Module 9: General Patient Care Flashcards
the first step in ensuring patient safety
patient identification
patient identification methods
- Joint Commission stresses using two pt identifiers
- state name and date of birth
- never state to pt and get them to confirm
what should you do at the end of each day
- disinfect the work area
- stock exam rooms
what should you do at the beginning of each day
- check rooms for cleanliness and adequate supplies
what does the daily schedule identify
- patient name
- reason for visit
how often should surfaces like counters and exam tables be cleaned
- beginning and end of each day
- between pts
2 common solutions used to disinfect surfaces
- sodium hypochlorite solution (1:10 bleach to water)
- commercial chemical surface disinfectant
things to keep stocked in an exam room
- personal protective equipment (PPE)
- sharps and biohazard waste containers
- exam gowns
- table paper
- anything specific needed or a particular visit
what injuries are children prone to in a medical setting
- fall on sharp objects
- choking on small items
- touching electrical sockets
precautions when assisting older patients or patients with disabilities
- assist with walking to room or getting on table
- emergency alert buttons in bathrooms
active listening
techniques to fully understand what is being communicated
open-ended questions
elicit a more detailed response without leading pt toward intended response
restatement
repeating or paraphrasing info relayed by pt to confirm accuracy
reflection
focusing on the main idea of the message and incorporating feelings the pt may be feeling
clarification
summarizing info relayed by pt to clear up confusion
nonverbal communication
gestures or actions that leave interpretation up to receiver
empathy
- displaying an understanding of what pt might be experiencing by imagining the experience is happening personally
- effective in establishing rapport
sympathy
- feeling pity for hardships of pt
- poor communication and burn-out
what is part of patient intake at every visit
- chief complaint
- medication review
chief complaint
- subjective
- best documented in pts own words
- identities reason for visit
drug reconciliation
- comparing meds a pt is taking with what it says they are taking in medical record
- necessary at every office visit
documenting allergy status
- ask pt about allergies and what reactions they had
- document in the medical record
personal and family history
- 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
audiometry
test determining level of hearing
visual acuity testing
use of tools such as Snellen chart to screen for visual impairments
urinalysis
evaluates urine for the presence of dissolved substances
anthropometric measurements
height and weight; head circumference in infants
vital signs
- aka cardinal signs
- temp, heart rate, respirations, blood pressure
- evaluate homeostasis
denver developmental screening test
series of activities used to determine developmental stage of children
who has scoliosis screenings
teenagers
mini-mental state examinations
- determines level of awareness of current events and recall of past events
- screens for dementia
- done on older adults
most common cause of pyrexia
- infection
pyrexia
- fever
- natural defense to fight invasive organisms
symptoms of fever
- chills
- anorexia
- malaise
- thirst
- generalized aching
what is used to measure oral temp
digital thermometer
what is used to measure aural/tympanic temp
tympanic thermometer
what is used to measure temporal temp
temporal artery scanner
what temperatures do axillary and rectal measurements determine
- axillary: skin
- rectal: core
what can result in inaccurate temperature results
- oral temp: ingesting hot or cold liquids
- aural/tympanic temp: cerumen (ear wax)
how is heart rate best palpated
- when artery can be pushed against a bone
- with second and third fingers
radial pulse
- thumb side of wrist
- most common for taking adult pulse
brachial pulse
- inside upper arm
- most common for children
carotid pulse
- in neck below jaw bone
- most common for emergency procedures
two ways to determine pulse
- palpation: touching
- auscultation: listening, usually with a stethoscope
apical pulse
listening to heart beat at apex of the heart
how is pulse evaluated
- rate: 70/min
- rhythm: regular
- strength: thready
thready
pulse difficult to detect or faint
bounding
very strong pulse
how are respirations evaluated
- rate
- rhythm: breathing pattern
- depth: how much air is inhaled
what counts as one respiration
inhale and exhale
wheezing
- whistling sounds on expiration
- body’s attempt to expel trapped air
rales
- clicking or crackling sounds on inspiration
- can sound moist or dry
rhonchi
- rattling snoring sounds
- associated with chronic lung diseases
blood pressure
- force of blood circulating through arteries
sphygmomanometer
- instrument used to measure blood pressure
units of blood pressure
millimeters of mercury (mmHg)
systolic pressure
- first sharp tapping sound heard
- blood begins to surge into artery
- Korotkoff phase 1
diastolic pressure
- last sound disappears
- blood flows freely
- Korotkoff stage 5
Korotkoff stage 2
- swishing sound as more blood flows
Korotkoff stage 3
- sharp tapping sounds as blood continues surging
Korotkoff stage 4
- sound changes to soft tapping
- begins to muffle
what happens to blood pressure as you age
tends to rise
blood pressure 140/90 mmHg or higher
hypertension
blood pressure 120-139/80-89 mmHg
prehypertension
pulse oximetry
- the percentage of oxygen saturation in the blood
- infrared light obtains a reading
where can a pulse oximetry probe be attached
- finger
- earlobe if necessary
what interferes with a pulse oximetry reading
- nail polish
- blocks infrared light
pain scale
- subjective
- rating pain from 1 to 10
from who and when should you gather a chief complaint and history
- all pts
- every visit
from who and when should you measure height
- all pts
- complete physical exam, scoliosis exam, if growth concerns are present
from who and when should you measure weight
- all pts
- every visit
from who and when should you measure head circumference
- children 3 y/o and younger
- complete physical exam, if growth concerns are present
from who and when should you measure temperature
- all pts
- every visit
from who and when should you measure heart rate
- all pts
- every visit
from who and when should you measure a respirations
- all pts
- every visit
from who and when should you measure blood pressure
- adults (children and infants vary)
- every visit
from who and when should you measure pulse oximetry
- pts with chronic lung disease or respiratory symptoms
- as needed based on symptoms and condition
from who and when should you measure visual acuity (Snellen chart)
- children (adults vary)
- complete physical exam, adult exams for work hiring
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
from who and when should you perform a urinalysis
- all pts
- maternity visit, complete physical exam, when urinary symptoms are present
what is one reason it is important to get a pts weight at every visit
medications are often determined based on weight
should BMI be used as an indicator of health or means to deliver diagnosis
no
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
where should you measure head circumference on an infant
- widest area
- usually right across the eyebrows