise
- red streaks extending from wound (lymphangitis)
175
how to remove dressings stuck to a wound
soak dressing in sterile saline or sterile water
176
difference between dressing and bandage
- dressing: sterile, cover wounds
- bandage: nonsterile, cover dressing
177
ultimate goals of CPR
restore circulation and breathing while minimizing complications
178
what causes breathing in pt with normal lung function
high carbon dioxide levels
179
what causes breathing in a pt with a pulmonary disease
low oxygen levels
180
steps of CPR
- check responsiveness
-activate emergency medical systems
- check carotid artery for pulse
- if no pulse, begin CPR
181
rate of CPR
- 100 to 120 chest compressions per minute
182
ratio of chest compressions to breaths
- 30 compressions to 2 breaths
183
most pts who go into cardiac arrest experience what heart rhythm
ventricular fibrillation
184
AED
- converts heart to normal sinus rhythm
- avoid touching metal like jewelry
185
what might a CMA do when assisting with a minor traumatic injury
- clean wounds
- prepare sterile field
- bandage wounds
- adminsiter injections
- instruct pts on signs of infection
- provide wound care
- schedule follow-up
186
how far around the sterile field is considered nonsterile
1 inch
187
how to maintain the sterile field
- open packages so they drop onto sterile field or are grasped by provider
- lip bottle of liquids prior to pouring into sterile containers
- do not leave field unattended, reach over field
- medication vials should be cleaned with alcohol prior to holding with two hands for provider to inject needle into
188
cryosurgery
- destroy cells with cold
- for warts or cervical dysplasia
- need liquid nitrogen and cryoprobe
- pt should expect discomfort as tissue warms
189
colposcopy/hysteroscopy
- inspect vagina/cervix/uterus and deliver treatments
- need coloscope/hysteroscope
- pt in lithotomy position
- not performed while pt is having menses
190
electrosurgery or electrocauterization
- pulse of electrical current burns tissue
- minimize or stop bleeding, destroy small polyps, break scar tissue
- need electrocautery unit
- avoid placing pad on hair or bony places
191
toenail removal
- remove what is causing ingrown toenail, local anesthetic used
- need sterile scissors and forceps or hemostats, anesthetic (xylocaine, bandage
- discomfort as anesthetic wears of, soaking in warm salt water facilitates healing
192
endoscopy
- inspection of GI tract
- need gastroscope/laparoscope/hysteroscope
193
mole or cyst removal
- need local anesthetic (xylocaine), scalpel or punch device, suture supplies
- obtain family history of melanoma, specimens sent to lab
194
wound inspection before suture removal
- crusty wounds need soaking with saline prior to removal of sutures
195
how to remove sutures/staples
- remove every other one while observing site
- if there is gaping, notify provider
- account for total number of staples/sutures
- cut close to knot and pull out with forceps
- can use butterfly closures to provide reinforcement after removal
196
discharge instructions
- activity restrictions
- diet restrictions
- wound care
- medications
- follow-up appointments
197
which insurance providers usually require precertification to cover expenses
managed care plans
198
precertification
approval obtained by insurance providers that identifies insurance coverage for diagnostic or therapeutic activities
199
what diagnostic procedure does not require precertification but may be less expensive at a participating provider's office
x-ray
200
what does the CMA need before sending a prescription
to be credentialed
201
which schedule of controlled substances can't be called to the pharmacy
schedule 2
202
parts of a prescription
- prescriber info
- DEA number
- pt info
- medication prescribed
- instructions
- signature
203
advantages of electronic prescriptions
- human error reduced
- rapidly sent
- medication abuse reduced
204
disadvantages of electronic prescriptions
- network problems
- person transmitting must be credentialed
205
procedural documentation
- how pt was prepared
- position used
- last time pt had anything to eat or drink
- procedural process
- how pt tolerated procedure
206
required components of medical record
- demographic info
- medication record
- progress notes: chief complaint, SOAP notes
- lab or diagnostic reports
207
how should the medical record be organized
chronologically with most recent reports on top
208
medical necessity
- used by third-party payers (insurance)
- identify that procedure to test is necessary
- needed for insurance to cover
209
upcoding
- coding for more than what was performed
- for higher reimbursement
- fraud and legal action
210
difference between EHR and EMR
- EHR: across multiple healthcare organizations
- EMR: within single healthcare organization
211
functions of EMR
- appointments
- prescription services
- billing procedures
- insurance services
- lab and ancillary services
- patient portal
212
why was patient portal designed
- to empower pt to take active role in their care
