Module 9: General Patient Care Flashcards

You may prefer our related Brainscape-certified flashcards:
1
Q

the first step in ensuring patient safety

A

patient identification

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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
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3
Q

what should you do at the end of each day

A
  • disinfect the work area
  • stock exam rooms
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4
Q

what should you do at the beginning of each day

A
  • check rooms for cleanliness and adequate supplies
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5
Q

what does the daily schedule identify

A
  • patient name
  • reason for visit
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6
Q

how often should surfaces like counters and exam tables be cleaned

A
  • beginning and end of each day
  • between pts
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7
Q

2 common solutions used to disinfect surfaces

A
  • sodium hypochlorite solution (1:10 bleach to water)
  • commercial chemical surface disinfectant
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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
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9
Q

what injuries are children prone to in a medical setting

A
  • fall on sharp objects
  • choking on small items
  • touching electrical sockets
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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
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11
Q

active listening

A

techniques to fully understand what is being communicated

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12
Q

open-ended questions

A

elicit a more detailed response without leading pt toward intended response

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13
Q

restatement

A

repeating or paraphrasing info relayed by pt to confirm accuracy

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14
Q

reflection

A

focusing on the main idea of the message and incorporating feelings the pt may be feeling

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15
Q

clarification

A

summarizing info relayed by pt to clear up confusion

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16
Q

nonverbal communication

A

gestures or actions that leave interpretation up to receiver

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17
Q

empathy

A
  • displaying an understanding of what pt might be experiencing by imagining the experience is happening personally
  • effective in establishing rapport
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18
Q

sympathy

A
  • feeling pity for hardships of pt
  • poor communication and burn-out
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19
Q

what is part of patient intake at every visit

A
  • chief complaint
  • medication review
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20
Q

chief complaint

A
  • subjective
  • best documented in pts own words
  • identities reason for visit
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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
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22
Q

documenting allergy status

A
  • ask pt about allergies and what reactions they had
  • document in the medical record
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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
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24
Q

audiometry

A

test determining level of hearing

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25
Q

visual acuity testing

A

use of tools such as Snellen chart to screen for visual impairments

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26
Q

urinalysis

A

evaluates urine for the presence of dissolved substances

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27
Q

anthropometric measurements

A

height and weight; head circumference in infants

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28
Q

vital signs

A
  • aka cardinal signs
  • temp, heart rate, respirations, blood pressure
  • evaluate homeostasis
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29
Q

denver developmental screening test

A

series of activities used to determine developmental stage of children

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30
Q

who has scoliosis screenings

A

teenagers

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31
Q

mini-mental state examinations

A
  • determines level of awareness of current events and recall of past events
  • screens for dementia
  • done on older adults
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32
Q

most common cause of pyrexia

A
  • infection
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33
Q

pyrexia

A
  • fever
  • natural defense to fight invasive organisms
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34
Q

symptoms of fever

A
  • chills
  • anorexia
  • malaise
  • thirst
  • generalized aching
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35
Q

what is used to measure oral temp

A

digital thermometer

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36
Q

what is used to measure aural/tympanic temp

A

tympanic thermometer

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37
Q

what is used to measure temporal temp

A

temporal artery scanner

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38
Q

what temperatures do axillary and rectal measurements determine

A
  • axillary: skin
  • rectal: core
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39
Q

what can result in inaccurate temperature results

A
  • oral temp: ingesting hot or cold liquids
  • aural/tympanic temp: cerumen (ear wax)
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40
Q

how is heart rate best palpated

A
  • when artery can be pushed against a bone
  • with second and third fingers
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41
Q

radial pulse

A
  • thumb side of wrist
  • most common for taking adult pulse
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42
Q

brachial pulse

A
  • inside upper arm
  • most common for children
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43
Q

carotid pulse

A
  • in neck below jaw bone
  • most common for emergency procedures
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44
Q

two ways to determine pulse

A
  • palpation: touching
  • auscultation: listening, usually with a stethoscope
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45
Q

apical pulse

A

listening to heart beat at apex of the heart

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46
Q

how is pulse evaluated

A
  • rate: 70/min
  • rhythm: regular
  • strength: thready
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47
Q

thready

A

pulse difficult to detect or faint

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48
Q

bounding

A

very strong pulse

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49
Q

how are respirations evaluated

A
  • rate
  • rhythm: breathing pattern
  • depth: how much air is inhaled
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50
Q

what counts as one respiration

A

inhale and exhale

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51
Q

wheezing

A
  • whistling sounds on expiration
  • body’s attempt to expel trapped air
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52
Q

rales

A
  • clicking or crackling sounds on inspiration
  • can sound moist or dry
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53
Q

rhonchi

A
  • rattling snoring sounds
  • associated with chronic lung diseases
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54
Q

blood pressure

A
  • force of blood circulating through arteries
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55
Q

sphygmomanometer

A
  • instrument used to measure blood pressure
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56
Q

units of blood pressure

A

millimeters of mercury (mmHg)

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57
Q

systolic pressure

A
  • first sharp tapping sound heard
  • blood begins to surge into artery
  • Korotkoff phase 1
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58
Q

diastolic pressure

A
  • last sound disappears
  • blood flows freely
  • Korotkoff stage 5
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59
Q

Korotkoff stage 2

A
  • swishing sound as more blood flows
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60
Q

Korotkoff stage 3

A
  • sharp tapping sounds as blood continues surging
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61
Q

Korotkoff stage 4

A
  • sound changes to soft tapping
  • begins to muffle
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62
Q

what happens to blood pressure as you age

A

tends to rise

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63
Q

blood pressure 140/90 mmHg or higher

A

hypertension

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64
Q

blood pressure 120-139/80-89 mmHg

A

prehypertension

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65
Q

pulse oximetry

A
  • the percentage of oxygen saturation in the blood
  • infrared light obtains a reading
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66
Q

where can a pulse oximetry probe be attached

A
  • finger
  • earlobe if necessary
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67
Q

what interferes with a pulse oximetry reading

A
  • nail polish
  • blocks infrared light
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68
Q

pain scale

A
  • subjective
  • rating pain from 1 to 10
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69
Q

from who and when should you gather a chief complaint and history

A
  • all pts
  • every visit
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70
Q

from who and when should you measure height

A
  • all pts
  • complete physical exam, scoliosis exam, if growth concerns are present
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71
Q

from who and when should you measure weight

A
  • all pts
  • every visit
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72
Q

from who and when should you measure head circumference

A
  • children 3 y/o and younger
  • complete physical exam, if growth concerns are present
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73
Q

from who and when should you measure temperature

A
  • all pts
  • every visit
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74
Q

from who and when should you measure heart rate

A
  • all pts
  • every visit
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75
Q

from who and when should you measure a respirations

A
  • all pts
  • every visit
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76
Q

from who and when should you measure blood pressure

A
  • adults (children and infants vary)
  • every visit
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77
Q

from who and when should you measure pulse oximetry

A
  • pts with chronic lung disease or respiratory symptoms
  • as needed based on symptoms and condition
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78
Q

from who and when should you measure visual acuity (Snellen chart)

A
  • children (adults vary)
  • complete physical exam, adult exams for work hiring
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79
Q

from who and when should you perform an EKG

A
  • adults (uncommon for children in ambulatory care)
  • complete physical exam in middle-aged adults, if experiencing chest pain
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80
Q

from who and when should you perform a urinalysis

A
  • all pts
  • maternity visit, complete physical exam, when urinary symptoms are present
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81
Q

what is one reason it is important to get a pts weight at every visit

A

medications are often determined based on weight

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82
Q

should BMI be used as an indicator of health or means to deliver diagnosis

A

no

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83
Q

how to measure infant height

A
  • 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
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84
Q

where should you measure head circumference on an infant

A
  • widest area
  • usually right across the eyebrows
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85
Q

can measurements as reported by a pt be recorded

A
  • yes, as a last resort
  • make note in chart to explain how measurement was obtained
86
Q

fowler’s

A
  • sitting at 90-degree angle
  • exams of eyes, ears, nose, throat, chest
87
Q

semi-fowler’s

A
  • sitting at a 45-degree angle
  • chest exam, supine exams is pt can’t lat flat, pt has SOB
88
Q

sims’

A
  • laying on left side with right leg flexed
  • exams of rectum, enema
89
Q

knee-chest

A
  • prone, bent at waist, resting on knees
  • gynecological or rectal exam, Tx of spinal adjustments
90
Q

jack-knife

A
  • lying over exam table
  • rectal exam, sigmoidoscopy
91
Q

lithotomy

A
  • lying flat with feet in stirrups
  • female pelvic exams
92
Q

dorsal recumbent

A
  • laying flat with knees bent
  • catheterization, genital exam of younger children
93
Q

prone

A
  • laying flat on abdomen
  • exams of the back, bottoms of feet
94
Q

supine

A
  • lying flat on back
  • front of body exams, CPR
95
Q

trandelenubrg

A
  • legs above head
  • shock
96
Q

reflex hammer examines which body part

A

knees

97
Q

tuning fork examines which body part

A

head

98
Q

temporal thermometer examines which body part

A

forehead

99
Q

otoscope examines which body part

A

ears

100
Q

stethoscope examines which body parts

A

heart, lungs, abdomen

101
Q

sphygmomanometer examines which body part

A

arm

102
Q

ophthalmoscope examines which body part

A

eyes

103
Q

speculum examines which body part

A

nose

104
Q

what should be obtained from the pt prior to administering medication

A

consent

105
Q

how many times should you check a medication

A
  • 3
  • compare med to order
  • after med is prepared
  • right after administering
106
Q

supplies for injection

A
  • correct syringe and needle
  • medication
  • alcohol swabs
  • gauze pad
  • bandage
  • sharps/biohazard container
  • gloves
107
Q

what is the needle safety act

A

OSHA needlestick safety act

108
Q

how to maintain sterility with injections

A
  • needle/medication packaging
  • expiration date of solutions
    -alcohol swabs on vial stopper
  • do not place exposed needle on countertop
109
Q

can you introduce a needle into a vial more than once

A

no, dulls needle and causes contamination

110
Q

only way to ever recap a needle

A
  • one-handed scoop method
  • only if absolutely necessary
  • only on clean needles
111
Q

what does needle gauge describe

A
  • diameter of the lumen of the needle
  • lower gauge = wider lumen
  • range from 14 to 31
112
Q

what does needle length describe

A
  • distance from hilt to point of needle
  • range from 3/8 to 4 in
113
Q

gauge and length for intradermal administration

A
  • gauge: 27 to 28
  • length: 3/8 in
114
Q

gauge and length for subcutaneous administration

A
  • gauge: 25 to 26
  • length: 1/2 to 5/8 in
115
Q

gauge and length for intramuscular administration

A
  • gauge: 20 to 23
  • length: 1 to 3 in
116
Q

how long should a pt wait after getting medication

A

10 to 15 mins to observe any adverse reactions

117
Q

why is the dorsogluteal site no longer recommended

A

potential complications that can occur if the sciatic nerve is damaged

118
Q

location and angle of deltoid muscle administration site

A
  • 1 to 2 in below acromion
  • 90-degrees
119
Q

who cannot receive an injection in the deltoid muscle

A

infants or children under 3 y/o

120
Q

max amount of medicine that can be administered in deltoid

A
  • 1 mL
  • some protocols say 2 to 3 mL
121
Q

is the deltoid massaged after medication administration

A

yes

122
Q

location and angle of ventrogluteal muscle administration site

A
  • placing heel of hand on greater trochanter, injection given where v is made between index and middle finger
  • 90-degrees
123
Q

when would you use the ventrogluteal site

A
  • deep IM injections
  • larger quantities needed
  • viscous medications
124
Q

location and angle of vastus lateralis muscle administration site

A
  • mid to upper outer thigh
  • 90-degrees
125
Q

when is the vastus lateralis muscle site used

A
  • infants and children under 3 y/o
126
Q

location and angle for subcutaneous administration

A
  • multiple sites should be rotated: upper outer arm, abdomen, thigh
  • 45-degrees
127
Q

should you massage the site after administering heparin or insulin

A

no

128
Q

location and angle for intradermal administration

A
  • anterior forearm with one hand width from wrist and elbow, upper back
  • 10 to 15 degrees
129
Q

what should you expect to see after intradermal medication administration

A

wheal

130
Q

should you massage an intradermal injection site

A

no

131
Q

what is the most common site for TB testing

A
  • mid forearm
  • intradermal
132
Q

what is the most common site for allergy testing

A
  • back
  • intradermal
133
Q

oral medication route

A
  • in the mouth
  • read liquids at lowest point of meniscus
134
Q

buccal medication route

A
  • between cheek and gums
  • fast absorption
  • do not chew or swallow
135
Q

sublingual medication route

A
  • under tongue
  • nitroglycerin tablets and spray
136
Q

inhalation medication route

A
  • 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
Q

topical medication route

A
  • reacts locally
  • typically oil or water-based
138
Q

mucosal medication route

A
  • absorb through mucous membranes
  • nose, vagina, rectum, eye, ear
  • can cause mucosal irritation
139
Q

transdermal medication route

A
  • continuous slow absorption
  • nicotine patches, pain meds, hormones delivery
140
Q

what should you do prior to administering medications to the ears or eyes or topical medications

A
  • ensure medication is at room temperature
  • pt properly positioned
  • gloves are worn
141
Q

how should you administer topical medications

A

with an applicator

142
Q

why would the eye be irrigated

A

remove foreign body or toxic substance

143
Q

why would the ear be irrigated

A

remove foreign body or wax

144
Q

how should eye irrigations be conducted

A

so solutions don’t flow down tear duct

145
Q

contraindication of ear irrigation

A
  • ruptured tympanic membrane
  • pt has tubes in the ears
146
Q

how often should you review emergency evacuation and response plans

A

annually

147
Q

triage

A
  • deliver immediate care to pt with life-threatening condition
  • ranking most critical to least critical
148
Q

what is the medical assistant responsible for in an emergency situation

A

making sure all equipment and supplies are ready

149
Q

what is imperative to wear when administering first aid

A

personal protective equipment

150
Q

what must be obtained for any open wound injury

A

tetanus immunization status

151
Q

abrasion

A
  • scrape or rub, superficial
  • apply pressure if bleeding, clean or flush to remove debris, apply bandage
152
Q

incision

A
  • sharp object causing straight cut, can be profuse bleeding
  • apply pressure to control bleeding, clean gently, apply bandage
153
Q

laceration

A
  • jagged, sharp object, profuse bleeding
  • apply pressure, clean gently, apply bandage
154
Q

puncture

A
  • stab, small, limited bleeding
  • pressure if bleeding, clean or flush to remove debris, apply bandage
155
Q

contusion

A
  • bruise, blunt-force trauma
  • apply ice, elevate, observe for complications (signs of intracranial pressure)
156
Q

concussion

A
  • brain shaken
  • measure vitals, observation, possible CT scan
157
Q

strain

A
  • stretching or tearing of muscle or tendon
  • RICE
158
Q

sprain

A
  • stretching or tearing of ligament
  • RICE
159
Q

fracture

A
  • bone break
  • control bleeding, immobilize, ice, check for pulse below fracture site, treat for shock
160
Q

anaphylaxis

A
  • severe allergic reaction, circulatory shutdown and respiratory distress
  • basic life support, oxygen, epinephrine, 911
161
Q

acute abdominal pain

A
  • general symptom, could be life-threatening
  • get detailed complaint, pt NPO, keep pt warm but don’t apply direct heat
162
Q

bleeding emergencies

A
  • internal or external
  • pressure, elevate, ice, monitor vitals, observe for shock
163
Q

degrees of burns

A
  • 1st degree: first layer, sunburn
  • 2nd degree: subcutaneous layer, blister
  • 3rd degree: muscle, dry and charred
  • electrical, chemical, thermal
164
Q

treatment of burns

A
  • remove pt from source
  • flush with cool water
  • do not remove clothing (unless chemical burn)
  • monitor vitals
  • observe for shock
165
Q

choking

A
  • obstruction of airway
  • ask pt if choking, Heimlich maneuver, perform CPR if unconscious
166
Q

diabetic coma

A
  • hyperglycemia
  • malaise, dry mouth, polydipsia, polyuria, nausea, vomiting, dyspnea
  • life-threatening if untreated
  • administer insulin, call 911
167
Q

insulin shock

A
  • hypoglycemia
  • sweating, anxiety, irritability, tachycardia, headache, hunger
  • life-threatening if untreated
  • administer glucose, call 911
168
Q

what should you administer when in doubt about the type of diabetic emergency

A

glucose

169
Q

seizures

A
  • can result from trauma, fever, disorders, or unknown causes
  • help pt lay down, tilt head to prevent aspiration, time seizure, 911
170
Q

generalized seizure

A

grand mal

171
Q

short staring episode seizure

A

petit mal

172
Q

term for when seizure continues

A

status epilepticus

173
Q

stroke

A
  • 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
Q

signs of infection

A
  • 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
Q

how to remove dressings stuck to a wound

A

soak dressing in sterile saline or sterile water

176
Q

difference between dressing and bandage

A
  • dressing: sterile, cover wounds
  • bandage: nonsterile, cover dressing
177
Q

ultimate goals of CPR

A

restore circulation and breathing while minimizing complications

178
Q

what causes breathing in pt with normal lung function

A

high carbon dioxide levels

179
Q

what causes breathing in a pt with a pulmonary disease

A

low oxygen levels

180
Q

steps of CPR

A
  • check responsiveness
    -activate emergency medical systems
  • check carotid artery for pulse
  • if no pulse, begin CPR
181
Q

rate of CPR

A
  • 100 to 120 chest compressions per minute
182
Q

ratio of chest compressions to breaths

A
  • 30 compressions to 2 breaths
183
Q

most pts who go into cardiac arrest experience what heart rhythm

A

ventricular fibrillation

184
Q

AED

A
  • converts heart to normal sinus rhythm
  • avoid touching metal like jewelry
185
Q

what might a CMA do when assisting with a minor traumatic injury

A
  • clean wounds
  • prepare sterile field
  • bandage wounds
  • adminsiter injections
  • instruct pts on signs of infection
  • provide wound care
  • schedule follow-up
186
Q

how far around the sterile field is considered nonsterile

A

1 inch

187
Q

how to maintain the sterile field

A
  • 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
Q

cryosurgery

A
  • destroy cells with cold
  • for warts or cervical dysplasia
  • need liquid nitrogen and cryoprobe
  • pt should expect discomfort as tissue warms
189
Q

colposcopy/hysteroscopy

A
  • inspect vagina/cervix/uterus and deliver treatments
  • need coloscope/hysteroscope
  • pt in lithotomy position
  • not performed while pt is having menses
190
Q

electrosurgery or electrocauterization

A
  • 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
Q

toenail removal

A
  • 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
Q

endoscopy

A
  • inspection of GI tract
  • need gastroscope/laparoscope/hysteroscope
193
Q

mole or cyst removal

A
  • need local anesthetic (xylocaine), scalpel or punch device, suture supplies
  • obtain family history of melanoma, specimens sent to lab
194
Q

wound inspection before suture removal

A
  • crusty wounds need soaking with saline prior to removal of sutures
195
Q

how to remove sutures/staples

A
  • 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
Q

discharge instructions

A
  • activity restrictions
  • diet restrictions
  • wound care
  • medications
  • follow-up appointments
197
Q

which insurance providers usually require precertification to cover expenses

A

managed care plans

198
Q

precertification

A

approval obtained by insurance providers that identifies insurance coverage for diagnostic or therapeutic activities

199
Q

what diagnostic procedure does not require precertification but may be less expensive at a participating provider’s office

A

x-ray

200
Q

what does the CMA need before sending a prescription

A

to be credentialed

201
Q

which schedule of controlled substances can’t be called to the pharmacy

A

schedule 2

202
Q

parts of a prescription

A
  • prescriber info
  • DEA number
  • pt info
  • medication prescribed
  • instructions
  • signature
203
Q

advantages of electronic prescriptions

A
  • human error reduced
  • rapidly sent
  • medication abuse reduced
204
Q

disadvantages of electronic prescriptions

A
  • network problems
  • person transmitting must be credentialed
205
Q

procedural documentation

A
  • how pt was prepared
  • position used
  • last time pt had anything to eat or drink
  • procedural process
  • how pt tolerated procedure
206
Q

required components of medical record

A
  • demographic info
  • medication record
  • progress notes: chief complaint, SOAP notes
  • lab or diagnostic reports
207
Q

how should the medical record be organized

A

chronologically with most recent reports on top

208
Q

medical necessity

A
  • used by third-party payers (insurance)
  • identify that procedure to test is necessary
  • needed for insurance to cover
209
Q

upcoding

A
  • coding for more than what was performed
  • for higher reimbursement
  • fraud and legal action
210
Q

difference between EHR and EMR

A
  • EHR: across multiple healthcare organizations
  • EMR: within single healthcare organization
211
Q

functions of EMR

A
  • appointments
  • prescription services
  • billing procedures
  • insurance services
  • lab and ancillary services
  • patient portal
212
Q

why was patient portal designed

A
  • to empower pt to take active role in their care