Patient Intake And Vitals Flashcards
Identify Patient
Ask for their full name and date of birth
Medical reconciliation
Comparing patient’s list of medications to the medical record as a safety measure to reduce the risk of improperly prescribing an incorrect or contraindication prescription
Patient missing a section to sign
Explain importance of getting all information so the provider has a better idea of your health history, also patient has right to refuse to answer
What is blood pressure
Force of blood circulating through arteries - measured in millimeters of mercury (mm Hg)
Systolic and Diastolic - when is it recorded
Systolic - first sharp tapping sound
Diastolic - last sound disappears completely
Proper blood pressure cuff size
Index line of the end of the cuff should fall within the range marked by the white range arrow - change if it falls outside the range
Contraindications for limb selection
One-sided mastectomy - use the arm on side not impacted by mastectomy
Bilateral mastectomy - use leg
Lymphedema - use leg
Dialysis fistula - use leg
Orthodontic hypotension
A significant drop in blood pressure during positional changes
Heart rate
Number of times the heart beats per minute
Most common pulse points
Radial, brachial, and carotid
Radial pulse
Located on thumb side of wrist
Brachial pulse
Inside upper arm
Carotid
Located in neck just below the jawbone
Temporal artery
Side of the forehead
Femoral artery
Inner groin area
Popliteal artery
Behind the knee
Posterior tibial artery
Behind the ankle
Dorsalis pedis artery
On top of the foot
What can be measured through auscultation
Blood pressure and pulse
What is apical pulse most commonly measured in?
Children, infants and adults with irregular heartbeats
Respiration includes
One complete inhalation and exhalation
Where can you put a pulse oximeter?
Most common - tip of fingernail (can be influenced by nail polish/artificial nails
Alternate side - earlobe
An axillary (Ax) temperature reading is generally how much lower than an oral temperature reading?
Approximately 1 degree Fahrenheit (0.6 degrees Celsius)
Tympanic (ear), rectal, and temporal artery temperatures are approximately 1 degree Fahrenheit (0.6 degrees Celsius) higher than
Oral readings
Converting Fahrenheit to Celsius
(Fahrenheit - 32) / 1.8
Converting Celsius to Fahrenheit
(Celsius x 1.8) + 32
Which of the Korotkoff phases is indicative of the diastolic readings?
Phase V
Korotkoff sounds
Phase I - first sound heart
Phase II - swishing sound
Phase III - sharp tapping sounds
Phase IV - soft tapping sound
Phase V - final sound heard
Which can occur if the wrong size of blood pressure cuff is used
The systolic and diastolic can be impacted by up to 6.9 mm Hg
What is a positive test for orthostatic hypotension
If patient had greater than 10/mm increase in heart rate
Greater than 20 mm Hg in blood pressure
Steps for radial pulse
- MA introduces themselves and explains procedure to patient
- Place two or three fingers on radial pulse
- Count the pulse for 30 seconds
- Multiply the number of beats counted in 30 seconds by 2
- Document the debate, time, pulse, strength and rhythm
Which are addressed when taking a pulse
Rate (beats per minute)
Rhythm (regular)
Strength (strong, weak, thready)
Bradypnea
abnormally
slow breathing
Tachypnea
rapid shallow breathing
Orthopnea
difficulty breathing unless in the upright position
Apnea
Periodic cessation (ending)
of breathing
Dyspnea
difficulty breathing
Respiratory expected reference range for an adult
12 to 20 breaths / minute
while observing pulse oximetry, MA notices the reading is 89% - what should MA do?
notify the provider and await further instruction
What does oximeter measure
oxygen saturation in the blood
What can affect a temperature reading?
Drinking hot or cold liquids, smoking, chewing gum, cold weather, hot weather, age, and menstrual cycle can affect a temperature reading
Which temperature site does not have to be indicated when documenting the reading in the patient’s health record
Oral
When asking 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, what signs should you look for when reporting?
Report all verbal and nonverbal responses to provider
Characteristics of patient’s pain
location, onset, duration, characteristics
The last menstrual period (LMP) is considered
the first day of the previous menstrual cycle
Normal or health weight
Range between 5th and 85th percentile
Height, weight and head circumference are measured during
infancy and early toddler years
Head circumference is not recommended past
birth to 36 months
How to respond to parents thinking that their baby is overweight
Explain measurements should stay within the grid and that patient’s weight is the __th percentile among other ___ month old patients of their sex
Taking weight
patients should remove shoes and heavy jackets
One kilogram equals
2.2 pounds
To convert pounds to kilograms
divide weight in pounds by 2.2
To convert kilograms to pounds
multiple the weight in kilograms by 2.2
To convert height from inches
divide the total number of inches by 12
Normal BMI
18.5 % to 24.9 %
How to determine BMI
703 multiplied by Individual’s weight (kg) / Individual’s height (in)^2
A patient has a cane to ambulate, what can the medical assistant do to help this patient balance on the scale if there are no handrails
Use a built in scale with hand rails or use a walker
What should normal range of temperature be for an adult
97.6 to 99.6
If patient is on beta-blocker medication
causes decreased blood pressure and decreased heart rate
If patient is in pain - what happens to blood pressure
increased blood pressure and increased heart rate
if patient has an illness - what happens to their temperature reading
increased temperature
A patient tells the MA they smoke, what’s an important question the MA should ask when measuring patient’s vital signs
find out when patient last smoked a cigarette - if they just did - their temperature will be falsely elevated
How to deal with abnormal blood pressure reading for patient
the MA identified other factor (anxiety and stress) which can contribute to elevated blood pressure. demonstrate important of reporting abnormal measurement to provider
How to deal with patient who doesn’t want to be weighed
Remain professional and gain trust - tell them it’s their right to refuse and don’t force them to get weighed
How to approach a patient requesting for a medication even though office policy may be to meet with a provider/speak to a nurse
“I want to make sure we are giving you the best possible care and treating your symptoms, I would like to start by having you speak with our provider in order to better understand your symptoms and ensure the right treatment is initiated - that may be the medication you suggested or something different would be more helpful - would this be okay?”
How can the MA’s emotional intelligence continue to promote office policies without feeling exhausted or fighting patient?
Identify the root of your negative responses, consider possible perspective of patient’s view that may overlap, connect and validate their feelings, discuss alternate options for care such as telehealth
A BMI of 25 to 29.9 is considered
overweight
A BMI less than 18.5 is considered
underweight
Which of the following manifestations should a MA expect to see in a patient who has COPD
Orthopnea - difficulty breathing in a recumbent position and is relieved by sitting or standing - usually they need to sit up to breathe or use multiple pillows to allow them to breathe as they sleep
Stage 1 hypertension
130 to 139 systolic and 80-89 diastolic
Elevated blood pressure
120 - 129 systolic and less than 80 diastolic
What does social history include
Diet, exercise, tobacco use, and substance abuse
What is included in past medical history
past illnesses, diseases, or surgeries in the past
What is included in the occupational history section
occupational hazards in patient’s life
What is included in family history
patient’s immediate family member’s history of diseases
A stethoscope if typically placed over which of the following arteries when blood pressure is ausculated
Brachial artery
When should MA obtain orthostatic vital signs
when patient reports feeling dizzy
High Blood pressure stage 2
140 mm Hg or higher
Hypertension crisis
higher than 180 mm Hg
Systolic / Diastolic in 1-3 year olds
90 to 105 / 55 to 70
Systolic / Diastolic in 3-6 years
95 to 110 / 60 - 75
Systolic / Diastolic in 6 to 12 years old
100 to 120 / 60 - 75
Demographic information includes
name, address, telephone number, insurance information, emergency contact
What does exertion (such as a long walk to the exam room) to do vital signs
increased blood pressure, increased heart rate, lower oxygen levels
Critical devices
Instruments that come in contact with normally sterile tissue
Non-critical devices
Instruments that come into contact with unbroken skin
Semi-critical devices
Instruments that come into contact with mucus membranes
Sterilization
is required for all instruments that will be used in a sterile field, even if they will not be used on a patient
Used needles should be disposed of
immediately, uncapped and placed in the sharps container
A needle’s gauge (G) refers to
the size of the opening of the needle, or lumen
Higher the gauge, the smaller/narrower the lumen
ex. 25G has a smaller lumen than 18G needle
Needle length is based on
inches, and can vary from 5/16 inches to 1 1/2 inches
Needle and syringe labeled indicates
___ml (how much liquid can be held)
__G (needle gauge is that much)
x __ in (needle length)
Subcutaneous injections - common medications
insulin, immunizations, and allergy medications
When performing a SubQ injections,
angle needle 45 degrees and ensure you can pinch at least 1 inch of skin in order to inject below it - can do it in upper, outer arm, abdominal region, and upper thigh - no more than 1.5 ml
Intradermal injections
angle at 5 to 15 degrees, wheal/bubble forms - can do it in forearm (most common) upper chest and upper back - no more than 0.1 ml
Intramuscular injections
angle at 90 degrees, common sites are deltoid (shoulder) ventrogluteral (outer hip), and vastus lateralis (upper, outer thigh) muscle - generally allow for larger administration of medication
Which needle size should be used for tuberculin (TB) test
26 G 1/2
Multidose vials usually expire
after 28 days unless the manufacturer states otherwise
Vials
a plastic or glass container that has a rubber stopper (diaphragm) on the top
Ampule
a sealed glass container designed to hold a single dose of medication
Pre-measured syringes
single dosed and packaged with the needle that is provided by the manufacturer
Hypodermic Syringe
measured in mL (sometimes in cc) but transitioning to mL
comes in a variety of sizes - 0.5 to 60mL
Tuberculin Syringe
narrow syringe
capacity of 0.5ml to 1ml
measured in mL
calibrated in hundredths (0.01mL) and tenths (0.1mL)
Insulin Syringe
Calibrated to match the dosage strength of insulin being used
marked U-100 and are designed to be used with insulin
needle, hub, and barrel are inseparable
When should refrigerators and freezers be checked for medications stored
Daily
Store refrigerated medications between
2˚ and 8˚ C (35˚ and 46˚ F)
Frozen medications must be stored between
–50˚ and –15˚ C (–58˚ and 5˚ F)
Medications with expiration dates and all supplies for injection
should be routinely checked, rotated to their expiration date
When any procedure is performed on a patient
it must be documented in the patient’s medical record. As the saying goes, “If it wasn’t documented, it wasn’t done.”
What is included in the MAR (Medication Administration Record)
Any allergies or history of allergies
What medication is being administered
Medication dosage
Administration route
When is it being administered—what time, how often, how long
The name of the health care provider who prescribed the medication
Medication stored at room temperature should be
20˚ to 25˚ C (68˚ to 77˚F)
Medications must be removed and disposed of immediately if they are
discontinued, expired, contaminated, deteriorated, unlabeled, or in cracked, soiled, or unsecured containers
Anytime a medication is disposed of, document the disposal on the Medication Disposition record
At which point should you initial or sign the MAR during the medication administration process
After administering the medication to the patient
What is eye irrigation
the process of using a sterile solution to flush the eyes of any foreign bodies or any toxic chemicals
Ear irrigation steps
- Warm solution
- Position the patient
- Examine the affected ear with an otoscope
- Hold the wash bin tightly below the affected ear
- Insert the tip of the syringe pointed toward the top of the ear canal and spray the solution
What is the advantage of a printed paper copy of a prescription
Eliminates issues caused by poor penmanship and the EHR software can perform a number of edits to reduce the occurrence of clinical errors.
What is considered most convenient and efficient when prescribing?
Electronic order by EHR that is transmitted to the pharmacy
When transmitting an e-prescription..
Pharmacy and provider must have approved software, prescribing software must be DEA EPCS approved, and provider must have DEA number for controlled substances
A compounding medication
mixes two or more drugs or ingredients
Demographic data
Name, address, birthdate, sex, gender, social security number, phone number, employment information
Administrative Data
Notice of Privacy policy forms, advanced directives, consent forms, medical records release forms
Health history
Chief complaint, present illness, past medical history, family history, social history, review of systems
Physical examination
assessment of each body part
Allergies
All known patient allergies
Medication record
Detailed information related to the patient’s medication
Continuity of Care
consultation report, home health care report, therapeutic service documents, hospital documents
Difference between EHR and EMR
EMRs are used within a single organization, while EHRs are designed to share patient information across multiple healthcare organizations
Health care providers and organizations are required to report statistics on communicable and infectious diseases to local and state government agencies
HIV/AIDS, tuberculosis, and sexually transmitted infections
What is a computerized provider order entry (CPOE)
process in which providers enter and sent treatment instructions, including medications, laboratory, and radiology orders, via a computer application rather than paper, fax, or phone
CPOE 6 step system
A provider will log into an EMR.
Once logged in, the provider will see a list of patients on the screen.
The provider can select a patient and use the system to order prescriptions, lab work, and medical scans.
The system automatically validates the order against a patient’s medical history, health insurance plan, and other relevant data that has been stored in the system.
If no error is detected, the order will be sent to a product or service provider, typically a pharmacy or lab.
Finally, this order is added to the patient’s permanent records, expediting future reviews, orders, and access for care providers.
What are the advantages of CPOE
identifies medication interactions, prevents incorrect dosage, recommends treatment options
What are the advantages of adding a CPOE with a CDSS (clinical decision support system)
prevents errors of medication ordering and suggest recommendations for medication dosage, routes of administration, and frequency
How do telehealth and telemedicine differ in their scope of online healthcare services?
Telemedicine is limited to online provider visits and clinical services, while telehealth encompasses a broader range, including education, training, and administrative services (non-patient and nonclinical services such as team meetings and professional development for the health care team).
Telehealth visits may include the following:
General health care, like wellness visits
Prescriptions for routine medicine
Dermatology (skin care)
Eye exams
Nutrition counseling
Mental health counseling
Urgent care conditions, such as sinusitis, urinary tract infections, and common rashes
Which of the following criteria is appropriate for a telehealth visit with a healthcare provider?
Patient meets the technology requirements, private area is needed, patient is self-reporting blood pressure readings, glucose, height, weight
Before administering any medication, what should the MA ask?
any allergies to medications?
